Letter regarding article by Gage et al, "selecting patients with atrial fibrillation for anticoagulation: stroke risk stratification in patients taking aspirin".
Explore the source record for details and available documents.
Atrial Fibrillation↗
SEARCH · Search PubMed
Results for “Patient stratification”
Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.
Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.
Use of dobutamine echocardiography for cardiac risk stratification of patients with chronic renal failure.
OBJECTIVES: This study sought to define the value of dobutamine echocardiography (DbE) for cardiac risk stratification in patients with chronic renal failure (CRF). DESIGN: Outcome study correlating results of DbE with late cardiac events in patients with CRF. SETTING: Academic medical centre. SUBJECTS: All patients with CRF (serum creatinine > 2.5 mg dL-1) undergoing DbE were studied; we analysed 193 consecutive patients (aged 63 +/- 13 years, 73 men). INTERVENTIONS: A standard dobutamine-atropine stress was administered until attainment of peak dose, or the development of severe ischaemia or side-effects. The electrocardiogram (ECG) and echocardiogram were obtained before, during and after stress. Ischaemia was identified by new or worsening wall-motion abnormalities with stress. OUTCOME MEASURES: Patients were followed up after 38 +/- 14 months for cardiac death, myocardial infarction or coronary disease progression requiring revascularization. RESULTS: DbE demonstrated ischaemia in 36 patients (19%), scar in 36 (19%) and a normal study in 121 patients. The heart-rate response to dobutamine was submaximal (< 85% age-predicted heart rate) in the absence of wall-motion abnormalities in 69 patients (36%), 54 of whom completed the protocol. Follow-up data were complete in 191 patients (99%); cardiac events occurred in 33 patients (17%), including 17 with cardiac death, 7 with infarction, and 9 requiring late revascularization. Spontaneous events occurred in 7 patients with ischaemia, 3 with scar (8%), 11 with a nondiagnostic study (16%) and 3 patients with a normal study (6%). Over the entire follow-up, the event-free survival in patients with ischaemia (66%) was markedly lower than those without ischaemia (84%, P = 0.006). However, the event rate in patients with nonischaemic responses increased from 8% to 16% between 24 and 40 months, and whilst ischaemia was an independent predictor of outcome at 24 months, it was not at 40 months. CONCLUSIONS: In patients with CRF, the identification of ischaemia at DbE is associated with a significant risk of adverse cardiac events. Patients with nonischaemic scans have a low frequency of events over short-term follow-up, but this increases at later follow-up. These later events may reflect progressive coronary disease, attributable to the atherogenic milieu of these patients, and imply that repeated testing may be required to maintain cardiac risk stratification in patients with CRF.
Adrenergic beta-Agonists↗
Stress echocardiography versus myocardial SPECT for risk stratification of patients with coronary artery disease.
PURPOSE OF REVIEW: Diagnostic testing using noninvasive imaging has become an integral part of risk stratification in patients with coronary artery disease. It is important to understand the integral strengths and weaknesses between the different modalities of stress testing and to apply accurately the type of test the clinical scenario demands. RECENT FINDINGS: There have been tremendous advances made in the field of cardiac imaging. Both myocardial perfusion imaging and stress echocardiographic techniques continue to evolve and play an important role in the assessment of patients with coronary artery disease. SUMMARY: In this review the authors discuss the relative merits of both stress echocardiography and myocardial single photon emission computed tomographic imaging for diagnosis and risk stratification of patients with coronary artery disease.
Cardiomyopathies↗
Stress myocardial perfusion imaging versus echocardiography for the diagnosis and risk stratification of patients with known or suspected coronary artery disease.
