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Hijazi W, Feng Y, Southern DA, Chew D, Filipchuk N, Har B, James M, Wilton S, Slomka PJ, Berman D, Miller RJH. Impact of myocardial perfusion and coronary calcium on medical management for coronary artery disease. Eur Heart J Cardiovasc Imaging 2024; 25:482-490. [PMID: 37889992 DOI: 10.1093/ehjci/jead288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/06/2023] [Accepted: 10/23/2023] [Indexed: 10/29/2023] Open
Abstract
AIMS Single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) remains one of the most widely used imaging modalities for the diagnosis and prognostication of coronary artery disease (CAD). Despite the extensive prognostic information provided by MPI, little is known about how this influences the prescription of medical therapy for CAD. We evaluated the relationship between MPI with computed tomography (CT) attenuation correction and prescription of acetylsalicylic acid (ASA) and statins. METHODS AND RESULTS We performed a retrospective analysis of consecutive patients who underwent SPECT MPI at a single centre between 2015 and 2021. Myocardial perfusion abnormalities and coronary calcium burden were assessed, with attenuation correction imaging 77.8% of patients. Medication prescriptions before and within 180 days after the test were compared. Associations between abnormal perfusion and calcium burden with ASA and statin prescription were assessed using multivariable logistic regression. In total, 9908 patients were included, with a mean age 66.8 ± 11.7 years and 5337 (53.9%) males. The prescription of statins increased more in patients with abnormal perfusion (increase of 19.2 vs. 12.0%, P < 0.001). Similarly, the presence of extensive CAC led to a greater increase in statin prescription compared with no calcium (increase 12.1 vs. 7.8%, P < 0.001). In multivariable analyses, ischaemia and coronary artery calcium were independently associated with ASA and statin prescription. CONCLUSION Abnormal MPI testing was associated with significant changes in medical therapy. Both calcium burden and perfusion abnormalities were associated with increased prescriptions of medical therapy for CAD.
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Affiliation(s)
- Waseem Hijazi
- Department of Cardiac Sciences, University of Calgary, 1403 - 29th St. NW, Calgary, AB, T2N 2T9, Canada
| | - Yuanchao Feng
- Department of Cardiac Sciences, University of Calgary, 1403 - 29th St. NW, Calgary, AB, T2N 2T9, Canada
| | - Danielle A Southern
- Department of Medicine, Cumming School of Medicine, University of Calgary, 1403 - 29th St. NW, Calgary, AB, T2N 2T9, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 1403 - 29th St. NW, Calgary, AB, T2N 2T9, Canada
- O'Brien Institute for Public Health, University of Calgary, 1403 - 29th St. NW, Calgary, AB, T2N 2T9, Canada
- Libin Cardiovascular Institute, University of Calgary, 1403 - 29th St. NW, Calgary, AB, T2N 2T9, Canada
| | - Derek Chew
- Department of Cardiac Sciences, University of Calgary, 1403 - 29th St. NW, Calgary, AB, T2N 2T9, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, 1403 - 29th St. NW, Calgary, AB, T2N 2T9, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 1403 - 29th St. NW, Calgary, AB, T2N 2T9, Canada
- O'Brien Institute for Public Health, University of Calgary, 1403 - 29th St. NW, Calgary, AB, T2N 2T9, Canada
- Libin Cardiovascular Institute, University of Calgary, 1403 - 29th St. NW, Calgary, AB, T2N 2T9, Canada
| | - Neil Filipchuk
- Department of Cardiac Sciences, University of Calgary, 1403 - 29th St. NW, Calgary, AB, T2N 2T9, Canada
| | - Bryan Har
- Department of Cardiac Sciences, University of Calgary, 1403 - 29th St. NW, Calgary, AB, T2N 2T9, Canada
| | - Matthew James
- Department of Medicine, Cumming School of Medicine, University of Calgary, 1403 - 29th St. NW, Calgary, AB, T2N 2T9, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 1403 - 29th St. NW, Calgary, AB, T2N 2T9, Canada
- O'Brien Institute for Public Health, University of Calgary, 1403 - 29th St. NW, Calgary, AB, T2N 2T9, Canada
