This study examined the impact of sarcopenia on long-term mortality in 200 patients who underwent endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms. Sarcopenia, defined as low skeletal muscle mass, was assessed on pre-operative CT scans. Patients with sarcopenia had significantly higher mortality rates than those without sarcopenia (76% vs 48%, p=0.016). On multivariate analysis, sarcopenia, hypertension, and older age were independent predictors of mortality following EVAR. The presence of sarcopenia on CT may help predict long-term survival in AAA patients undergoing EVAR.
Clinical and epidemiological profile of patients undergoing total hip arthro...David Sadigursky
Clinical and epidemiological profile of patients undergoing total hip arthroplasty.
Rheumatology and Orthopedic Medicine
Rheumatol Orthop Med, 2017 doi: 10.15761/ROM.1000120
1) The study examined the relationship between pericardial fat volumes measured by cardiac MRI and atrial fibrillation (AF) in 110 patients undergoing AF ablation and 20 control patients without AF.
2) The results showed that higher pericardial fat volumes were significantly associated with the presence of AF, longer duration of AF, and greater AF symptom burden. Higher fat volumes also predicted recurrence of AF after ablation.
3) Pericardial fat volumes were also correlated with larger left atrial volumes. These associations between pericardial fat and AF severity/outcomes remained even after adjusting for body weight and other measures of adiposity.
This study investigated risk factors associated with primary knee osteoarthritis in 174 Middle Eastern patients. The mean age was 59.9 years and most patients were female. Obesity, with a BMI over 24, was present in 96.5% of cases. Lower back pain in the previous year was reported by 49.4% of patients. A strong association was found between BMI and knee osteoarthritis. Gender was also found to be a risk factor, with knee osteoarthritis being more prevalent in females.
In this study of 277 post-menopausal women, the researchers found:
1) Higher bone mineral density was associated with increased severity of disc space narrowing at both the lumbar spine and femoral sites.
2) There was no association found between bone mineral density and severity of osteophytes.
3) Biochemical markers of bone resorption (CTX levels) decreased with increased severity of disc space narrowing, but were not associated with osteophyte severity. This suggests disc space narrowing may have a protective effect against bone loss through decreased bone resorption.
This study investigated factors associated with the onset of generalized osteoarthritis (OA) in older women through qualitative interviews. It found that hereditary factors were present in most participants. Participants also believed that depression, stress, diet, and low health status during vulnerable periods like World War II contributed to their OA. The findings generate hypotheses for future quantitative studies to test.
This study examined the relationship between hormone replacement therapy (HRT) use and osteoarthritis (OA) in women. The study analyzed radiographic data from 1003 women and found that current HRT users had a 3-fold lower risk of knee OA compared to never users. Current HRT use was also associated with a non-significant reduced risk of distal interphalangeal OA. No clear protective effect was seen for carpometacarpal OA. Past HRT use showed weaker or no protective effects. The results suggest HRT may have a protective effect against OA when used continuously but not after stopping use. Larger prospective studies are still needed to confirm these findings.
Ultrasonography in Abdominal Aortic Aneurysm Diagnosis (A Literature Review)Ramzee Small
Introduction to Abdominal Aortic Aneurysm, Signs and Symptoms of AAA, possible treatment, Diagnosis of Abdominal Aortic Aneurysm. Diagnosing Abdominal Aortic Aneurysm with Ultrasonography. Appearance of AAA on a sonogram and limitation of ultrasound in diagnosing Abdominal Aortic Aneurysm.
This study examined the association between estrogen receptor alpha (ERα) gene haplotypes and radiographic osteoarthritis (OA) of the knee in 1,483 elderly men and women. Three haplotypes (px, PX, Px) were identified. Carriage of the PX haplotype was associated with an increased prevalence and severity of radiographic knee OA, with odds ratios of 1.3 for heterozygotes and 2.2 for homozygotes. Separate analyses showed the association was driven by osteophytosis. This study provides evidence that polymorphisms in the ERα gene are risk factors for radiographic knee OA in both men and women.
Clinical and epidemiological profile of patients undergoing total hip arthro...David Sadigursky
Clinical and epidemiological profile of patients undergoing total hip arthroplasty.
Rheumatology and Orthopedic Medicine
Rheumatol Orthop Med, 2017 doi: 10.15761/ROM.1000120
1) The study examined the relationship between pericardial fat volumes measured by cardiac MRI and atrial fibrillation (AF) in 110 patients undergoing AF ablation and 20 control patients without AF.
2) The results showed that higher pericardial fat volumes were significantly associated with the presence of AF, longer duration of AF, and greater AF symptom burden. Higher fat volumes also predicted recurrence of AF after ablation.
3) Pericardial fat volumes were also correlated with larger left atrial volumes. These associations between pericardial fat and AF severity/outcomes remained even after adjusting for body weight and other measures of adiposity.
This study investigated risk factors associated with primary knee osteoarthritis in 174 Middle Eastern patients. The mean age was 59.9 years and most patients were female. Obesity, with a BMI over 24, was present in 96.5% of cases. Lower back pain in the previous year was reported by 49.4% of patients. A strong association was found between BMI and knee osteoarthritis. Gender was also found to be a risk factor, with knee osteoarthritis being more prevalent in females.
In this study of 277 post-menopausal women, the researchers found:
1) Higher bone mineral density was associated with increased severity of disc space narrowing at both the lumbar spine and femoral sites.
2) There was no association found between bone mineral density and severity of osteophytes.
3) Biochemical markers of bone resorption (CTX levels) decreased with increased severity of disc space narrowing, but were not associated with osteophyte severity. This suggests disc space narrowing may have a protective effect against bone loss through decreased bone resorption.
This study investigated factors associated with the onset of generalized osteoarthritis (OA) in older women through qualitative interviews. It found that hereditary factors were present in most participants. Participants also believed that depression, stress, diet, and low health status during vulnerable periods like World War II contributed to their OA. The findings generate hypotheses for future quantitative studies to test.
This study examined the relationship between hormone replacement therapy (HRT) use and osteoarthritis (OA) in women. The study analyzed radiographic data from 1003 women and found that current HRT users had a 3-fold lower risk of knee OA compared to never users. Current HRT use was also associated with a non-significant reduced risk of distal interphalangeal OA. No clear protective effect was seen for carpometacarpal OA. Past HRT use showed weaker or no protective effects. The results suggest HRT may have a protective effect against OA when used continuously but not after stopping use. Larger prospective studies are still needed to confirm these findings.
Ultrasonography in Abdominal Aortic Aneurysm Diagnosis (A Literature Review)Ramzee Small
Introduction to Abdominal Aortic Aneurysm, Signs and Symptoms of AAA, possible treatment, Diagnosis of Abdominal Aortic Aneurysm. Diagnosing Abdominal Aortic Aneurysm with Ultrasonography. Appearance of AAA on a sonogram and limitation of ultrasound in diagnosing Abdominal Aortic Aneurysm.
