ObjectivesTo perform an updated meta-analysis to evaluate the long-term cardiovascular and cerebrovascular outcomes among migraineurs.SettingA meta-analysis of cohort studies performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.Data sourcesThe MEDLINE, Web of Science and Cochrane Central Register of Controlled Trials databases were searched for relevant articles.ParticipantsA total of 16 cohort studies (18 study records) with 394 942 migraineurs and 757 465 non-migraineurs were analysed.Primary and secondary outcome measuresMajor adverse cardiovascular and cerebrovascular events (MACCE), stroke (ie, ischaemic, haemorrhagic or non-specified), myocardial infarction (MI) and all-cause mortality. The outcomes were reported at the longest available follow-up.Data analysisSummary-adjusted hazard ratios (HR) were calculated by random-effects Der-Simonian and Liard model. The risk of bias was assessed by the Newcastle-Ottawa Scale.ResultsMigraine was associated with a higher risk of MACCE (adjusted HR 1.42, 95% confidence interval [CI] 1.26 to 1.60, P<0.001, I2=40%) driven by a higher risk of stroke (adjusted HR 1.41, 95% CI 1.25 to 1.61, P<0.001, I2=72%) and MI (adjusted HR 1.23, 95% CI 1.03 to 1.43, P=0.006, I2=59%). There was no difference in the risk of all-cause mortality (adjusted HR 0.93, 95% CI 0.78 to 1.10, P=0.38, I2=91%), with a considerable degree of statistical heterogeneity between the studies. The presence of aura was an effect modifier for stroke (adjusted HR aura 1.56, 95% CI 1.30 to 1.87 vs adjusted HR no aura 1.11, 95% CI 0.94 to 1.31, P interaction=0.01) and all-cause mortality (adjusted HR aura 1.20, 95% CI 1.12 to 1.30 vs adjusted HR no aura 0.96, 95% CI 0.86 to 1.07, Pinteraction<0.001).ConclusionMigraine headache was associated with an increased long-term risk of cardiovascular and cerebrovascular events. This effect was due to an increased risk of stroke (both ischaemic and haemorrhagic) and MI. There was a moderate to severe degree of heterogeneity for the outcomes, which was partly explained by the presence of aura.PROSPERO registration number CRD42016052460.

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BackgroundContemporary outcomes of transcatheter aortic valve replacement (TAVR) in nonagenarians are unknown.Methods and ResultsWe identified 13 544 nonagenarians (aged 90–100 years) who underwent TAVR between 2012 and 2016 using Medicare claims. Generalized estimating equations were used to study the change in short‐term outcomes among nonagenarians over time. We compared outcomes between nonagenarians and non‐nonagenarians undergoing TAVR in 2016. A mixed‐effect multivariable logistic regression was performed to determine predictors of 30‐day mortality in nonagenarians in 2016. A center was defined as a high‐volume center if it performed ≥100 TAVR procedures per year. After adjusting for changes in patients’ characteristics, risk‐adjusted 30‐day mortality declined in nonagenarians from 9.8% in 2012 to 4.4% in 2016 (P<0.001), whereas mortality for patients <90 years decreased from 6.4% to 3.5%. In 2016, 35 712 TAVR procedures were performed, of which 12.7% were in nonagenarians. Overall, in‐hospital mortality in 2016 was higher in nonagenarians compared with younger patients (2.4% versus 1.7%, P<0.05) but did not differ in analysis limited to high‐volume centers (2.2% versus 1.7%; odds ratio: 1.33; 95% CI, 0.97–1.81; P=0.07). Important predictors of 30‐day mortality in nonagenarians included in‐hospital stroke (adjusted odds ratio [aOR]: 8.67; 95% CI, 5.03–15.00), acute kidney injury (aOR: 4.11; 95% CI, 2.90–5.83), blood transfusion (aOR: 2.66; 95% CI, 1.81–3.90), respiratory complications (aOR: 2.96; 95% CI, 1.52–5.76), heart failure (aOR: 1.86; 95% CI, 1.04–3.34), coagulopathy (aOR: 1.59; 95% CI, 1.12–2.26; P<0.05 for all).ConclusionsShort‐term outcomes after TAVR have improved in nonagenarians. Several procedural complications were associated with increased 30‐day mortality among nonagenarians.

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Background: Contemporary patterns in management and outcomes of critical limb ischemia among United States veterans are unknown. Methods: We used Veterans Health Administration data to identify patients admitted for critical limb ischemia between 2005 and 2014. We examined temporal trends in incidence, management, and outcomes. Results: A total of 20 938 veterans with critical limb ischemia were hospitalized between 2005 and 2014. Mean age was 67.8 years. Incidence decreased from 0.3 to 0.24 per 1000 persons from 2005 to 2013, P <0.01. During the study period, there was a temporal increase in use of revascularization within 90 days of hospitalization—endovascular (11.2% in 2005 to 18.4% in 2014), surgical (23.8% in 2005 to 26.4% in 2014), and hybrid (6.2% in 2005 to 13.1% in 2014, P value for trend <0.01). Statin prescriptions increased from 47.4% in 2005 to 60.9% in 2014 ( P value for trend <0.01). There was a significant decline in risk-adjusted mortality (11.8% in 2005 to 9.7% in 2014) and major amputation (19.8% in 2005 to 12.9% in 2014; P value for trend <0.01 for both) at 90 days. In adjusted analyses, revascularization was associated with a lower risk of mortality (RR, 0.45 [95% CI, 0.41–0.50]; P <0.001) and major amputation at 90 days (RR, 0.23 [95% CI, 0.21–0.26]; P <0.001). Nearly half of the patients who underwent amputation did not receive an invasive vascular procedure within the preceding 90 days. There was large site-level variation in the use of revascularization (median rate, 41.7% [interquartile range, 12.5%–53.2%]). Differences in patient case-mix explained only 8% of site-level variation in receipt of revascularization. Conclusions: Over the past decade, use of revascularization increased among veterans with critical limb ischemia, which was accompanied by a reduction in mortality and major amputation. However, opportunities to further improve care in this high-risk population still remain.