Stress perfusion imaging and stress echocardiography (ECHO) are both very useful for assessment of diagnosis and risk stratification of patients with coronary artery disease (CAD). Both techniques have been well validated during exercise and inotropic stress, but coronary vasodilation stress is better used in combination with perfusion imaging. The overall sensitivity for detection of CAD is slightly higher by single photon emission computed tomography (SPECT) than by two-dimensional (2D) ECHO during all stress modalities, whereas the specificity is slightly higher by ECHO, although the differences in general are not statistically significant. SPECT, however, appears to be superior to ECHO in the diagnosis of isolated circumflex stenosis, as well as for the correct identification of multivessel CAD. A substantially greater amount of information is available regarding risk stratification with SPECT than with 2D ECHO. Although the data suggest that both techniques are very useful for risk stratification of patients with stable CAD, after myocardial infarction, and for preoperative risk stratification, the risk for cardiac events is lower in the presence of a normal stress SPECT study than of a normal stress ECHO.
Coronary Disease↗
Significance of inducible ventricular flutter/fibrillation in risk stratification in patients with coronary artery disease.
BACKGROUND: Although inducible ventricular fibrillation (VF) has been used as an indication for prophylactic implantation of cardioverter-defibrillators (ICDs) in patients with coronary artery disease (CAD), the significance of inducible VF remains controversial. METHODS: Among 364 CAD patients who underwent electrophysiologic (EP) study for risk stratification, 23 patients, 12 without any history of VF or cardiac arrest (group A) and 11 with previously documented VF or cardiac arrest (group B), exhibited inducible ventricular flutter (VFL) or VF and subsequently underwent ICD implantation. Additionally, 11 CAD patients without previous VF or cardiac arrest, who had no inducible ventricular tachyarrhythmias but received an ICD, were included for comparison (group C). RESULTS: During 2 years of follow-up, 1 (8%), 5 (45%), and 1 (9%) patients had appropriate ICD shocks in groups A, B, and C, respectively. The survival free from appropriate ICD shocks was significantly lower in group B compared to groups A and C (p<0.05). There were no significant differences in age, sex, ejection fraction (EF), or induction protocol between groups A and B or between groups A and C. CONCLUSIONS: In CAD patients with inducible VFL/VF, patients without any history of VF or cardiac arrest had significantly lower incidence of appropriate ICD shocks when compared to those with such clinical events. Conversely, in CAD patients without any history of VF or cardiac arrest, incidence of appropriate ICD shocks was similar regardless of inducible VFL/VF. Inducible VFL/VF is therefore not useful as an indication for prophylactic ICD implantation in this patient population.
Aged↗
Extragastrointestinal (soft tissue) stromal tumors: an analysis of 48 cases with emphasis on histologic predictors of outcome.
The clinicopathologic features of 48 tumors that were histologically similar to gastrointestinal stromal tumors but occurred in the soft tissues of the abdomen were analyzed to determine their overall similarity to their gastrointestinal counterpart, their biologic behavior, and the parameters that predict risk for adverse outcome. Classic leiomyomas and leiomyosarcomas were specifically excluded. The tumors occurred in 32 women and 16 men, who ranged in age from 31 to 82 years (mean, 58 years). Forty tumors arose from the soft tissue of the abdominal cavity, and the remainder arose from the retroperitoneum. They ranged in size from 2.1 to 32.0 cm and varied from tumors composed purely of rounded epithelioid cells to those composed of short fusiform cells set in a fine fibrillary collagenous background with some cases showing a mixed pattern. Tumors displayed variable amounts of stromal hyalinization, myxoid change, and cyst formation. The tumors expressed CD117 (c-kit receptor) (100%), CD34 (50%), neuron-specific enolase (44%), smooth muscle actin (26%), desmin (4%), and S-100 protein (4%). Tumors were evaluated with respect to several parameters: size (<10 cm or >10 cm), cellularity (low or high), mitoses (0 to 2 per 50 high-power fields, >2 per 50 high-power fields), nuclear atypia (1 to 3+), cell type (epithelioid, spindled, or mixed), and necrosis (absent or present). These parameters were then evaluated in univariate and multivariate analysis with respect to adverse or nonadverse outcome, the former defined as metastasis or death from tumor. Follow-up information was obtained for 31 patients (range, 4 to 84 months; median, 24 months). One patient presented with an adverse event and, therefore, was excluded from subsequent analysis. Twelve patients (39%) developed metastases or died of tumor. In univariate analyses, cellularity, mitotic activity (>2 per 50 high-power fields), and necrosis were associated with statistically significant increases in the risk for adverse outcome. Despite the relatively small sample size, in a multivariable analysis mitotic activity (relative risk, 7.46; P = .09) and necrosis (relative risk, 3.75; P = .07) displayed trends toward independent predictive value. No association was noted between histologic pattern and outcome. Although only 39% of tumors behaved in a malignant fashion, this figure probably represents a conservative estimate because long-term follow-up (>5 years) was available for only a limited number of patients. Stratification of patients who have extragastrointestinal stromal tumor into those with 0 to 1 adverse histologic factors versus those with 2 to 3 offers the advantage of separating patients into two groups that have a markedly different risk for adverse outcome in the short term (0.02 events versus 0.54 events per person-year; P < .001, respectively). Extragastrointestinal (soft tissue) stromal tumors are histologically and immunophenotypically similar to their gastrointestinal counterpart but have an aggressive course more akin to small intestinal than gastric stromal tumors.