This study examined the association between estrogen receptor alpha (ERα) gene haplotypes and radiographic osteoarthritis (OA) of the knee in 1,483 elderly men and women. Three haplotypes (px, PX, Px) were identified. Carriage of the PX haplotype was associated with an increased prevalence and severity of radiographic knee OA, with odds ratios of 1.3 for heterozygotes and 2.2 for homozygotes. Separate analyses showed the association was driven by osteophytosis. This study provides evidence that polymorphisms in the ERα gene are risk factors for radiographic knee OA in both men and women.
This study evaluated the feasibility of transthoracic echocardiography (TTE) for assessing cardiac function in 76 patients with septic shock. TTE was able to determine left ventricular systolic function in 90% of patients, right ventricular function in 99%, and left ventricular diastolic function in 73%. Diastolic dysfunction was present in 50% of patients. Factors like obesity, mechanical ventilation, age, and illness severity did not impact the ability of TTE to evaluate cardiac function. TTE is therefore a reliable tool for comprehensive cardiac assessment, including diastolic function, in critically ill septic shock patients.
Revista Brasileira de Ortopedia 2014 PaganiMarcelo Guerra
1) The study compared the body mass index (BMI) of elderly patients aged 65+ who were hospitalized with fractures of the proximal femur from falls, to elderly patients without fractures.
2) It found that patients with fractures were significantly taller and had a significantly lower average BMI (22.6) than those without fractures (average BMI of 25.5).
3) Among fracture patients, 12% had low weight, 62.7% normal weight, 24% overweight, and 1.3% obese, while among non-fracture patients the percentages were 5.6%, 43.8%, 33.7%, and 9.8% respectively.
This study evaluated the efficacy of colchicine in preventing in-stent restenosis in 90 patients undergoing percutaneous coronary intervention with bare-metal stents. Patients were divided into 3 groups: those receiving a bare-metal stent plus colchicine, bare-metal stent alone, or a drug-eluting stent. After 6 months of follow up, the rates of in-stent restenosis and target vessel revascularization were significantly lower in patients receiving colchicine plus bare-metal stent compared to bare-metal stent alone. There was no difference in stent thrombosis rates between groups. The study suggests that colchicine may be useful for reducing restenosis and need for repeat procedures when
Crowe y hartofilakidis classification ddc in adultsMaripaz Lara
This study evaluated the reliability of the Crowe and Hartofilakidis classification systems for developmental dysplasia of the hip in adults. Three experienced hip surgeons independently classified 209 osteoarthritic hips using both classification systems on two separate occasions. Inter-observer reliability was substantial to almost perfect, with kappa coefficients ranging from 0.85 to 0.93. Intra-observer reliability was also substantial to almost perfect, with kappa coefficients ranging from 0.80 to 0.95. Both classification systems demonstrated excellent reliability for assessing developmental dysplasia of the hip.
This document discusses mitral regurgitation (MR), including:
1) MR can be primary (valvular) or secondary (ventricular) and its prevalence increases with age, affecting over 9% of those over age 75;
2) Untreated severe MR is associated with increased morbidity and mortality, yet only a small percentage of eligible patients receive surgical treatment each year;
3) While surgery is recommended for symptomatic primary MR, it provides little benefit for secondary MR; newer minimally invasive options such as the MitraClip procedure are being studied.
The document summarizes clinical trials conducted to evaluate MultiFunction CardioGram (MCG), a computational biology approach to cardiac diagnosis, compared to coronary angiography. Over 1,000 patients across multiple centers underwent both MCG testing and angiography with results analyzed double-blind. Trials found MCG detected coronary stenosis with sensitivities of 60-80% and specificities over 75%, with areas under the ROC curve of 0.87 or higher. MCG severity scores correlated with angiographic stenosis and could stratify patients by disease severity.
Custodiol versus blood cardioplegia in complex cardiac operationsSutan Müdô
This study compared outcomes of patients receiving Custodiol (a crystalloid cardioplegic solution) versus blood cardioplegia for myocardial protection during complex cardiac surgery. The study reviewed 1,900 cardiac surgeries between 2005-2011, with 126 using Custodiol and 1,774 using blood cardioplegia. After propensity score matching, there were no significant differences in 30-day mortality, morbidity outcomes, or any other endpoints between the 71 matched Custodiol and blood cardioplegia patients. The study concluded that Custodiol provides myocardial protection comparable to blood cardioplegia for complex cardiac surgery in a convenient and simple way. A randomized trial is still warranted to further compare myocardial protection strategies.
This document summarizes bone cement implantation syndrome (BCIS), an important cause of intraoperative mortality and morbidity in patients undergoing cemented hip arthroplasty. The document proposes a definition and severity classification for BCIS. It reviews the incidence, clinical features, risk factors, pathophysiology, risk reduction strategies, and management of BCIS. High risk patients, such as those undergoing long-stem hip arthroplasty, are more likely to experience hypotension, hypoxia, or other complications from BCIS during cementation. Invasive monitoring should be considered for high risk patients undergoing cemented hip arthroplasty.
This document discusses evidence for performing carotid endarterectomy (CEA) on asymptomatic patients with severe carotid artery stenosis. Three major trials from 1993-2004 found CEA reduced future stroke risk in asymptomatic patients with 60-99% stenosis by 38-53% compared to medical management alone. However, the benefits were smaller than for symptomatic patients and varied between patient subgroups. Current guidelines state CEA may be considered for asymptomatic high-grade stenosis if the surgeon has a perioperative stroke/death rate below 3%. Individual patient factors must be weighed.
This systematic review examined the influence of pitch count and type on elbow and shoulder injuries in adolescent baseball pitchers. Four studies met the inclusion criteria of evaluating the relationship between pitching workload, pitch type, and injury risk in players aged 13-18 years old. Two studies found that pitching over 75 pitches per game increased the risk of shoulder pain and pitching over 600 pitches per season increased the risk of elbow pain. Another study observed an increased injury risk when pitching over 8 months, more than 80 pitches per appearance, or pitching through fatigue. An additional study associated increased age and slider pitching with greater elbow injury risk. The studies suggest that higher pitch counts and certain pitch types may elevate injury risk in adolescent pitchers.
Cryopreserved saphenous vein allografts were evaluated for infragenual bypass surgery in 92 patients with critical limb ischemia over 15 years. Primary and primary assisted patency rates at 1 year were 49.9% and 55.7%, and limb salvage rates at 1, 3, and 5 years were 85%, 70%, and 64%. While allografts are an alternative to prosthetic materials when autologous veins are unavailable, better patient selection and use of statins may improve results, though availability remains limited.
The document summarizes research on return to sport activity (RTS) following total hip arthroplasty (THA). Key findings include:
- Studies report wide variation in rates of RTS from 54-98% and time to RTS from 16-28 weeks. Higher activity levels were associated with younger age, male gender, lower BMI, pre-op sport participation, and lack of other joint pain.
- Intensity of returned sports is generally lower than pre-op levels, though some studies found equal or better performance in 44-71% of patients who returned to sports.
- Recommendations for allowed sports vary significantly between studies and surgeon groups, though cycling, swimming and golf are commonly considered permissible while
Vascular repair after firearm injury is associated with increased morbidity a...anomwiradana
This study analyzed data from 648,662 patients with firearm injuries between 1993-2014 using the National Inpatient Sample database. The key findings were:
1) 9.9% (63,973) of firearm injuries involved a concurrent vascular repair, with these patients more likely to be younger, male, black, on Medicaid, and have lower income.