- Libin Cardiovascular Institute, University of Calgary, 1403 - 29th St. NW, Calgary, AB, T2N 2T9, Canada
| | - Stephen Wilton
- Department of Cardiac Sciences, University of Calgary, 1403 - 29th St. NW, Calgary, AB, T2N 2T9, Canada
| | - Piotr J Slomka
- Division of Artificial Intelligence in Medicine, Department of Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA
- Department of Imaging, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA
| | - Daniel Berman
- Division of Artificial Intelligence in Medicine, Department of Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA
- Department of Imaging, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA
| | - Robert J H Miller
- Department of Cardiac Sciences, University of Calgary, 1403 - 29th St. NW, Calgary, AB, T2N 2T9, Canada
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Kotrri G, Youngson E, Fine NM, Howlett JG, Lyons K, Paterson DI, Ezekowitz J, McAlister FA, Miller RJ. Right Ventricular Systolic Pressure Trajectory as a Predictor of Hospitalization and Mortality in Patients With Chronic Heart Failure. CJC Open 2023; 5:671-679. [PMID: 37744660 PMCID: PMC10516718 DOI: 10.1016/j.cjco.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 05/25/2023] [Indexed: 09/26/2023] Open
Abstract
Background Pulmonary hypertension is common among patients with heart failure (HF). Right ventricular systolic pressure (RVSP) is frequently used to assess its presence and severity. Although RVSP has been associated with adverse outcomes, the importance of serial measurements has not been studied. We evaluated associations between serial RVSP measurements and cardiovascular events in patients with HF. Methods Patients with HF and 2 echocardiograms performed ≥ 6 months apart were included. RVSP was categorized, using the second echocardiogram, as follows: normal (< 40 mm Hg); severely elevated (≥ 60 mm Hg); moderately elevated (50-59 mm Hg); or mildly elevated (40-49 mm Hg). Patients also were classified according to change in RVSP categories between echocardiograms. The primary outcome was time to HF hospitalization (HFH) or all-cause mortality (ACM) after the second echocardiogram. Results In total, 4319 patients were included (median age: 78 years; 52.1% female). During a median follow-up period of 19.4 months, HFH/ACM occurred in 2714 patients (62.8%). In multivariable analysis, baseline RSVP that was mildly elevated (1069 patients, hazard ratio [HR] 1.31, 95% confidence interval [CI] 1.12-1.54), moderately elevated (797 patients, HR 1.54, 95% CI 1.30-1.82), or severely elevated (837 patients, HR 1.92, 95% CI 1.60-2.31) was independently associated with HFH/ACM. Additionally, improving RVSP was associated with increased HFH/ACM in both categorical (HR 1.16, 95% CI 1.01-1.33) and continuous analyses. Conclusions RVSP measurements identify patients at increased risk who may require more-aggressive monitoring and medical therapy. Our study raises the hypothesis that, in addition to the absolute value of RVSP, improving RVSP category may identify higher-risk patients, but further study is needed to elucidate the underlying reasons.
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Affiliation(s)
- Gynter Kotrri
- Division of Cardiology, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Erik Youngson
- Data and Research Services, Alberta SPOR SUPPORT Unit and Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - Nowell M. Fine
- Division of Cardiology, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jonathan G. Howlett
- Division of Cardiology, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kristin Lyons
- Division of Cardiology, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - D. Ian Paterson
- Faculty of Medicine and Dentistry, University of Alberta Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Justin Ezekowitz
- Faculty of Medicine and Dentistry, University of Alberta Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Finlay A. McAlister
- Faculty of Medicine and Dentistry, University of Alberta Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Robert J.H. Miller