Abdominal Neoplasms↗
Use of genomic signatures in therapeutics development in oncology and other diseases.
Pharmacogenomics is the science of determining how the benefits and adverse effects of a drug vary among a target population of patients based on genomic features of the patient's germ line and diseased tissue. By identifying those patients who are most likely to respond while eliminating serious adverse effects, the therapeutic index of a drug can be substantially increased. This may facilitate demonstrating the effectiveness of the drug and may avoid subsequent problems due to serious adverse events. Our objective here is to provide clinical trial designs and analysis strategies for the utilization of genomic signatures as classifiers for patient stratification or patient selection in therapeutics development. We review methods for the development of genomic signature classifiers of treatment outcome in high-dimensional settings, where the number of variables available for prediction far exceeds the number of cases. The split-sample and cross-validation methods for obtaining estimates of prediction accuracy in developmental studies are described. We present clinical trial designs for utilizing genomic signature classifiers in therapeutics development. The purpose of the classifier is to facilitate the identification of groups of patients with a high probability of benefiting from it and avoiding serious adverse events. We distinguish exploratory analysis during the development of the genomic classifier from prospective planning and rigorous testing of therapeutic hypotheses in studies that utilize the genomic classifier in therapeutics development. We discuss a variety of clinical trial designs including those utilizing specimen collection and assay prospectively for newly accrued patients and those involving a prospectively planned analysis of archived specimens from a previously conducted clinical trial. Our discussion of the development and use of classifiers of efficacy is mostly focused on applications in oncology using classifiers based on biomarkers measured in tumors. Some of the same considerations apply, however, to development of efficacy and safety classifiers in nononcologic diseases based on single-nucleotide germline polymorphisms.
Biomarkers↗
Cancer surveillance in longstanding ulcerative colitis: endoscopic appearances help predict cancer risk.
BACKGROUND AND AIMS: The risk of colorectal cancer is increased in ulcerative colitis (UC). Patients with UC have diverse colonoscopic appearances. Determining colonoscopic markers for cancer risk could allow patient risk stratification. PATIENTS AND METHODS: Following on from an earlier study which demonstrated a correlation between inflammation severity and neoplasia risk, a case control study was performed to look for colonoscopic markers of colorectal neoplasia risk in UC. Each patient with neoplasia detected between 1988 and 2002 was matched with two non-dysplastic colitic controls. Data were collected on post-inflammatory polyps, scarring, strictures, backwash ileitis, a shortened, tubular, or featureless colon, severe inflammation, and normal looking surveillance colonoscopies. RESULTS: Cases (n = 68) and controls (n = 136) were well matched. On univariate analysis, cases were significantly more likely to have post-inflammatory polyps (odds ratio (OR) 2.14 (95% confidence interval 1.24-3.70)), strictures (OR 4.22; 1.08-15.54), shortened colons (OR 10.0; 1.17-85.6), tubular colons (OR 2.03; 1.00-4.08), or segments of severe inflammation (OR 3.38; 1.41-10.13), and less likely to have had a macroscopically normal looking colonoscopy (OR 0.40; 0.21-0.74). After multivariate analysis, a macroscopically normal looking colonoscopy (OR 0.38; 0.19-0.73), post-inflammatory polyps (2.29; 1.28-4.11), and strictures (4.62; 1.03-20.8) remained significant. The five year risk of colorectal cancer following a normal looking colonoscopy was no different from that of matched general population controls. CONCLUSIONS: Macroscopic colonoscopic features help predict neoplasia risk in UC. Features of previous/ongoing inflammation signify an increased risk. A macroscopically normal looking colonoscopy returns the cancer risk to that of the general population: it should be possible to reduce surveillance frequency to five years in this cohort.