2) Patients undergoing vascular repair had higher injury severity scores and were more likely to have abdomen/pelvis or extremity injuries from assault.
3) Patients undergoing vascular repair had higher rates of in-hospital mortality (5.51% vs 1.98%), acute renal failure, venous thromboembolic events, pulmonary complications, cardiac complications, sepsis
DR. MAICOL AUGUSTO CORTEZ SANDOVAL/Fibrilacion auricular subclinica MAICOL AUGUSTO
1) The document discusses subclinical atrial fibrillation (AF) which are episodes of high atrial rate (>6 minutes) detected by implanted cardiac devices in patients without a previous diagnosis of AF.
2) Studies have found the prevalence of subclinical AF detected by devices ranges from 30-60% in patients with devices.
3) Subclinical AF appears to evolve into clinically apparent AF over time and is associated with increased risks of stroke and other thromboembolic events, particularly for longer episodes lasting over 24 hours.
4) Further research is still needed to understand the relationship between subclinical AF detected by devices and cardiovascular outcomes like stroke risk.
Presentation given by Dr Adnan Saithna, Professor of Orthopedic Surgery, at AAOS 2020, on the relationship between early post-operative extension deficit and subsequent risk of cyclops syndrome following ACL reconstruction
Adiposity and incidence of heart failure hospitalization and m ortalityGabriel J Santos
This study examined the association between measures of adiposity (body mass index [BMI] and waist circumference [WC]) and the incidence of heart failure hospitalization and mortality in Swedish men and women. The results showed that higher BMI was associated with greater risk of heart failure, and this association declined with increasing age. Higher WC was also associated with increased risk, and among women the risk was increased at all levels of BMI. Both BMI and WC were independent predictors of heart failure risk in men.
This document discusses athlete's heart and the use of echocardiography in evaluating it. It notes that intense dynamic training can cause eccentric hypertrophy while intense isometric training causes concentric hypertrophy. It references several studies on using new echocardiography techniques to differentiate physiological cardiac remodeling in athletes from pathology. One study found 4D strain imaging useful to identify subtle abnormalities. Other studies examined global longitudinal strain for assessing athlete's heart and the role of cardiac biomarkers to improve diagnosis. The document provides an overview of research on evaluating cardiac changes in athletes using echocardiography.
1) Carotid intima-media thickness (CIMT) measurement is used to assess subclinical atherosclerosis and predict cardiovascular risk. It involves ultrasound imaging of the carotid arteries.
2) Standardized protocols have been developed for measuring CIMT at specific locations in the carotid arteries. Automated methods have good correlation with manual measurements.
3) Higher CIMT is associated with increasing age. Baseline and progression of CIMT over time can predict future cardiovascular events independent of traditional risk factors. However, other emerging risk markers may provide better prediction than CIMT alone.
The Impact Visceral Abdominal Fat and Muscle Mass Using CT on Patients with S...semualkaira
The association between abdominal visceral
fatty area (VFA) and muscle mass and mortality is not fully understood despite the fact that being overweight is an established
risk factor for the onset and severity of acute pancreatitis (AP). We
assessed the effect of VFA on severe AP (SAP) mortality
The aim of this study was to investigate the association of adipose
and muscle parameters with the severity grade of AP
Exercise stress echocardiography in patients with aortic stenosis: impact of baseline diastolic dysfunction and functional capacity on mortality and aortic valve replacement
Authors: Andrew N. Rassi, Wael AlJaroudi, Sahar Naderi, M Chadi Alraies, Venu Menon, Leonardo Rodriguez, Richard Grimm, Brian Griffin, Wael A. Jaber
http://www.thecdt.org/article/view/2855
This study evaluated the feasibility of transthoracic echocardiography (TTE) for assessing cardiac function in 76 patients with septic shock. TTE was able to determine left ventricular systolic function in 90% of patients, right ventricular function in 99%, and left ventricular diastolic function in 73%. Diastolic dysfunction was present in 50% of patients. Factors like obesity, mechanical ventilation, age, and illness severity did not impact the ability of TTE to evaluate cardiac function. TTE is therefore a reliable tool for comprehensive cardiac assessment, including diastolic function, in critically ill septic shock patients.
Revista Brasileira de Ortopedia 2014 PaganiMarcelo Guerra
1) The study compared the body mass index (BMI) of elderly patients aged 65+ who were hospitalized with fractures of the proximal femur from falls, to elderly patients without fractures.
2) It found that patients with fractures were significantly taller and had a significantly lower average BMI (22.6) than those without fractures (average BMI of 25.5).
3) Among fracture patients, 12% had low weight, 62.7% normal weight, 24% overweight, and 1.3% obese, while among non-fracture patients the percentages were 5.6%, 43.8%, 33.7%, and 9.8% respectively.
This study evaluated the efficacy of colchicine in preventing in-stent restenosis in 90 patients undergoing percutaneous coronary intervention with bare-metal stents. Patients were divided into 3 groups: those receiving a bare-metal stent plus colchicine, bare-metal stent alone, or a drug-eluting stent. After 6 months of follow up, the rates of in-stent restenosis and target vessel revascularization were significantly lower in patients receiving colchicine plus bare-metal stent compared to bare-metal stent alone. There was no difference in stent thrombosis rates between groups. The study suggests that colchicine may be useful for reducing restenosis and need for repeat procedures when
Crowe y hartofilakidis classification ddc in adultsMaripaz Lara
This study evaluated the reliability of the Crowe and Hartofilakidis classification systems for developmental dysplasia of the hip in adults. Three experienced hip surgeons independently classified 209 osteoarthritic hips using both classification systems on two separate occasions. Inter-observer reliability was substantial to almost perfect, with kappa coefficients ranging from 0.85 to 0.93. Intra-observer reliability was also substantial to almost perfect, with kappa coefficients ranging from 0.80 to 0.95. Both classification systems demonstrated excellent reliability for assessing developmental dysplasia of the hip.
This document discusses mitral regurgitation (MR), including:
1) MR can be primary (valvular) or secondary (ventricular) and its prevalence increases with age, affecting over 9% of those over age 75;
2) Untreated severe MR is associated with increased morbidity and mortality, yet only a small percentage of eligible patients receive surgical treatment each year;
3) While surgery is recommended for symptomatic primary MR, it provides little benefit for secondary MR; newer minimally invasive options such as the MitraClip procedure are being studied.
The document summarizes clinical trials conducted to evaluate MultiFunction CardioGram (MCG), a computational biology approach to cardiac diagnosis, compared to coronary angiography. Over 1,000 patients across multiple centers underwent both MCG testing and angiography with results analyzed double-blind. Trials found MCG detected coronary stenosis with sensitivities of 60-80% and specificities over 75%, with areas under the ROC curve of 0.87 or higher. MCG severity scores correlated with angiographic stenosis and could stratify patients by disease severity.