- Division of Cardiology, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Lau D, Pannu N, Yeung RO, Scott-Douglas N, Klarenbach S. Use of sodium-glucose cotransporter 2 inhibitors in Alberta adults with chronic kidney disease: a cross-sectional study identifying care gaps to inform knowledge translation. CMAJ Open 2023; 11:E101-E109. [PMID: 36720493 PMCID: PMC9894653 DOI: 10.9778/cmajo.20210281] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Sodium-glucose cotransporter 2 (SGLT2) inhibitors have important kidney and cardiovascular benefits in adults with chronic kidney disease. Among adults with diabetes, we characterized the prevalence of chronic kidney disease eligible for SGLT2 inhibitor treatment, based on definitions of eligibility from trials and diabetes guidelines, and assessed the predictors of SGLT2 inhibitor use. METHODS We conducted a cross-sectional study using linked administrative data from Alberta Health in adults with diabetes (2002-2019). Chronic kidney disease was defined as an estimated glomerular filtration rate (eGFR) less than 90 mL/min/1.73 m2 with severe or greater proteinuria (trial-based definition); or eGFR less than 60 mL/min/1.73 m2 or moderate or greater proteinuria regardless of eGFR (diabetes guideline-based definition). Predictors (sociodemographic characteristics, comorbidities and health care utilization) of SGLT2 inhibitor use were identified using logistic regression. RESULTS Of 446 315 adults with diabetes, 76 630 (17.2%, guideline-based definition; 12 867 [2.9%], trial-based definition) had chronic kidney disease eligible for SGLT2 inhibitor treatment. A total of 7.1% used SGLT2 inhibitors. Older age, lower hemoglobin A1c (HbA1c) levels, female sex, lower neighbourhood income, rural residence and hospital admission were among variables associated with nonuse of SGLT2 inhibitors (adjusted odds ratios [ORs] from 0.13 [age ≥ 85 yr] to 0.92 [rural residence], p < 0.05). Family physician visits were associated with higher SGLT2 inhibitor use (adjusted OR 4.01, p < 0.001 for > 4 visits/yr). Considering all adults, both with and without diabetes, 162 012 individuals with chronic kidney disease (5% of all Alberta adults) may benefit from treatment with SGLT2 inhibitors. INTERPRETATION Many adults with chronic kidney disease would derive heart and kidney benefits from treatment with SGLT2 inhibitors but had low SGLT2 inhibitor use as of 2019. Efforts will be needed to address lower use of SGLT2 inhibitors among female, older and lower-income adults, and to enhance primary care and promote awareness of the benefits of SGLT2 inhibitors independent of glycemic control.
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Affiliation(s)
- Darren Lau
- Department of Medicine (Lau, Pannu, Yeung, Klarenbach), University of Alberta, Edmonton, Alta.; Department of Medicine (Scott-Douglas), University of Calgary, Calgary, Alta.
| | - Neesh Pannu
- Department of Medicine (Lau, Pannu, Yeung, Klarenbach), University of Alberta, Edmonton, Alta.; Department of Medicine (Scott-Douglas), University of Calgary, Calgary, Alta
| | - Roseanne O Yeung
- Department of Medicine (Lau, Pannu, Yeung, Klarenbach), University of Alberta, Edmonton, Alta.; Department of Medicine (Scott-Douglas), University of Calgary, Calgary, Alta
| | - Nairne Scott-Douglas
- Department of Medicine (Lau, Pannu, Yeung, Klarenbach), University of Alberta, Edmonton, Alta.; Department of Medicine (Scott-Douglas), University of Calgary, Calgary, Alta
| | - Scott Klarenbach
- Department of Medicine (Lau, Pannu, Yeung, Klarenbach), University of Alberta, Edmonton, Alta.; Department of Medicine (Scott-Douglas), University of Calgary, Calgary, Alta
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Miller RJ, Nabipoor M, Youngson E, Kotrri G, Fine NM, Howlett JG, Paterson ID, Ezekowitz J, McAlister FA. Heart failure with mildly reduced ejection fraction: retrospective study of ejection fraction trajectory risk. ESC Heart Fail 2022; 9:1564-1573. [PMID: 35261203 PMCID: PMC9065872 DOI: 10.1002/ehf2.13869] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/02/2022] [Accepted: 02/17/2022] [Indexed: 11/10/2022] Open
Abstract
