Cardiovascular Event Risk Increased After Sepsis Hospitalization
Despite improvements in recognizing and managing patients with sepsis, short‐term mortality among this population continues to be high, and survivors of hospitalization remain at elevated risk for death and other adverse clinical events. Sepsis survivors may suffer from neurocognitive impairment, physical weakness, and other functional limitations, but cardiovascular disease (CVD) is increasingly being acknowledged as an important risk factor for sepsis.
“Although some prior studies have suggested that sepsis survivors may be at higher risk for post-discharge cardiovascular events for years after they’re hospitalized, those analyses have relevant limitations,” explains Jacob C. Jentzer, MD, FACC, FAHA. “It’s important to increase our understanding of cardiovascular risks among sepsis survivors. Links between infection and CVD have been proposed for many years in clinical research, but sepsis has not been well recognized as a cardiovascular risk factor in and of itself.”
A More Robust Approach for Higher-Quality Evidence
For a study published in the Journal of the American Heart Association, Dr. Jentzer and colleagues described associations between sepsis during hospitalization and subsequent death and rehospitalization among survivors while accounting for preexisting CVD and acute organ failure during hospitalization. “We wanted to confirm and expand on prior literature to better understand the association between sepsis and specific cardiovascular outcomes, including individual types of cardiovascular events,” Dr. Jentzer says. “We used what we believe are more robust methods to minimize limitations and provide higher-quality evidence.”
The study included data on patients who survived a medical or nonsurgical hospitalization for sepsis lasting at least 2 nights from 2009 to 2019. The study population included more than 2 million survivors of nonsurgical hospitalization. Nearly one-third (35.8%) of patients had a sepsis hospitalization, including implicit sepsis in 448,644 cases, explicit sepsis in 124,841 cases, and both implicit and explicit sepsis in 235,188 cases.
Sepsis Raises Risks of Severe Outcomes for Cardiovascular Events
When compared with hospitalized patients who did not have a sepsis diagnosis, those hospitalized with sepsis had higher risks of all post-discharge adverse events examined in the study. “Patients with, or at risk for CVD who survived sepsis were at substantially elevated risk for death from cardiovascular events after hospital discharge,” says Dr. Jentzer (Figure). “These patients were also at considerably higher risk of all-cause rehospitalization and rehospitalization for cardiovascular events after hospital discharge. This elevated risk was additive to preexisting CVD and other known risk factors.”
Patients with sepsis during hospitalization differed substantially from those without sepsis in the study. Patients hospitalized with sepsis were at increased risk for all types of CVD events, including atherosclerotic and nonatherosclerotic events. Those hospitalized with sepsis also had a higher overall risk profile, including a greater degree of critical illness and more acute and chronic CVD. Even after adjusting or stratifying for these factors, patients with sepsis remained at higher risk of subsequent adverse outcomes.
Sepsis Survivors Might Be Candidates for Intensifying Cardiovascular Prevention
According to the study team, clinicians caring for survivors of sepsis should be aware of their high risk of atherosclerotic and nonatherosclerotic CVD events. “Our results suggest that patients who survive sepsis are important candidates for optimization or intensification of cardiovascular prevention efforts, such as managing known CVD and preexisting CVD risk factors,” Dr. Jentzer says. “It’s well known that ‘deprescription’—a temporary or permanent discontinuation of prior preventive cardiovascular medications—is not infrequent in hospitalized patients, even in those with sepsis. It’s critically important to avoid deprescription or to reinstitute prescriptions after discharge as soon as feasible.”
The increased risk for CVD after sepsis hospitalization warrants careful follow‐up and optimization of guideline‐directed medical therapies in patients with pre-existing CVD. “In future research, it’s important to determine whether adding, changing, or uptitrating new or existing cardiovascular preventive medications around the time of discharge can reduce risks for future cardiovascular events among sepsis survivors,” says Dr. Jentzer.
High-risk places affected by respiratory outbreaks
A respiratory virus outbreak has been declared at Southbridge Lakehead long-term care home.
The outbreak is facility-wide at the Vickers Street home. Restrictions are in place on admissions, transfers, discharges, social activities and visitation until further notice.
There are now four active respiratory outbreaks in high-risk settings in the Thunder Bay district, including at Hogarth Riverview Manor on the first floor and 2 North and on Plaza 1 at Pioneer Ridge.
A facility-wide COVID-19 outbreak is also ongoing at the Manitouwadge Hospital.
There are no active influenza outbreaks in the district.
The Thunder Bay District Health Unit reports that emergency department visits because of respiratory-related complaints have decreased and are at seasonal levels in its catchment area and the influenza A surge overall has subsided with the peak in cases and hospitalizations having taken place in November of 2022.
COVID-19 does continue to circulate with 104 new lab-confirmed cases in the last seven days.
Hospitalization numbers are stable with 23 people in the hospital with COVID in the district, including three in intensive care units.
The health unit continues to stress the importance of precautions like getting the annual flu vaccine and latest COVID booster as well as wearing a face mask, particularly indoors and crowded places. Also, stay home when sick.