Adolescent↗
Diagnosis and risk stratification in patients with acute coronary syndromes according to ESC guidelines.
Diagnosis and risk stratification of patients with acute coronary syndromes remain extremely important in order to avoid unnecessary hospitalizations on the one hand, and to improve prognosis of these patients on the other. For diagnosis of acute coronary syndromes, an ECG should be obtained at rest, troponin T and I should be measured on admission and again 6 to 12 h later, and myoglobin or CK-MB should be determined in patients with recent syndromes and those with recurring ischemia. Risk should be assessed upon admission and repeatedly during the hospital stay. Early risk indicators are: age, male sex, previous manifestation of coronary artery disease, history of left ventricular dysfunction or congestive heart failure and ongoing chest pain, as well as ST depression, transient ST segment elevation, and elevated levels of troponin T or I. Longer term risk assessment in unstable coronary artery disease includes rest and stress echocardiography, exercise ECG, thallium scintigraphy, as well as coronary angiography and left ventriculography. Markers of high long-term risk are old age, prior history of myocardial infarction, diabetes, elevated levels of C-reactive protein, and the extent of coronary artery disease and left ventricular dysfunction.
Acute Disease↗
Usefulness of the Killip classification for early risk stratification of patients with acute myocardial infarction in the 1990s compared with those treated in the 1980s. Israeli Thrombolytic Survey Group and the Secondary Prevention Reinfarction Israeli Nifedipine Trial (SPRINT) Study Group.
The classification introduced in 1967 by Killip et al has proved to be a useful method for early risk stratification of patients with acute myocardial infarction (AMI). Over the past 3 decades the overall mortality due to AMI has decreased significantly. The present study evaluates the usefulness of the Killip classification as a method for early risk stratification of patients with AMI in the 1990s. One thousand eight hundred seventy-three consecutive AMI patients were hospitalized in 25 coronary care units operating in Israel, and were followed for 1 year. Higher Killip class was found to be associated with increased in-hospital and 1-year mortality, in thrombolysis- and nonthrombolysis-treated patients (30-day mortality for all patients was 5%, 21%, 35%, and 67% in Killip classes I to IV, respectively). The overall mortality among AMI patients in the 1990s was found to be lower for each Killip class compared with a comparable patient population with AMI, hospitalized in Israel in the 1980s. Thus, the Killip classification is a useful method for early risk stratification of AMI patients in the 1990s.
Aged↗
B-type natriuretic peptide and peak exercise oxygen consumption provide independent information for risk stratification in patients with stable congestive heart failure.