Custodiol versus blood cardioplegia in complex cardiac operationsSutan Müdô
This study compared outcomes of patients receiving Custodiol (a crystalloid cardioplegic solution) versus blood cardioplegia for myocardial protection during complex cardiac surgery. The study reviewed 1,900 cardiac surgeries between 2005-2011, with 126 using Custodiol and 1,774 using blood cardioplegia. After propensity score matching, there were no significant differences in 30-day mortality, morbidity outcomes, or any other endpoints between the 71 matched Custodiol and blood cardioplegia patients. The study concluded that Custodiol provides myocardial protection comparable to blood cardioplegia for complex cardiac surgery in a convenient and simple way. A randomized trial is still warranted to further compare myocardial protection strategies.
This document summarizes bone cement implantation syndrome (BCIS), an important cause of intraoperative mortality and morbidity in patients undergoing cemented hip arthroplasty. The document proposes a definition and severity classification for BCIS. It reviews the incidence, clinical features, risk factors, pathophysiology, risk reduction strategies, and management of BCIS. High risk patients, such as those undergoing long-stem hip arthroplasty, are more likely to experience hypotension, hypoxia, or other complications from BCIS during cementation. Invasive monitoring should be considered for high risk patients undergoing cemented hip arthroplasty.
This document discusses evidence for performing carotid endarterectomy (CEA) on asymptomatic patients with severe carotid artery stenosis. Three major trials from 1993-2004 found CEA reduced future stroke risk in asymptomatic patients with 60-99% stenosis by 38-53% compared to medical management alone. However, the benefits were smaller than for symptomatic patients and varied between patient subgroups. Current guidelines state CEA may be considered for asymptomatic high-grade stenosis if the surgeon has a perioperative stroke/death rate below 3%. Individual patient factors must be weighed.
This systematic review examined the influence of pitch count and type on elbow and shoulder injuries in adolescent baseball pitchers. Four studies met the inclusion criteria of evaluating the relationship between pitching workload, pitch type, and injury risk in players aged 13-18 years old. Two studies found that pitching over 75 pitches per game increased the risk of shoulder pain and pitching over 600 pitches per season increased the risk of elbow pain. Another study observed an increased injury risk when pitching over 8 months, more than 80 pitches per appearance, or pitching through fatigue. An additional study associated increased age and slider pitching with greater elbow injury risk. The studies suggest that higher pitch counts and certain pitch types may elevate injury risk in adolescent pitchers.
Cryopreserved saphenous vein allografts were evaluated for infragenual bypass surgery in 92 patients with critical limb ischemia over 15 years. Primary and primary assisted patency rates at 1 year were 49.9% and 55.7%, and limb salvage rates at 1, 3, and 5 years were 85%, 70%, and 64%. While allografts are an alternative to prosthetic materials when autologous veins are unavailable, better patient selection and use of statins may improve results, though availability remains limited.
The document summarizes research on return to sport activity (RTS) following total hip arthroplasty (THA). Key findings include:
- Studies report wide variation in rates of RTS from 54-98% and time to RTS from 16-28 weeks. Higher activity levels were associated with younger age, male gender, lower BMI, pre-op sport participation, and lack of other joint pain.
- Intensity of returned sports is generally lower than pre-op levels, though some studies found equal or better performance in 44-71% of patients who returned to sports.
- Recommendations for allowed sports vary significantly between studies and surgeon groups, though cycling, swimming and golf are commonly considered permissible while
Vascular repair after firearm injury is associated with increased morbidity a...anomwiradana
This study analyzed data from 648,662 patients with firearm injuries between 1993-2014 using the National Inpatient Sample database. The key findings were:
1) 9.9% (63,973) of firearm injuries involved a concurrent vascular repair, with these patients more likely to be younger, male, black, on Medicaid, and have lower income.
2) Patients undergoing vascular repair had higher injury severity scores and were more likely to have abdomen/pelvis or extremity injuries from assault.
3) Patients undergoing vascular repair had higher rates of in-hospital mortality (5.51% vs 1.98%), acute renal failure, venous thromboembolic events, pulmonary complications, cardiac complications, sepsis
DR. MAICOL AUGUSTO CORTEZ SANDOVAL/Fibrilacion auricular subclinica MAICOL AUGUSTO
1) The document discusses subclinical atrial fibrillation (AF) which are episodes of high atrial rate (>6 minutes) detected by implanted cardiac devices in patients without a previous diagnosis of AF.
2) Studies have found the prevalence of subclinical AF detected by devices ranges from 30-60% in patients with devices.
3) Subclinical AF appears to evolve into clinically apparent AF over time and is associated with increased risks of stroke and other thromboembolic events, particularly for longer episodes lasting over 24 hours.
4) Further research is still needed to understand the relationship between subclinical AF detected by devices and cardiovascular outcomes like stroke risk.
Presentation given by Dr Adnan Saithna, Professor of Orthopedic Surgery, at AAOS 2020, on the relationship between early post-operative extension deficit and subsequent risk of cyclops syndrome following ACL reconstruction
Adiposity and incidence of heart failure hospitalization and m ortalityGabriel J Santos
This study examined the association between measures of adiposity (body mass index [BMI] and waist circumference [WC]) and the incidence of heart failure hospitalization and mortality in Swedish men and women. The results showed that higher BMI was associated with greater risk of heart failure, and this association declined with increasing age. Higher WC was also associated with increased risk, and among women the risk was increased at all levels of BMI. Both BMI and WC were independent predictors of heart failure risk in men.
This document discusses athlete's heart and the use of echocardiography in evaluating it. It notes that intense dynamic training can cause eccentric hypertrophy while intense isometric training causes concentric hypertrophy. It references several studies on using new echocardiography techniques to differentiate physiological cardiac remodeling in athletes from pathology. One study found 4D strain imaging useful to identify subtle abnormalities. Other studies examined global longitudinal strain for assessing athlete's heart and the role of cardiac biomarkers to improve diagnosis. The document provides an overview of research on evaluating cardiac changes in athletes using echocardiography.
1) Carotid intima-media thickness (CIMT) measurement is used to assess subclinical atherosclerosis and predict cardiovascular risk. It involves ultrasound imaging of the carotid arteries.
2) Standardized protocols have been developed for measuring CIMT at specific locations in the carotid arteries. Automated methods have good correlation with manual measurements.
3) Higher CIMT is associated with increasing age. Baseline and progression of CIMT over time can predict future cardiovascular events independent of traditional risk factors. However, other emerging risk markers may provide better prediction than CIMT alone.