AIMS Heart failure with mildly reduced ejection fraction (HFmrEF) is associated with a favourable prognosis compared with heart failure (HF) with reduced ejection fraction (EF). We assessed whether left ventricular ejection fraction (LVEF) trajectory can be used to identify groups of patients with HFmrEF who have different clinical outcomes in a large retrospective study of patients with serial imaging. METHODS AND RESULTS Patients with HF and ≥2 echocardiograms performed ≥6 months apart were included if the LVEF measured 40-49% on the second study. Patients were classified as HFmrEF-Increasing if LVEF had increased ≥10% (n = 450), HFmrEF-Decreasing if LVEF had decreased ≥10% (n = 512), or HFmrEF-Stable if they did not meet other criteria (n = 389). The primary outcome was all-cause mortality or cardiovascular hospitalization after the second echocardiogram. Associations with time to first event were assessed with multivariable Cox analyses adjusted for age, co-morbidities, and medications. In total, 1351 patients with HFmrEF (median age 74, 64.2% male) were included with 28.8% exhibiting stable LVEF. During median follow-up of 15.3 months, the composite outcome occurred in 811 patients. During follow-up, patients with HFmrEF-Increasing were less likely to experience the primary outcome [adjusted hazard ratio (HR) 0.72, 95% confidence interval (CI) 0.60-0.88, P < 0.001] compared with HFmrEF-Stable. Patients with HFmrEF-Decreasing were more likely to experience the composite outcome in unadjusted analyses (unadjusted HR 1.19, 95% CI 1.01-1.40, P = 0.040) but not adjusted analyses (adjusted HR 1.16, 95% CI 0.98-1.37, P = 0.092). Associations with death or HF hospitalizations were similar (HFmrEF-Increasing: adjusted HR 0.72, 95% CI 0.59-0.88, P = 0.005; HFmrEF-Decreasing: adjusted HR 1.20, 95% CI 1.01-1.44, P = 0.044). Patients with HFmrEF-Decreasing had a similar risk of the composite outcome as patients with HF with reduced EF (adjusted HR 1.03, 95% CI 0.89-1.20, P = 0.670). Patients with HFmrEF-Increasing were less likely to experience the composite outcome compared with patients with HF with preserved EF (adjusted HR 0.73, 95% CI 0.62-0.87, P < 0.001). CONCLUSIONS Amongst patients with HFmrEF, those exhibiting positive LVEF trajectory were less likely to experience adverse outcomes after correcting for important confounders including medical therapy. Categorizing HFmrEF patients based on LVEF trajectory provides meaningful clinical information and may assist clinicians with management decisions.
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Affiliation(s)
- Robert J.H. Miller
- Division of Cardiology, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of MedicineUniversity of CalgaryCalgaryABCanada
| | - Majid Nabipoor
- Data and Research Services, Alberta SPOR Support Unit and Provincial Research Data ServicesAlberta Health ServicesEdmontonABCanada
| | - Erik Youngson
- Data and Research Services, Alberta SPOR Support Unit and Provincial Research Data ServicesAlberta Health ServicesEdmontonABCanada
| | - Gynter Kotrri
- Division of Cardiology, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of MedicineUniversity of CalgaryCalgaryABCanada
| | - Nowell M. Fine
- Division of Cardiology, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of MedicineUniversity of CalgaryCalgaryABCanada
| | - Jonathan G. Howlett
- Division of Cardiology, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of MedicineUniversity of CalgaryCalgaryABCanada
| | - Ian D. Paterson
- Canadian VIGOUR Centre, Faculty of Medicine and DentistryUniversity of Alberta5‐134 Clinical Sciences BuildingEdmontonABT6R 2R3Canada
| | - Justin Ezekowitz
- Canadian VIGOUR Centre, Faculty of Medicine and DentistryUniversity of Alberta5‐134 Clinical Sciences BuildingEdmontonABT6R 2R3Canada
| | - Finlay A. McAlister
- Canadian VIGOUR Centre, Faculty of Medicine and DentistryUniversity of Alberta5‐134 Clinical Sciences BuildingEdmontonABT6R 2R3Canada
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5
