2 Minute Medicine Rewind July 11, 2022

Racial and Ethnic Disparities in the Trends and Outcomes of Cardiogenic Shock Complicating Peripartum Cardiomyopathy

1. Among patients with peripartum cardiomyopathy complicated by cardiogenic shock, there was a higher risk of in-hospital mortality in Black and Hispanic patients compared to White patients, which affirmed racial and ethnic disparities in these populations.

Evidence Rating Level: 2 (Good)

Peripartum cardiomyopathy (PPCM) is heart failure which can begin during the final month of pregnancy through five months postpartum. Mortality from PPCM can often arise secondary to complications such as cardiogenic shock. While studies have shown that the incidence of PPCM is higher amongst Black patients compared to White patients, racial and ethnic disparities in PPCM complicated by cardiogenic shock are unknown. In this multicenter retrospective cohort study, 1945 hospitalized patients with PPCM complicated by cardiogenic shock were assessed for in-hospital mortality, as well as mechanical circulatory support and heart transplantation. Among these selected patients, 48.6% were Black (n=947), 12.1% were Hispanic (n=236), and 39.2% were White (n=762). Compared to White patients, Black and Hispanic patients had a significantly higher risk of in-hospital mortality (aOR 1.67, 95%CI 1.21-2.32, and aOR 2.20, 95%CI 1.45-3.33, respectively). The results additionally show that Hispanic patients had the highest rate of requiring mechanical circulatory support (35.6%), followed by Black patients (21.0%). Other clinical factors associated with increased risk of in-hospital mortality among PPCM patients included chronic kidney disease, diabetes, obesity, and antepartum hemorrhage. In conclusion, the findings of this study are consistent with previous discussions surrounding race and ethnicity in cardiovascular outcomes among pregnant and postpartum patients – a higher risk of mortality exists in Black and Hispanic patients compared to White patients. While this study is limited due to its retrospective nature and reliance on administrative data, it derives information from a large sample of nationally represented data, owing to a high degree of generalizability to the broader US population. Further research investigating factors involved in racial and ethnic disparities among patients with PPCM will be critical in improving health outcomes in this population.

Comparison of Pregnancy Preferences Preceding vs Year 1 of the COVID-19 Pandemic

1. The onset of the COVID-19 pandemic initially stalled and reversed the prior trend of a greater desire for pregnancy, during early 2020 COVID-19 surges.

Evidence Rating Level: 2 (Good)

The COVID-19 pandemic has presented several disruptions to sexual and reproductive health of the vast public. The resultant economic instability and strain on healthcare systems may have compromised access to contraceptive care, fertility treatments, abortion, subsequently altering perceptions surrounding pregnancy. Several survey-based research studies report that modified pregnancy preferences were prevalent early in the pandemic; however, robust evidence regarding the effects of the pandemic on pregnancy remains sparse. In this longitudinal cohort study, 861 participants completed the Desire to Avoid Pregnancy (DAP) Scale (range, 0-4), a validated instrument measuring pregnancy preferences with respect to cognitive desires, affective feelings, and anticipated consequences. Prior to the pandemic onset, DAP scores declined 0.06 points per quarter (95%CI -0.07 to -0.04). During the summer surge of 2020, DAP scores began to increase slightly to 0.05 points per quarter and during the fall 2020 surge, scores declined to -0.11 points per quarter. As higher DAP scores are indicative of an increased desire to avoid pregnancy, these findings suggest that the onset of the COVID-19 pandemic initially stalled and reversed the prior trend toward a greater desire for pregnancy over time. While this study presents an interesting outlook on pregnancy preferences early in the pandemic, it has several limitations. For instance, as all participants in the study were affected by COVID-19, the influence of other large-scale events could not be taken into consideration due to lack of a control group to examine differential changes by exposure. Additionally, the focus of this study remained on 2020 rather than longitudinal effects of the pandemic on pregnancy. However, the findings of this study still do warrant further investigation into optimizing reproductive care during future disruptions to medical access.

Incidence and Predictors of Multimorbidity Among Older Adults in Korea: A 10-Year Cohort Study

1. The incidence of multimorbidity increased with age amongst the Korean geriatric population.

2. The strongest predictors of multimorbidity in the Korean population included alcohol consumption, social interaction and support, obesity, and smoking.

Evidence Rating Level: 2 (Good)

With the rapid growth of the aging population, multimorbidity has become a significant global concern and presents substantial burdens on the healthcare system. Several studies have focused on identifying key determinants and at-risk populations for multimorbidity; however, longitudinal studies remain quite scarce, to date. In this longitudinal cohort study, 1967 participants from the Korean Longitudinal Study of Aging (KLoSA) were assessed for physician-diagnosed conditions including hypertension, diabetes, cancer, lung disease, liver disease, cardiovascular disease, rheumatoid disease, digestive system disease, and dementia, to evaluate multimorbidity over a 10-year follow-up period. Multimorbidity was defined as the co-existence of at least two of the aforementioned conditions. Sociodemographic information, lifestyle factors, health behaviors, and psychosocial factors of the participants were additionally identified. Over the 10-years of follow-up, 625 patients developed multimorbidity, with a 31.8% cumulative incidence rate. A history of consuming alcohol was the strongest predictor of multimorbidity incidence during the 10-year period (HR 1.73, 95%CI 1.37-2.19). Other factors significantly increasing risk of multimorbidity included low social interaction level (HR 1.61, 95%CI 1.31-1.99), obesity (HR 1.65, 95%CI 1.34-2.02), and a history of smoking (HR 1.55, 95%CI 1.26-1.91). In conclusion, this study provides important information regarding the incidence of multimorbidity among the Korean geriatric population and discusses critical factors that may contribute to an increased risk of morbid conditions. However, this study remains limited as only a Korean population was examined, and as such, the findings cannot be generalized to the broader population. Nonetheless, the results of this study do warrant further investigation into factors involved in multimorbidity among geriatric populations in attempt to prevent and reduce the inevitable burden on healthcare.