The Impact Visceral Abdominal Fat and Muscle Mass Using CT on Patients with S...semualkaira
The association between abdominal visceral
fatty area (VFA) and muscle mass and mortality is not fully understood despite the fact that being overweight is an established
risk factor for the onset and severity of acute pancreatitis (AP). We
assessed the effect of VFA on severe AP (SAP) mortality
The aim of this study was to investigate the association of adipose
and muscle parameters with the severity grade of AP
Exercise stress echocardiography in patients with aortic stenosis: impact of baseline diastolic dysfunction and functional capacity on mortality and aortic valve replacement
Authors: Andrew N. Rassi, Wael AlJaroudi, Sahar Naderi, M Chadi Alraies, Venu Menon, Leonardo Rodriguez, Richard Grimm, Brian Griffin, Wael A. Jaber
http://www.thecdt.org/article/view/2855
A Speckle Tracking Echocardiographic Study for Correlation Between Global Lef...Premier Publishers
Global longitudinal strain (GLS) measured by Two-dimensional speckle tracking imaging (2D-STI) has been shown to be useful for assessing subtle changes in the left ventricular function with increasing severity of aortic stenosis (AS) in patients with preserved left ventricular ejection fraction (LVEF). To evaluate the relation between the severity of valve stenosis and GLS measured by 2D-STI in AS patients with normal LVEF. We studied 65 subjects (age, 53_75 years) with normal LVEF (≥50%) but without overt coronary artery disease. Patients were stratified into four groups (control, mild, moderate and severe AS), the clinical characteristics and echocardiographic findings were compared among the groups. Using dedicated software, we measured GLS in the apical four, two and three -chamber views. LVEF was not significantly different among the four groups. However, GLS showed significant differences among the four groups (controls;18.9±1.4, mild: 18.8±1.3, moderate: 15.35±1.6and severe: 12.42±1.4, ANOVA P = 0.001), GLS was significantly correlated with AVA, mean PG and LV mass index. Despite unchanged LVEF, GLS gradually decreased as severity of AS increases. GLS measured by 2D-STI is useful to assess subtle changes in LV function in AS patients.
This meta-analysis examined short-term and long-term mortality rates following elective open abdominal aortic aneurysm (AAA) repair versus endovascular aneurysm repair (EVAR) based on data from four randomized controlled trials with a total of 2783 patients. The analysis found that 30-day all-cause mortality was significantly higher for open repair compared to EVAR (3.2% vs 1.2%). However, there was no significant difference in long-term all-cause mortality between the two groups. Reintervention rates were higher following EVAR compared to open repair (18.9% vs 9.3%), but this finding was considered doubtful due to large heterogeneity. No significant differences were found between the
Early Detection of Left Ventricular Dysfunction in Type II Diabetic Patients ...Premier Publishers
To assess Left ventricular (LV) systolic dysfunction using 2D speckle tracking echocardiography (STE) in asymptomatic type II Diabetic patients. We acquired three LV short-axis, and three LV apical views in 100 asymptomatic diabetic patients with normal LV ejection fraction (EF) and 25 age-matched healthy volunteers. We measured end-systolic longitudinal strain (LS), radial strain (RS), and circumferential strain (CS) in 18 LV segments. There were no significant differences in LVEF between two groups. Diabetic patients had more advanced diastolic dysfunction and increased LV mass compared with controlled group. Basal, middle, and apical LSs were significantly lower in diabetic patients compared with control subjects, with 43% (43/100) of the diabetic patients showing abnormal global LS values (cut-off value: 217.2 mean 2SD in control subjects Conclusion: Detecting subclinical LV systolic dysfunction by using 2D speckle tracking echocardiography (STE) might provide useful information of the risk stratification in an asymptomatic diabetic population.
This study analyzed the prevalence of bovine aortic arch configurations in patients with and without thoracic aortic pathology. The researchers reviewed over 800 computed tomography scans and found that 31% of patients had some form of bovine arch. Specifically, 15% had a Type I bovine arch and 16% had a Type II. When comparing 156 patients with thoracic aortic dissection or aneurysm to controls, the study found those with pathology were more likely to have a Type II bovine arch. They concluded that patients with bovine arch configurations may be associated with higher levels of thoracic aortic disease.
This document contains abstracts from presentations at the 29th Annual Northeast Regional Scientific Meeting. The abstracts describe several studies involving nuclear imaging techniques:
1. A study evaluating the reproducibility of quantitative measurements from FDG PET and gallium scans in distinguishing between interstitial nephritis and acute tubular necrosis in rats. It found the measurements to be highly reproducible.
2. A case report describing how SPECT/CT imaging with indium-111 labeled white blood cells revealed unsuspected pulmonary septic emboli in a patient with infected hemodialysis access.
3. A case report where bone SPECT/CT identified an acute pelvic fracture that was missed on other imaging in a patient
Atrial fibrillation after successful cardioversionalatawi2
1) Researchers measured C-reactive protein (CRP) levels in 67 patients before successful electrical cardioversion for atrial fibrillation or flutter.
2) At the one-month follow-up, 22 patients (33%) experienced a recurrence of their arrhythmia.
3) Higher pre-cardioversion CRP levels were associated with a significantly increased risk of arrhythmia recurrence at one month, even after adjusting for potential confounding factors. CRP was the only independent predictor of recurrence on multivariate analysis.
- Several studies have found that older liver transplant recipients (over age 60) have similar short-term outcomes to younger recipients in terms of postoperative morbidity, mortality, and length of hospital stay. However, long-term survival is significantly lower in older recipients, largely due to non-hepatic age-related causes of death.
- While patient survival is lower in older recipients, graft survival is not significantly different between older and younger groups. The increased mortality in older patients is attributed to infections, cardiac events, and neurological causes rather than hepatic causes.
- Careful consideration of medical fitness and life expectancy due to comorbidities is important when evaluating older recipients for liver transplantation. While age alone should not preclude transplantation, risks
This study investigated factors that influence the need for preoperative vascular imaging before harvesting a vascularized fibular flap. The researchers analyzed 185 angiograms and found significant correlations between lower extremity artery pathology and risk factors like high cholesterol, high blood pressure, coronary heart disease, diabetes, and increased age. Specifically, increased age was the strongest predictor of vessel pathology. The study concludes that preoperative vascular imaging should be performed in patients with medical comorbidities to reduce the risks of flap failure and donor site complications when harvesting a fibular flap.
Murley Meghan Thesis Female Heart Rate Variability - A Pilot Reliability StudyMeghan Murley
This pilot study evaluated the reliability of assessing heart rate variability (HRV) in females. Intra-class correlation values for time domain HRV measures ranged from 0.68-0.98, showing good reliability. Frequency domain measures were less reliable, ranging from 0.68-0.86. Editing ECG data had little impact on HRV measures. Heart rate was significantly lower and stroke volume significantly higher in the supine position compared to sitting. The study demonstrated adequate reliability for measuring HRV to inform a larger study.
1. Continuous CSF sampling studies are generally well tolerated, with the most common adverse events being post-dural puncture headache and back pain.
2. Some patient groups, such as females, the elderly, and those with mood disorders, report a higher frequency of adverse events.
3. Factors such as larger CSF needle size, higher CSF volumes removed, and multiple sampling periods increased adverse event rates, while smaller needle sizes reduced adverse events.
4. CSF sampling windows of 26-36 hours were equally tolerated, and a 14-day interval between repeated sampling allowed for good tolerability.
1) The study compared systemic right ventricular function in unoperated and physiologically repaired congenitally corrected transposition of the great arteries (CCTGA) patients to healthy controls, using MRI dobutamine stress testing.
2) At baseline, systemic right ventricular volumes were larger but ejection fraction was lower in CCTGA patients compared to controls. However, all groups responded appropriately to dobutamine stress with increases in stroke volume and cardiac index.
3) While CCTGA patients had diminished ejection fraction at baseline compared to controls, their systemic right ventricle responded similarly to dobutamine stress, suggesting preserved cardiac reserve. MRI dobutamine stress may help identify CCTGA patients who can be observed without operation.