OBJECTIVES: The aim of this study was to compare the prognostic value of peak oxygen consumption (VO(2)) and B-type natriuretic peptide (BNP) in patients with stable congestive heart failure (CHF). BACKGROUND: Previous studies have demonstrated that both peak VO(2) and BNP are useful for risk stratification in patients with CHF. No study has compared the respective prognostic value of these two parameters in a large series of patients receiving a combination of angiotensin-converting enzyme inhibitors and of beta-blockers. METHODS: Patients with stable CHF underwent radionuclide angiography, echocardiography, 24-h Holter monitoring, and a cardiopulmonary exercise test. Blood samples were drawn for standard measurements and for hormonal determinations. RESULTS: After a median follow-up period of 787 days, there were 75 cardiac-related deaths and three urgent transplantations. Independent predictors of cardiac survival were percent of maximal predicted VO(2) (%VO(2), relative risk [RR] = 2.84 [95% confidence interval, CI = 1.73 to 4.65], p < 0.00001), BNP (RR = 3.17 [95% CI 1.68 to 5.96], p = 0.0004), left atrial diameter (LAD) (RR = 2.04 [95% CI 1.25 to 3.34], p = 0.004), age (RR = 1.93 [95% CI 1.22 to 3.05], p = 0.005), and aldosterone (RR = 1.84 [95% CI 1.12 to 3.00], p = 0.015). In patients with infra-median levels of BNP (<109 pg/ml), age was the only independent predictor of cardiac survival. However, in patients with supra-median levels of BNP, independent predictors of cardiac survival were %VO(2) (RR = 3.76 [95% CI 2.19 to 6.45], p < 0.00001) and LAD (RR = 1.90 [95% CI 1.10 to 3.28], p = 0.02). CONCLUSIONS: B-type natriuretic peptide, in combination with %VO(2), improves risk stratification of patients with stable CHF.
Age Factors↗
Wall thickening assessment with tissue harmonic echocardiography results in improved risk stratification for patients with non-ST-segment elevation acute chest pain.
OBJECTIVES: To demonstrate whether the improved imaging quality gained by using tissue harmonic echocardiography in place of fundamental echocardiography results in the improved risk stratification of patients presenting with non-ST-elevation acute chest pain. METHODS AND RESULTS: Eighty patients with over 30 min of non-ST-elevation chest pain that had lasted less than 6 h were recruited. All patients underwent resting tissue harmonic and fundamental echocardiographic scans. Diagnosis for acute myocardial infarction was made on a 24 h creatine kinase-MB sample. Echocardiographic images were reported by two experienced blinded observers. Patients were followed up at least 4 months after admission. Endpoints included all-cause mortality, non-fatal myocardial infarction and revascularisation procedures. Tissue harmonic echocardiography allowed assessment of all myocardial segments in all patients compared to 43/78 patients ( p<0.001 ) with fundamental echocardiography. A wall thickening abnormality demonstrated on tissue harmonic echocardiography and not fundamental echocardiography was a significant predictor of index myocardial infarction on admission ( p<0.007 ) and for an adverse cardiac event during follow up ( p=0.002 ). CONCLUSIONS: Tissue harmonic echocardiography is superior to fundamental echocardiography for accurate assessment of systolic wall thickening and hence risk stratification for patients presenting with acute chest pain and non-diagnostic electrocardiogram changes.
Acute Disease↗
Risk stratification of patients with advanced squamous cell carcinoma of cervix treated by radiotherapy alone.
PURPOSE: To identify prognostic factors for local and distant relapse and perform risk stratification for patients with advanced cervical cancer treated with radiotherapy (RT) alone. METHODS AND MATERIALS: A total of 1031 patients with Stage IB-IVA squamous cell carcinoma of the cervix treated with full-course RT but without any chemotherapy were included for analysis. Of these, 311 patients with nonbulky Stage IB-IIA disease were designated the reference group and the other 720 patients were the study group. The associations of stage, squamous cell carcinoma antigen (SCC-ag) level, hemoglobin level, age, cell differentiation, and pelvic lymph node status with treatment failure were evaluated. The independent prognostic factors were identified by multivariate analysis. The study group was further stratified into subgroups using combinations of these risk factors. RESULTS: In the study group, independent risk factors for local relapse were advanced stage and age <45 years. The 5-year local relapse-free survival rate was 86% for patients > or =45 years with bulky Stage IB-IIA or IIB disease, and was even greater, up to 90% if the SCC-ag level was <2. In contrast, it was 65% for patients with Stage IIIB who were <45 years old. The independent risk factors for distant failure were advanced stage, SCC-ag level >2, and positive pelvic lymph nodes. The 5-year distant relapse-free survival rate was 83% for patients with bulky Stage IB-IIA and IIB disease, SCC-ag level <2, and negative lymph nodes and 43% for patients with Stage III, SCC-ag level >2, and positive lymph nodes. CONCLUSION: The risk of treatment failure in advanced-stage cervical cancer patients treated by RT alone can be more precisely predicted by risk stratification. A certain subgroup of patients had better control than the others. The benefit of treating these relatively low-risk patients with additional treatment such as concurrent chemotherapy should be further evaluated in prospective studies or meta-analyses.
