Congenital Heart Disease
Risk of Pneumonia in Adults With Closed Versus Unclosed Atrial Septal Defect (from a Nationwide Cohort Study)

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Atrial septal defect (ASD) is associated with pulmonary hyperperfusion and inflammation and has been linked with increased risk of pneumonia. We investigated the risk of pneumonia in patients with ASD and the impact of ASD closure in a nationwide cohort study. All adults in Denmark (n = 1,168) diagnosed with ASD from 1977 to 2009 were identified through Danish public registries. We compared the risk of hospitalization for pneumonia, use of antibiotics, and mortality with age- and gender-matched general population controls. The median follow-up from time of diagnosis was 9.6 years (range 1 to 33). Cox regression analysis showed that both patients with closed (n = 863) and unclosed (n = 305) ASD had a higher risk of hospitalization for pneumonia (adjusted hazard ratios [HRs] 2.8, 95% confidence interval [CI] 2.3 to 3.5 and 3.1, 95% CI 2.4 to 4.0, respectively) than controls. Patients with ASD also used more antibiotics (adjusted HR for closure 1.4, 95% CI 1.3 to 1.5 and adjusted HR for no closure 1.4, 95% CI 1.2 to 1.6) than the controls. Antibiotic use normalized (adjusted HR 1.1, 95% CI 1.0 to 1.3) and the risk of pneumonia decreased (adjusted HR 1.8, 95% CI 1.1 to 3.0) within 5 years after closure. The proportion of patients with ASD with pneumonia-related death (8.4%) was comparable with that of the general population (9.5%). In conclusion, patients with ASD had a substantially higher risk of hospitalization for pneumonia and used more antibiotics than the general population. The pneumonia risk diminished, but did not completely normalize, 5 years after closure.

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Methods

This study was based on national medical registries in Denmark. The Danish health-care system is publically funded and, for the most part, free of charge. Data from all hospitals are gathered in nationwide public registries, which may be cross-linked using the unique personal identification number provided for every inhabitant since 1968.

Information on dates of birth, immigration, and death was identified in the Danish Civil Registration System.10 We used the Danish National Patient Registry

Results

The inclusion criteria were met by 1,168 patients who had been diagnosed at 1 of 80 hospitals in Denmark since 1977 (Figure 1). The majority (74%) had been diagnosed in 1 of the 4 Danish university hospitals. The median follow-up time was 9.6 years (range 1 to 33.3). Patients with ASD were grouped according to whether they underwent closure or not during follow-up (Table 1). Most patients were diagnosed after the age of 40 years (mean age at the time of diagnosis was 47.4).

Pneumonia admissions

Discussion

In this nationwide cohort study including 1,168 patients with ASD, we found that patients with ASD had a substantially increased long-term risk of hospital admission with pneumonia compared with the general population. The risk was increased for both patients with and without closure.

This increased risk of pneumonia in patients with ASD has only been sparsely described previously. We found no difference in pneumonia-related death between the patients with ASD considered collectively and the

Disclosures

The authors have no conflicts of interest to disclose.

References (21)

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This study was funded by Aarhus University (Aarhus, Denmark) and the Central Denmark Region (Viborg, Denmark). None of these institutions had a role in preparing or submitting this manuscript.

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