This study compared the long-term (18-month) outcomes of supervised exercise (SE), stent revascularization (ST), and optimal medical therapy (OMT) for patients with claudication due to aortoiliac peripheral artery disease. 79 patients completed the 18-month follow-up assessment. The study found that both SE and ST resulted in significantly greater improvements in peak walking time and claudication onset time compared to OMT. SE and ST also provided durable improvements in quality of life measures up to 18 months. Both SE and ST had better long-term outcomes than OMT alone for treating claudication, demonstrating the durability of exercise interventions for peripheral artery disease.
This study reviewed the management of 1432 grown-up congenital heart disease patients over 10 years at a tertiary hospital in India. It found a early morbidity rate of 5.2% and identified previous sternotomy, emergency procedures, cross-clamp time over 45 minutes, and cyanotic disease as significant risk factors. Outcomes were generally good with a mortality rate of 1.4% and 86% follow-up completeness. However, the study was limited by its single center retrospective design and loss to follow-up of simpler cases.
This study compared long-term outcomes of children randomized to balloon angioplasty (BA) or surgery for treatment of native coarctation of the aorta (CoA) during childhood. Of the original 36 subjects, 21 returned for evaluation 10-12 years later. Resting blood pressure, exercise performance, and magnetic resonance imaging results were similar between groups. However, BA was associated with a higher rate of aneurysm formation (35% vs 0%) and greater differences in blood pressure between legs during exercise compared to surgery. Only 50% of BA subjects remained free of aneurysms or need for repeat procedures, compared to 87.5% of surgery subjects. The risk of complications was higher with BA than surgery as a long
1) A study examined 103 heart attack patients treated with high-dose statins and found plaque volume decreased slightly (0.9%) in the arteries not responsible for the heart attack.
2) A randomized study of 296 heart attack patients found that performing revascularization of additional blocked arteries beyond the heart attack artery led to fewer total cardiac events (10% vs 21%) over 12 months compared to only treating the heart attack artery.
3) A study of 738 patients with chronic total blockages and good collateral blood flow found that revascularizing the blockages reduced cardiac death and total cardiac events compared to medical treatment alone, showing benefit of revascularization even in patients with established collateral circulation.
At the bifurcation, the shear forces peak at the carina, creating areas of high endothelial shear stress.
The development of atherosclerosis in the LMCA has been linked to flow haemodynamics, with atherosclerotic plaques described at areas of low endothelial shear stress in the lateral wall of the bifurcation, opposite to the carina.
Conversely, the carina is often free from disease, probably owing to the protective effect of high shear stress against plaque formation.
The length of the LMCA also influences stenosis location and morphology. In short LMCA (<10 mm), lesions develop more frequently near the ostium than in the bifurcation (55% versus 38%), whereas in long arteries, lesions develop predominantly near the bifurcation (ostium 18% versus bifurcation 77%).
Furthermore, ostial lesions more frequently have negative remodelling, larger luminal areas, and less calcium than distal lesions.
Role of Left Ventricular Mass Index Versus Left Ventricular Relative Wall Thi...Premier Publishers
This study examined left ventricular geometry in 100 patients with non-cardioembolic ischemic stroke using echocardiography. The study found that concentric remodeling was the most common left ventricular pattern at 43%, followed by normal geometry at 27%, concentric hypertrophy at 22%, and eccentric hypertrophy at 8%. Abnormal left ventricular relative wall thickness was more common than abnormal left ventricular mass index, occurring in 61.4% versus 38.6% of patients. The results suggest that assessing relative wall thickness in addition to mass index can help identify more patients with left ventricular remodeling who may be at increased risk of stroke.
Similar to Vasc Med-2016-Hale-1358863X15624025 (20)
2. 2 Vascular Medicine
(KT). The summation of these muscle groups represented
the total skeletal muscle area (cm2) used for establishing the
presence or absence of sarcopenia. Sarcopenia was defined
as having a skeletal muscle area <114.0 cm2 (men) or <89.8
cm2 (women); this definition was originally derived from
data in donor liver transplantation patients and later used to
assess sarcopenia in CLI patients.2,3 Sarcopenia is not yet a
well-defined entity; as such, we performed a quartile analy-
sis on the distribution of muscle mass in EVAR patients to
evaluate the definition of sarcopenia used in the literature.
Data collection and statistical analysis
Data collection included patient demographics and comor-
bidities, including: age, sex, race, diabetes (DM), smok-
ing status, coronary artery disease (CAD), hypertension
(HTN), obesity, chronic obstructive pulmonary disease
(COPD), and AAA diameter (cm). The presence of CAD
was defined as having an abnormal electrocardiogram,
prior myocardial infarction, prior coronary bypass, or
prior percutaneous coronary intervention. Hypertension
was defined as having a resting blood pressure greater
than 140/90 mmHg or requiring antihypertensive medica-
tions. Obesity was defined as having a body mass index
(BMI) greater than 30.0. COPD was defined as having a
history of pulmonary obstructive disease or required use
of home oxygen secondary to lung disease. Data were
analyzed according to the last available follow-up visit.
Social security death index data were helpful in determin-
ing the date of death, which was the primary endpoint.
Follow up was defined as the date of the procedure to the
last date of observation.
Baseline descriptive statistics were used to determine the
study population, followed by bivariate analysis to determine
the differences in patient demographics. The differences in
continuous variables were analyzed using parametric t-tests
and the differences in discrete variables were analyzed with
chi-squared or, in the case of small sample sizes (n<5),
Fisher’s exact tests. Differences in Kaplan–Meier survival
curves were analyzed using a log-rank test. Statistically sig-
nificant covariates in the bivariate analyses were incorpo-
rated into a multivariate logistic regression. Resulting odds
ratios and 95% confidence intervals were calculated for each
covariate in the multivariate analysis. Data analysis was
performed using R statistical software (version 3.1.3; R
Foundation for Statistical Computing, Vienna, Austria).
Results
Patient characteristics and analysis
The original abdominal CT scans on 200 patients withAAA
who subsequently underwent EVAR by the vascular sur-
gery service at Greenville Health System were analyzed.
Overall demographic information is presented in Table 1.
There were 175 men and 25 women in the study. Mean age
at the time of treatment was 74 ± 7.5 years. The overall
mortality rate was 51%, with a median follow up of 8.4
years (interquartile range, 5.3–11.7) and median time to
death of 5.4 years (interquartile range, 3.0–8.4). Five major
postoperative complications were noted: two ruptures, one
graft migration, one graft infection, and one acute aneu-
rysm expansion.
The mean skeletal muscle area for all patients was 138.2
± 27.9 cm2. The majority of the EVAR sarcopenia patients
were in the lowest quartile of total muscle mass. The break-
down of the quartile analysis on skeletal muscle mass is
described in Table 2.
From the 200 AAA patients, 25 had sarcopenia and 175
did not. Demographic differences between patients with
sarcopenia and without are also described in Table 1.
Patients with sarcopenia tended to be older (77.9 vs 73.0
years; p=0.002), female (32% vs 9.7%; p=0.005), and have
a slightly larger aneurysm at the time of repair (5.87 cm vs
5.53 cm; p=0.080). Furthermore, patients with sarcopenia
had a significantly higher mortality rate during follow-up
than those without (76% vs 48%; p=0.016) (Figure 1).