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McAlister FA, Wang T, Wang X, Chu A, Goodman SG, van Diepen S, Jackevicius CA, Kaul P, Udell J, Ko DT, Kwong JC, Austin PC, Lee DS. Statins and SARS-CoV-2 Infection: Results of a Population-Based Prospective Cohort Study of 469 749 Adults From 2 Canadian Provinces. J Am Heart Assoc 2021; 10:e022330. [PMID: 34689613 PMCID: PMC8751814 DOI: 10.1161/jaha.121.022330] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background Small observational studies have suggested that statin users have a lower risk of dying with COVID‐19. We tested this hypothesis in a large, population‐based cohort of adults in 2 of Canada’s most populous provinces: Ontario and Alberta. Methods and Results We examined reverse transcriptase–polymerase chain reaction swab positivity rates for SARS‐CoV‐2 in adults using statins compared with nonusers. In patients with SARS‐CoV‐2 infection, we compared 30‐day risk of all‐cause emergency department visit, hospitalization, intensive care unit admission, or death in statin users versus nonusers, adjusting for baseline differences in demographics, clinical comorbidities, and prior health care use, as well as propensity for statin use. Between January and June 2020, 2.4% of 226 142 tested individuals aged 18 to 65 years, 2.7% of 88 387 people aged 66 to 75 years, and 4.1% of 154 950 people older than 75 years had a positive reverse transcriptase–polymerase chain reaction swab for SARS‐CoV‐2. Compared with 353 878 nonusers, the 115 871 statin users were more likely to test positive for SARS‐CoV‐2 (3.6% versus 2.8%, P<0.001), but this difference was not significant after adjustment for baseline differences and propensity for statin use in each age stratum (adjusted odds ratio 1.00 [95% CI, 0.88–1.14], 1.00 [0.91–1.09], and 1.06 [0.82–1.38], respectively). In individuals younger than 75 years with SARS‐CoV‐2 infection, statin users were more likely to visit an emergency department, be hospitalized, be admitted to the intensive care unit, or to die of any cause within 30 days of their positive swab result than nonusers, but none of these associations were significant after multivariable adjustment. In individuals older than 75 years with SARS‐CoV‐2, statin users were more likely to visit an emergency department (28.2% versus 17.9%, adjusted odds ratio 1.41 [1.23–1.61]) or be hospitalized (32.7% versus 21.9%, adjusted odds ratio 1.19 [1.05–1.36]), but were less likely to die (26.9% versus 31.3%, adjusted odds ratio 0.76 [0.67–0.86]) of any cause within 30 days of their positive swab result than nonusers. Conclusions Compared with statin nonusers, patients taking statins exhibit the same risk of testing positive for SARS‐CoV‐2 and those younger than 75 years exhibit similar outcomes within 30 days of a positive test. Patients older than 75 years with a positive SARS‐CoV‐2 test and who were taking statins had more emergency department visits and hospitalizations, but exhibited lower 30‐day all‐cause mortality risk.
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Affiliation(s)
- Finlay A. McAlister
- The Department of MedicineFaculty of Medicine and DentistryUniversity of AlbertaEdmontonAlbertaCanada
- The Alberta Strategy for Patient Oriented Research Support UnitEdmontonCanada
- The Canadian VIGOUR CentreUniversity of AlbertaEdmontonCanada
| | - Ting Wang
- The Alberta Strategy for Patient Oriented Research Support UnitEdmontonCanada
| | - Xuesong Wang
- ICES (formerly Institute for Clinical Evaluative Sciences)TorontoCanada
| | - Anna Chu
- ICES (formerly Institute for Clinical Evaluative Sciences)TorontoCanada
- University of TorontoCanada
| | - Shaun G. Goodman
- The Department of MedicineFaculty of Medicine and DentistryUniversity of AlbertaEdmontonAlbertaCanada
- The Canadian VIGOUR CentreUniversity of AlbertaEdmontonCanada
- University of TorontoCanada
- Division of CardiologySt. Michael’s HospitalTorontoCanada
| | - Sean van Diepen
- The Canadian VIGOUR CentreUniversity of AlbertaEdmontonCanada
- Department of Critical Care MedicineUniversity of AlbertaEdmontonCanada
- Division of CardiologyDepartment of MedicineUniversity of AlbertaEdmontonCanada
| | - Cynthia A. Jackevicius
- ICES (formerly Institute for Clinical Evaluative Sciences)TorontoCanada
- University of TorontoCanada
- Western University of Health SciencesPomonaCA