Evaluation of the Effectiveness and Costs of Inhaled Methoxyflurane Versus Usual Analgesia for Prehospital Injury and Trauma: Non-Randomized Clinical Study

1. Methoxyflurane was more effective in achieving faster pain reduction in a prehospital trauma setting compared to usual analgesic practices involving Entonox, intravenous morphine, and intravenous paracetamol.

Evidence Rating Level: 2 (Good)

Acute pain secondary to prehospital injury is frequently managed by Emergency Medical Service personnel; however, pain has been shown to be often inadequately treated. Usual analgesic practice for trauma pain in a prehospital setting includes opioids, paracetamol, Entonox (inhalation analgesic mixture of nitric oxide and oxygen), and non-steroidal anti-inflammatory medications. Barriers to pain management include incorrect pain assessments, limited choices of analgesics, and contraindications to effective pharmaceutical options. Methoxyflurane is a fluorinated hydrocarbon anesthetic that is easy to administer via inhaler, has a good safety profile, and is widely used as an inhalational analgesic in Australia. Despite this, there is limited evidence regarding the clinical and cost effectiveness of methoxyflurane in the prehospital environment. In this non-randomized clinical study, the benefits and economic costs of adding methoxyflurane to prehospital analgesic protocol was assessed in comparison to Entonox, intravenous morphine, and intravenous paracetamol. Overall, 483 patients were administered methoxyflurane and comparison data of patients using Entonox, intravenous morphine, and intravenous paracetamol was obtained from pre-existing ambulance service databases. The time to achieve maximum pain relief was significantly shorter in patients using methoxyflurane (26.5 minutes, 95%CI 24.9-27.9) compared to Entonox (44.4 minutes, 95%CI 39.5-49.3), intravenous morphine (41.8 minutes, 95%CI 38.9-44.7), and intravenous paracetamol (40.8 minutes, 95%CI 34.7-46.9). In addition, methoxyflurane was easy to administer for most patients and number of adverse events were low. In conclusion, methoxyflurane appears to be effective in achieving faster pain reduction compared to usual analgesic practices, in a prehospital setting. These findings will have significant implications for pain management in a prehospital, trauma environment where speed of stabilization is of utmost importance. Further research using randomized controlled designs directly comparing methoxyflurane to the current gold standards can be crucial in optimizing acute pain treatment in the future.

Association of Pulmonary Function with Late-Life Cardiac Function and Heart Failure Risk: The ARIC Study

1. Among patients with no pre-existing heart failure or pulmonary disease, both obstructive and restrictive spirometry patterns were associated with elevated pulmonary pressures, higher NT-proBNP levels, and an overall increased risk of incident heart failure, particularly in late life.

Evidence Rating Level: 2 (Good)

It is well known that pulmonary and cardiac function declines with increasing age; however, the association of pulmonary dysfunction with late-life heart failure and cardiac function is not elucidated in current literature. In this longitudinal cohort study, 3854 participants belonging to the Atherosclerosis Risk in Communities (ARIC) cohort with no pre-existing heart failure or pulmonary disease were assessed over five visits for lung function using spirometry, and cardiac structure and function using echocardiography. Incident heart failure was documented based on active surveillance of hospitalizations and by participant self-report. Interestingly, lower FEV1/FVC ratios on spirometry were associated with higher NT-proBNP values. Additionally, lower ppFVC (percent predicted forced vital capacity) was associated with left ventricular hypertrophy, increased left ventricular filling pressure, and high-sensitivity C-reactive protein. A lower FEV1/FVC ratio was associated with an increased risk of incident heart failure with preserved ejection fraction (HR 1.31, 95%CI 0.98-1.74) and heart failure with reduced ejection fraction (HR 1.24, 95%CI 0.91-1.70), when adjusted for confounding variables. In conclusion, the results of this study affirm that poor performance on spirometry with reduced FEV1/FVC ratio as well as lower ppFVC values is associated with increased risk of cardiovascular comorbidities, particularly in late life. As lung dysfunction is relatively easy to assess using spirometry, elderly patients at risk for late-life heart failure can be identified based on pulmonary function. However, it is important to note that this study has several limitations. For instance, spirometry was performing without using bronchodilators so reversible obstruction was not detected. In addition, as this cohort was followed for more than 20 years, survivorship bias may be present, ultimately confounding the incidence of heart failure in this population. Nonetheless, these findings warrant future research into targeting pulmonary dysfunction to decrease risk of heart failure in older adults.

Image: PD

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