Figure 1 shows the Kaplan–Meier life table analysis sur-
vival probabilities. The survival curves start to separate
between years 3 and 4, with a statistical difference that
strengthens over time (log-rank test, p=0.016).
When comparing living with deceased patients, three
important statistical demographic differences were seen
in those who died: increased age at time of EVAR (75.9
vs 71.2 years; p<0.001), presence of hypertension (92.2%
vs 81.4%; p=0.040), and presence of sarcopenia (18.5% vs
6.19%; p=0.016) (Table 1). Logistic regression analysis
was used to compare these three significant variables; sex
was also included in the analysis, as it was strongly associ-
ated with sarcopenia (Table 3). The odds ratios and 95%
confidence intervals shown in Table 3 demonstrate the sig-
nificance of sarcopenia (OR 3.17, 95% CI 1.20–9.54),
hypertension (OR 2.73, 95% CI 1.17–7.11), and advanced
age (76–85 years) (OR 0.97, 95% CI 1.04–3.58) on mortal-
ity following EVAR. Sex did not play a significant role in
mortality, nor did it act as a confounding factor with the
other three variables.
Discussion
These data confirm sarcopenia as an independent predictor
of long-term mortality in patients treated for AAA with
EVAR. Although risk prediction models for elective aneu-
rysm repair have been created, they primarily center on
30-day mortality, as opposed to long-term mortality (i.e.
Glasgow aneurysm score, Leiden Score, Hardman Index).4–6
However, in 2013, the Vascular Surgical Group of New
England (VSGNE) did identify four major and four minor
risk factors for assessing long-term survival (5 years) fol-
lowing AAA repair.7 Their major risk criteria included:
unstable angina or recent myocardial infarction, age >80
years, oxygen-dependent COPD, and estimated glomerular
filtration rate <30 ml/min/1.73 m2. The minor risk criteria
included: age 75–79 years, prior myocardial infarction, sta-
ble angina, and not taking aspirin or statins. Based on these
criteria, patients were evaluated and stratified as ‘low risk’
(no major risk factors, 1–2 minor risk factors), ‘medium
risk’ (1 major, 1–3 minor), or ‘high risk’ (1–2 major, >3
minor). The VSGNE ‘high risk’ group showed a mortality
rate of 43% at 5 years; this compares favorably to our group
of EVAR patients with sarcopenia who had a 5-year
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3. Hale et al. 3
mortality rate of 40%. These data suggest that preoperative
risk assessment of long-term survival could potentially be
simplified to measuring sarcopenia. Complex risk predic-
tion models tend to lose calibration over time, so the sim-
pler the model, the less recalibration is needed.8
In our study, patients with sarcopenia had a signifi-
cantly higher long-term mortality rate during follow up
than those without (76% vs 48%; p=0.016). However,
noticeable separation between the two survival curves in
Figure 1 is not seen until year 4, with the gap continuing to
increase over time. As future studies on other patient popu-
lations are conducted, longer follow-up (5+ years) may be
necessary to accurately assess the long-term impact sarco-
penia has on patient outcomes, specifically mortality. The
measurement technique and cutoff values we used to
determine and define sarcopenia were previously utilized
in a study that evaluated mortality in patients with CLI.2
The cutoff values for skeletal muscle mass (<114.0 cm2 for
men and <89.8 cm2 for women) represent patients below
the fifth percentile of the standard value in healthy adults.3
We believe this is representative of our AAA population,
Table 1. Patient characteristics.
All Sarcopenia Mortality
Yes No p-value Deceased Living p-value
n 200 25 175 103 97
Age, years, mean (SD) 74 (7.5) 77.9 (7.5) 73.0 (7.4) 0.002 75.9 (7.2) 71.2 (7.1) <0.001
Race, n (%) 0.873 0.878
White 188 (94) 24 (96.0) 164 (93.7) 97 (94.2) 91 (93.8)
African American 11 (5.5) 1 (4.0) 10 (5.7) 6 (5.83) 5 (5.15)
Other 1 (0.5) 0 (0) 1 (0.57) 0 (0) 1 (1.03)
Sex, n (%) 0.005 0.789
Male 175 (87.5) 17 (68.0) 158 (90.3) 89 (86.4) 86 (88.7)
Female 25 (12.5) 8 (32.0) 17 (9.7) 14 (13.6) 11 (11.3)
Smoking status, n (%) 0.815 0.162
Former 109 (54.5) 15 (60.0) 94 (53.7) 62 (60.2) 47 (48.5)
Never 33 (16.5) 4 (16.0) 29 (16.6) 17 (16.5) 16 (16.5)
Current 58 (29) 6 (24.0) 52 (29.7) 24 (23.3) 34 (35.0)
ESRD, n (%) 0.267 0.107
Renal insufficiency 30 (15) 4 (16.0) 26 (14.9) 19 (18.5) 11 (11.3)
No 168 (84) 1(4.0) 1 (0.57) 82 (79.6) 86 (88.7)
Yes 2 (1) 20 (80.0) 148 (54.6) 2 (1.9) 0 (0)
DM, n (%) 42 (21.0) 5 (20.0) 37 (21.1) 1.000 25 (24.3) 17 (17.5) 0.319
CAD, n (%) 123 (61.5) 17 (68.0) 106 (60.6) 0.621 68 (66.0) 55 (56.7) 0.163
HTN, n (%) 174 (87) 22 (88.0) 152 (86.9) 1.000 95 (92.2) 79 (81.4) 0.040
Hyperlipid, n (%) 120 (60) 12 (48.0) 108 (61.7) 0.275 59 (57.3) 61 (62.9) 0.507
Obese, n (%) 33 (16.5) 2 (8.0) 31 (17.7) 0.349 16 (15.5) 17 (17.5) 0.850
COPD, n (%) 52 (26) 11 (44.0) 41 (23.4) 0.051 32 (31.1) 20 (20.6) 0.128
Dementia, n (%) 8 (4) 1 (4.0) 7 (4.0) 1.000 4 (3.88) 4 (4.12) 1.000
Sarcopenia, n (%) 25 (12.5) 19 (18.5) 6 (6.19) 0.016
Men 17 (9.7) 17 (68.0) 0 (0) 13 (12.6) 4 (4.12) 0.049
Women 8 (32.0) 8 (32.0) 0 (0) 6 (5.83) 2 (2.06) 0.378
Total skeletal area,
cm2 mean (SD)
138.2 (27.9) 96.2 (14.0) 144.2 (24.0) <0.001 133.6 (27.1) 143.0 (28.2) 0.017
AAA diameter, cm,
mean (SD)
5.76 (0.91) 5.87 (1.13) 5.53 (0.87) 0.080 5.65 (1.04) 5.50 (0.73) 0.233
Mortality 103 (51.5) 19 (76.0) 84 (48.0) 0.016 103 (100.0)
Time till death, years
(median)
5.43 4.94 5.66 0.532 5.91
ESRD, end-stage renal disease; DM, diabetes mellitus; CAD, coronary artery disease; HTN, hypertension; COPD, chronic obstructive pulmonary
disease;AAA, abdominal aortic aneurysm.