Adult↗
Enhanced prognostic stratification of patients with left ventricular hypertrophy with the use of single-photon emission computed tomography.
BACKGROUND: Patients with left ventricular hypertrophy (LVH) are at increased risk of future cardiovascular events. Little is known about risk stratification of these patients with the use of myocardial perfusion imaging. This study sought to assess the prognostic stratification of patients with LVH by using myocardial perfusion single-photon emission computed tomography (SPECT). METHODS AND RESULTS: We studied 633 consecutive patients with electrocardiographic evidence of LVH who underwent dual isotope myocardial perfusion SPECT (rest thallium 201/stress technetium 99m sestamibi) and were followed up for a mean period of 22 +/- 7 months. During the follow-up period, 67 events (35 cardiac deaths and 32 nonfatal myocardial infarctions) occurred (6% annual event rate). The results of the perfusion scan significantly risk-stratified the population; patients with normal scans had a low rate of nonfatal myocardial infarction and cardiac death (<1% per year of follow-up). The rates of cardiac events increased significantly as a function of the scan result: 4.9% in patients with mildly abnormal scans and 10. 3% in moderately to severely abnormal scans. Cox proportional hazards analysis demonstrated that after adjusting for pretest likelihood of coronary artery disease (the most predictive clinical variable; chi(2) = 15.5, P <.001), summed stress score (the most predictive nuclear variable; chi(2) = 18, P <.0001) added significant incremental prognostic information (global chi(2) increased from 15.5 to 36; P <.001). CONCLUSIONS: In patients with LVH with an overall high cardiac event rate, SPECT provided enhanced stratification by adding significant incremental prognostic information over clinical and historic variables.
Aged↗
Immunohistochemical profiling based on Bcl-2, CD10 and MUM1 expression improves risk stratification in patients with primary nodal diffuse large B cell lymphoma.
Clinical outcome in patients with diffuse large B cell lymphomas (DLBCL) is poorly predictable. Expression of proteins related to germinal centre B (GCB) cell or activated B cells (ABC) and expression of apoptosis-regulating proteins Bcl-2 and XIAP have been found previously to be strongly associated with clinical outcome. In this study we aimed to develop an algorithm based on expression of GCB/ABC-related proteins CD10, Bcl-6 and MUM1 and apoptosis-inhibiting proteins Bcl-2, XIAP and cFLIP for optimal stratification of DLBCL patients into prognostically favourable and unfavourable groups. Expression of CD10 and cFLIP was associated with better overall survival (both p = 0.03), whereas expression of MUM1, Bcl-2 and XIAP was associated with poor clinical outcome (p = 0.01, p = 0.0007 and p = 0.03, respectively). Multivariate analysis revealed that Bcl-2 was the strongest prognostic marker followed by CD10 and MUM1. Stratification of patients according to a new algorithm based on expression of these three markers improved patient risk stratification into low and particularly high clinical risk groups (p = 0.04 and p < 0.0001, respectively). We conclude that, in our group of primary nodal DLBCLs, a new algorithm, based on expression of the apoptosis-inhibiting protein Bcl-2 and the GCB/ABC-related proteins CD10 and MUM1, strongly predicts outcome in International Prognostic Index (IPI)-low and -high patients. Its predictive power is stronger than previously published algorithms based on only GCB/ABC- or apoptosis-regulating proteins.