| | - Padma Kaul
- The Department of MedicineFaculty of Medicine and DentistryUniversity of AlbertaEdmontonAlbertaCanada
- The Canadian VIGOUR CentreUniversity of AlbertaEdmontonCanada
| | - Jacob Udell
- ICES (formerly Institute for Clinical Evaluative Sciences)TorontoCanada
- University of TorontoCanada
- University Health NetworkTorontoCanada
| | - Dennis T. Ko
- ICES (formerly Institute for Clinical Evaluative Sciences)TorontoCanada
- Schulich Heart ProgramSunnybrook Health Sciences CentreTorontoCanada
| | - Jeffrey C. Kwong
- ICES (formerly Institute for Clinical Evaluative Sciences)TorontoCanada
- University of TorontoCanada
- Public Health OntarioTorontoCanada
| | - Peter C. Austin
- ICES (formerly Institute for Clinical Evaluative Sciences)TorontoCanada
- University of TorontoCanada
| | - Douglas S. Lee
- ICES (formerly Institute for Clinical Evaluative Sciences)TorontoCanada
- University of TorontoCanada
- University Health NetworkTorontoCanada
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Wang K, Youngson E, Bakal JA, Thomas J, McAlister FA, Oudit GY. Cardiac reverse remodelling and health status in patients with chronic heart failure. ESC Heart Fail 2021; 8:3106-3118. [PMID: 34002942 PMCID: PMC8318501 DOI: 10.1002/ehf2.13417] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/10/2021] [Accepted: 04/30/2021] [Indexed: 12/16/2022] Open
Abstract
AIMS This study aims to assess long-term changes in left ventricular ejection fraction (LVEF) together with echocardiographic markers of cardiac remodelling and their association with prognosis and patient-reported quality of life (QoL). METHODS AND RESULTS We conducted a retrospective analysis of serial echocardiograms performed between January 2009 and December 2019 in 1089 patients (median age 63 years, 71.0% men) enrolled in the Mazankowski Heart Function Clinic Registry who had at least two echocardiograms separated by ≥12 months. We classified the patients into four subgroups by their baseline and LVEF trajectories: persistent heart failure with reduced ejection fraction (persistent HFrEF, n = 364), recovered ejection fraction (HFrecEF, n = 325), transient recovery in ejection fraction (HFtrecEF, n = 117), and preserved ejection fraction (HFpEF, n = 283); 4490 echocardiograms were included in the present analysis, with 4.1 ± 1.8 echocardiograms available per patient during follow-up. Reductions in echocardiographic markers of cardiac remodelling, including LVIDd [adjusted odds ratio (aOR): 2.22, 95% confidence interval (CI) 1.75-2.86], LVIDs (aOR: 2.44, 95% CI 2.00-2.94), left ventricular mass index (aOR: 1.15, 95% CI 1.09-1.22), E/e' ratio (aOR: 1.15, 95% CI 1.02-1.30), left atrial volume index (aOR: 1.10, 95% CI 1.03-1.16), along with an increase in the maximum recommended daily dose of renin-angiotensin system inhibitors (aOR: 1.04, 95% CI 1.01-1.07) and mineralocorticoid-receptor antagonists (aOR: 1.06, 95% CI 1.01-1.11) at 2 years, strongly predicted the HFrecEF classification, which was further sustained at 5 years of follow-up. However, changes in these parameters were mostly absent in patients experiencing only a transient recovery in LVEF (HFtrecEF), closely resembling patients with persistent HFrEF. In the multivariable analysis, HFrecEF patients had lower risk of all-cause mortality alone [adjusted hazard ratio (aHR): 0.46, 95% CI 0.23-0.93], and composite all-cause (aHR: 0.59, 95% CI 0.49-0.73), cardiovascular (aHR: 0.47, 95% CI 0.36-0.61), and heart failure (aHR: 0.50, 95% CI 0.35-0.70) related hospitalizations with mortality than patients with persistent HFrEF. QoL assessed through the shortened Kansas City Cardiomyopathy Questionnaire-12 at the end of follow-up was greater in patients with HFrecEF by 5.2, 12.4, and 9.4 points than persistent HFrEF, HFtrecEF, and HFpEF, respectively. CONCLUSIONS Patients with HFrecEF experienced progressive normalization in echocardiographic markers of cardiac remodelling characterized by reductions in left ventricular dimensions and mass in tandem with reductions in left atrial volume and E/e' ratio, which is associated with better prognosis and QoL.