Table 2. Total skeletal muscle area.
Size cm2 Died, n (%)
Total area
Mean ± SD 138.2 ± 27.9
Quartiles, men
Q1, n=44 < 124.3 28 (63.6)
Q2, n=44 124.4–140.1 24 (54.5)
Q3, n=43 140.2–159.6 19 (43.2)
Q4, n=44 >159.7 18 (40.9)
Quartiles, women
Q1, n=7 < 86.7 5 (71.4)
Q2, n=6 86.8–101.8 3 (50.0)
Q3, n=6 101.9–118.7 3 (50.0)
Q4, n=6 >118.8 3 (50.0)
Quartiles, combined
Q1, n=51 mixeda 33 (64.7)
Q2, n=50 mixed 27 (54.0)
Q3, n=49 mixed 22 (44.9)
Q4, n=50 mixed 21 (42.0)
aMixed by sex differences.
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4. 4 Vascular Medicine
as our 5-year survival rate in those without sarcopenia was
78.3%, compared to 77.5% in their CLI patients without
sarcopenia (Figure 1). The sarcopenic CLI population had
a lower 5-year survival rate (23.5%) than our AAA sarco-
penic population (40%). Sarcopenia is a consistent marker
of reduced survival, particularly in patients with CLI.
A similar measurement technique was used by Lee et al.
in a study that evaluated 262 patients who underwent open
AAA repair.9 They measured psoas muscle area on CT at
the L4 vertebra, as opposed to L3 in our study. At the 2.3-
year mean follow-up, 55 (21%) of their patients had died.
As psoas muscle area decreased, mortality increased; this
relationship was logarithmic and non-linear. Lee et al. used
the word ‘frailty’ to describe this patient-centered charac-
teristic and suggested that the measurement of psoas
muscle volume was an excellent predictor of mortality. Our
study builds upon these data by measuring more muscle
groups to define a threshold of low muscle mass. By defin-
ing sarcopenia to be a natural aspect of aging that involves
the reduction of skeletal muscle tissue, mass, and function,
we feel this is a more specific term than frailty.
A BMI greater than 30 has been shown to increase AAA
mortality risk. Using the National Surgical Quality
Improvement Program database (NSQIP), Giles et al.
showed a twofold increase in mortality in the morbidly
obese compared to the non-obese.10 We analyzed total mus-
cle area in quartiles and saw no relationship to mortality as
long as patients were ‘above the threshold’ for sarcopenia
(Table 2). With that said, the morbidly obese patient may
also be sarcopenic, as BMI is not equivalent to muscle mass
and should be measured and analyzed separately.11
In our study, women with AAA were more likely than
men to have sarcopenia (32.0% versus 9.7%; p=0.005). The
literature suggests that sex does not play a significant role
in long-term survival following aneurysm repair; however,
sarcopenia was not assessed in these studies.12,13 Although,
in our study, the number of women was low (n=25), sarco-
penia may be helpful in assessing risk based on sex. Further
investigation using a larger population of women would
strengthen, or refute, the association.
Lim et al. provided a contemporary study to the EVAR 2
Trial by evaluating high-risk EVAR patients.14,15 Using a
Figure 1. Survival curves of patients with and without sarcopenia who underwent EVAR.
Table 3. Logistic regression results comparing all significant
demographic variables in patients (living vs deceased)
undergoing EVAR.
Odds ratio 95% Confidence interval
(Intercept) 0.31 (0.12, 0.72)
Age 76–85 0.97 (1.04, 3.58)
Hypertension 2.73 (1.17, 7.11)
Sarcopenia 3.17 (1.20, 9.54)
Sex 0.97 (0.38, 2.44)
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5. Hale et al. 5
backward stepwise logistic regression analysis, they identi-
fied five prognostic indicators for post-EVAR death; these
included: age, chronic kidney disease stages 4 and 5, con-
gestive heart failure, home oxygen use, and current cancer
therapy. Mortality at 4 years in their trial was 35%, in the
EVAR 2 it was 36%, and in our sarcopenic patients it was
28% (Figure 1).
Elderly patients (>80 years) are more frequently being
treated with EVAR than open repair since the perioperative
risk is lower.16,17 Our data showed that patients >76 years of
age were at an approximately twofold risk for mortality
(Table 3). However, when we modeled multiple variations
of age, no arrangement of age with sarcopenia was found to
significantly impact mortality. This conclusion appears to
confound logic, as both age and sarcopenia were deter-
mined to be independent risk factors (Table 3). However,
this unexpected outcome is likely due to the combination of
our small study population (only 12.5% of patients had sar-
copenia) and the low age difference (4.9 years) between
those with sarcopenia and without. A larger study would
likely resolve this Type II error and provide an effect strong
enough to reach statistical significance.
In this study, the median follow up until death or the end
of the study was 8.4 years, with an interquartile range of
5.3–11.7 years. Our short-term mortality rate (3.5% at >6
months), as well as our 5-year mortality rate (20.5%), were
comparable to the EVAR population reported in the EVAR
1 Trial (4.1% at 6 months, 20.8% at 4 years).18 To our
knowledge, this paper represents the longest follow up, in
terms of mortality, on AAA patients undergoing EVAR in
the literature (Table 4).
Limitations
This study has all the inherent limitations of a retrospective
study performed from a prospective database. The entire
AAA population was not studied as most open AAA
patients fall out of follow-up and do not frequently require
CT scans at follow-up. However, considering we were
focusing on the long-term mortality and not perioperative
events, those who returned for their annual office visits
comprised the study population.
Lost to follow up can be a significant limitation in any
retrospective study. We had previously reported on sur-
vival in EVAR patients who participated in a clinical trial
(mandated follow up) as compared to those treated outside
of a trial (real-world follow-up). The long-term mortality
(5 years) was remarkably consistent between these two
patient populations, with a mortality rate of 36–39%.19
This compares quite favorably to our overall study popula-
tion where we noted a 40% mortality rate at 5 years. This
suggests that a sensitivity analysis on those lost to follow-
up is unnecessary.
Women and minorities are underrepresented in this
study population, which makes the data less generalizable.
We did not measure the use of aspirin or statins in our
patients, which may alter long-term outcomes. Lastly,
acquiring archived CT scan images performed prior to 2004
was challenging; this represented a major limitation to
evaluating all EVAR patients in this study.
Conclusion
The presence of sarcopenia on a CT scan is an important,
patient-specific, risk factor for long-term mortality in AAA
patients treated with EVAR. Pending further study, these data
suggest that sarcopenia may aid in the pre-procedural long-
term survival assessment of patients undergoing EVAR.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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Table 4. Patient deaths according to time since EVAR.
All patients Sarcopenia No sarcopenia
(n=200) (n=25) (n=175)
Mortality
All, n (%) 103 (51.5) 19 (76.0) 84 (48.0)
Time since procedure
0–6 months 7 (3.5) 0 (0) 7 (4.0)
6 months
– 5 years
41 (20.5) 10 (40.0) 31 (17.7)
5–10 years 39 (19.5) 5 (20.0) 34 (19.4)
10 years 16 (8.0) 4 (16.0) 12 (6.9)
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6. 6 Vascular Medicine
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