Adult↗
Improved risk stratification in patients with coronary artery disease. Application of a survival function using continuous exercise and angiographic variables.
Assessment of prognosis plays an important role in the management of patients with CAD. The objective of the study was to improve risk stratification in patients with known coronary angiographic findings. We analyzed the prognostic importance of 13 angiographic, exercise, and clinical variables in 1183 medically treated patients with documented CAD. Five-year actuarial survival rate (5-YSR) was 87%. Multivariate analysis with the proportional hazards regression model revealed four continuous and one discrete variable to be of independent prognostic importance (chi 2 value): cardiac output at the highest work load (COmax) (chi 2 = 80.7); coronary score (chi 2 = 18.6); heart volume by X-ray (chi 2 = 14.7); maximal pulmonary wedge pressure during exercise (chi 2 = 5.3), and history of myocardial infarction (chi 2 = 4.8). Inclusion of these variables in the survival function according to the regression model resulted in excellent prediction of 5-YSR, e.g. in the patients with three-vessel disease (N = 399): actuarial 5-YSR was 80%, calculated 81%. Patients with three-vessel disease and COmax greater than 11.21 min-1 (N = 188) had an actuarial 5-YSR of 88%, calculated 89%; if COmax was less than 11.21 min-1 the actuarial 5-YSR was 71%, calculated 70%. Patients with three-vessel disease from an independent cohort of surgically treated patients (N = 507) had a calculated 5-YSR under an assumed medical regimen of 77%.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Three-year prospective validation of a pre-endoscopic risk stratification in patients with acute upper-gastrointestinal haemorrhage.
OBJECTIVE: To assess the accuracy of a risk stratification that is used at initial assessment to identify groups with increased risk of mortality and requirement for urgent treatment intervention. DESIGN: Prospective assessment of risk stratification in consecutive patients with acute upper-gastrointestinal haemorrhage. METHODS: Over a 3-year period, 1349 consecutive patients with acute upper-gastrointestinal haemorrhage presenting to a single teaching hospital were prospectively risk stratified before endoscopy and followed up for outcome. MAIN OUTCOME MEASURES: Two-week, all-cause mortality, re-bleeding, and need for urgent treatment intervention. RESULTS: Stratification within the high-risk group predicted a significant increased risk of 2-week, all-cause mortality (P < 0.001) when compared with intermediate- and low-risk patients (11.8%, 3% and 0%, respectively), re-bleeding (P < 0.001) (44.1%, 2.3% and 0%, respectively), and need for urgent treatment intervention (P < 0.001) (71%, 40.6% and 2.6%, respectively). CONCLUSIONS: Over a 3-year period, medical staff at this institution have routinely used this risk stratification, which identifies groups of patients at high and low risk of mortality, re-bleeding and need for urgent treatment intervention following acute upper-gastrointestinal haemorrhage. Use of this risk stratification should allow targeting of more intensive treatment where it might be of most benefit. Those patients at lowest risk from outpatient management are also identified.
Acute Disease↗
Risk stratification for patients with community-acquired pneumonia.
Community-acquired pneumonia (CAP) is a common medical illness with a prognosis that ranges from rapid complete recovery to severe medical complications and death. Approximately 4 million adults are diagnosed with CAP in the US each year; with more than 600,000 (15%) hospitalised. An estimated $4 billion is expended annually on patients with CAP, with inpatient therapy costing as much as 20 times that of outpatient antimicrobial therapy. Determining severity of illness and using this information to risk-stratify patients with CAP is important from several perspectives. Clinically, understanding prognosis can assist physicians in the initial site of treatment decision (home versus hospital) and can be used to communicate expected outcomes to patients. From a research perspective, risk stratification can be used to select appropriate patient subgroups for clinical trials and to provide severity-adjusted outcomes comparisons. From a policy perspective, severity-adjusted outcomes can be used as a proxy for quality of medical care.
Cohort Studies↗