WHO advisers to consider whether obesity medication should be added to Essential Medicines List
Advisers to the World Health Organization will consider next month whether to add liraglutide, the active ingredient in certain diabetes and obesity medications, to its list of essential medicines.
The list, which is updated every two years, includes medicines “that satisfy the priority health needs of the population,” WHO says. “They are intended to be available within the context of function health systems at all times, in adequate amounts in the appropriate dosage forms, of assured quality and at prices that individuals and the community can afford.”
The list is “a guide for the development and updating of national and institutional essential medicine lists to support the procurement and supply of medicines in the public sector, medicines reimbursement schemes, medicine donations, and local medicine production.”
The WHO Expert Committee on the Selection and Use of Essential Medicines is scheduled to meet April 24-28 to discuss revisions and updates involving dozens of medications. The request to add GLP-1 receptor agonists such as liraglutide came from four researchers at US institutions including Yale University and Brigham and Women’s Hospital.
These drugs mimic the effects of an appetite-regulating hormone, GLP-1, and stimulate the release of insulin. This helps lower blood sugar and slows the passage of food through the gut. Liraglutide was developed to treat diabetes but approved in the US as a weight-loss treatment in 2014; its more potent cousin, semaglutide, has been approved for diabetes since 2017 and as an obesity treatment in 2021.
The latter use has become well-known thanks to promotions from celebrities and on social media. It’s sold under the name Ozempic for diabetes and Wegovy for weight loss. Studies suggest that semaglutide may help people lose an average of 10% to 15% of their starting weight – significantly more than with other medications. But because of this high demand, some versions of the medication have been in shortage in the US since the middle of last year.
The US patent on liraglutide is set to expire this year, and drugmaker Novo Nordisk says generic versions could be available in June 2024.
The company has not been involved in the application to WHO, it said in a statement, but “we welcome the WHO review and look forward to the readout and decision.”
“At present, there are no medications included in the [Essential Medicines List] that specifically target weight loss for the global burden of obesity,” the researchers wrote in their request to WHO. “At this time, the EML includes mineral supplements for nutritional deficiencies yet it is also described that most of the population live in ‘countries where overweight and obesity kills more people than underweight.’ “
WHO’s advisers will make recommendations on which drugs should be included in this year’s list, expected to come in September.
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“This particular drug has a certain history, but the use of it probably has not been long enough to be able to see it on the Essential Medicines List,” Dr. Francesco Blanca, WHO director for nutrition and food safety, said at a briefing Wednesday. “There’s also issues related to the cost of the treatment. At the same time, WHO is looking at the use of drugs to reduce weight excess in the context of a systematic review for guidelines for children and adolescents. So we believe that it is a work in progress, but we’ll see what the Essential Medicines List committee is going to conclude.”
Some pediatric surgeries may be postponed as pediatric ICU faces strain: Shared Health
Re-emerging levels of respiratory illness have caused increased patient numbers at the HSC Children’s pediatric intensive care unit over the last week, and some non-urgent procedures may be postponed, Shared Health says.
On Thursday morning, there were 17 pediatric patients in the intensive care unit, and a considerable number of which were already experiencing health issues that were aggravated by respiratory illness. The unit’s normal baseline is nine, Shared Health said in a Thursday media release.
The release said patient volumes at the children’s emergency department are stable but more children with flu-like symptoms have been recorded coming in over the last two weeks, going from a low of 22 in mid-March to 47 on Wednesday.
A variety of respiratory illnesses are spreading through the community and have contributed to the increased level of patients in the pediatric intensive care unit, according to Shared Health.
Meanwhile, the number of patients in the neonatal intensive care unit was at 51 on Thursday morning, which is slightly above the unit’s normal baseline capacity of 50.
Ten staff are being temporarily reassigned to the pediatric intensive care unit to deal with the increased level of patients, the release said.
Some staff are being pulled from the pediatric surgical and recovery units, which means non-urgent procedures may be postponed due to the reassignments, Shared Health said.
Families of patients impacted by the postponements will be contacted, they said, and all urgent and life-threatening surgeries will go unhindered.
Families can protect their children from respiratory illnesses by limiting their contact with people exhibiting cold-like symptoms, washing their hands frequently and staying up to date on vaccinations, Shared Health said.
Patient volumes increased last month
While overall wait times at emergency and urgent care centres were stable in February, Shared Health said daily patient volumes in the province went up.
The daily average of patients seeking care was 750 last month, which is an increase from 730.4 in January, according to a separate Thursday news release.
The average length of stay for patients in emergency or urgent care units to be transferred to an inpatient unit went down to 21.77 hours last month, which is an improvement from 22.5 hours in January, the release said.
The overall number of people who left without being seen went down last month, from 13 per cent in January to 12.1 per cent in February, according to Shared Health. It also decreased at the HSC emergency department, from 25 per cent in January to 23.4 per cent last month.
Shared Health is reminding Manitobans to continue to call 911 in case of an emergency, and said the sickest and most injured patients will remain their priority.
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