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Affiliation(s)
- Kaiming Wang
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, T6G 2S2, Canada.,Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Erik Youngson
- Alberta Strategy for Patient Oriented Research (SPOR) Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Jeffrey A Bakal
- Alberta Strategy for Patient Oriented Research (SPOR) Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Jissy Thomas
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, T6G 2S2, Canada.,Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Finlay A McAlister
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.,Alberta Strategy for Patient Oriented Research (SPOR) Unit, University of Alberta, Edmonton, Alberta, Canada.,Division of General Internal Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Gavin Y Oudit
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, T6G 2S2, Canada.,Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
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7
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Sandhu RK, Islam S, Dover D, Andrade JG, Ezekowitz J, McAlister FA, Hawkins NM, Kaul P. Real world Data on the Concurrent Use of P-glycoprotein or Cytochrome 3A4 Drugs and Non-vitamin K Antagonist Oral Anticoagulants in Non-Valvular Atrial Fibrillation. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 8:195-201. [PMID: 33480405 DOI: 10.1093/ehjqcco/qcab002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 01/01/2021] [Accepted: 01/06/2021] [Indexed: 12/18/2022]
Abstract
AIM To determine the concurrent use of P-glycoprotein (P-gp) or Cytochrome (CYP) 3A4 drugs and non-vitamin K antagonist oral anticoagulants (NOACs) among non-valvular AF (NVAF) patients in clinical practice. METHODS AND RESULTS Administrative databases identified all adults (≥ 18 years) with incident or prevalent NVAF who initiated a NOAC in an outpatient or inpatient setting, between July 2012-March 2019 in Alberta, Canada. Concurrent use was defined as a P-gp or CYP3A4 dispensation in the 100 days prior to and overlapping NOAC dispensation. The P-gp and CYP3A4 drugs were categorized into 3 groups and drug-drug interactions classified according to the 2018 European Heart Rhythm Association practical guide. Time-varying Cox models calculated crude hazard ratio (HR) of outcomes at 1-year. A total of 642,255 NOAC dispensations occurred for 36,566 NVAF patients. Of these, 71,643 (11.2%) had a concurrent dispensation of an interacting P-gp or CYP3A4 drug. Overall, the drug-drug interaction was defined as contraindicated in 2.5%, avoid/caution in 2.3%, and for another 6.7% should require a dose adjustment. When all drug-drug interactions were considered, inappropriate NOAC prescribing occurred in 63% (n = 45,080) of dispensations. There was a significantly higher risk of death (HR 1.58, 1.47-1.70) for a drug-drug interaction but not for stroke (p = 0.89) or major bleeding risk (p = 0.13). CONCLUSIONS The concurrent use of P-gp or CYP3A4 drugs and NOACs was uncommon but important since almost two-thirds of patients with drug-drug interactions had inappropriate NOAC dosing and a higher risk of death. More attention to this issue is needed.
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Affiliation(s)
- Roopinder K Sandhu
- Division of Cardiology, University of Alberta, Edmonton, Canada.,Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada
| | | | - Douglas Dover
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada
| | - Jason G Andrade
- Dvision of Cardiology, University of British Columbia, Vancouver, Canada
| | - Justin Ezekowitz
- Division of Cardiology, University of Alberta, Edmonton, Canada.,Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada
| | - Finlay A McAlister
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada.,Division of General Medicine, University of Alberta, Edmonton, Canada
| | | | - Padma Kaul
- Division of Cardiology, University of Alberta, Edmonton, Canada.,Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada
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McAlister FA, Tonelli M, Wiebe N, Lin M, Svenson LW, Dean S. The ecology of medical care for adults in Alberta, 2002/03 to 2016/17: a retrospective cohort study. CMAJ Open 2020; 8:E169-E177. [PMID: 32184280 PMCID: PMC7082108 DOI: 10.9778/cmajo.20190188] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND If we are to improve the patient experience, knowing where and with whom people receive professional health advice and treatment (the ecology of medical care) is the first step. We designed this study to define the ecology of medical care in Alberta and to examine whether province-wide implementation of 5 policy changes between 2003 and 2012 changed patterns of care among adults in the province. METHODS This was a retrospective cohort study of adults (age ≥ 18 yr) in Alberta using routinely collected data from 6 linked administrative health databases, the 2016 Canadian Community Health Survey and the Alberta Health Link teletriage system. We collected data on all encounters with pharmacists, primary care physicians, specialists, emergency departments and hospitals in 2002/03, 2009/10 and 2016/17. RESULTS Between 2002/03 and 2016/17, the community-dwelling adult population of Alberta increased from 2.66 million to 3.84 million; the median age increased from 41 to 43 years, and the proportion with at least 1 ambulatory-care-sensitive condition increased from 20.6% to 27.8%. The proportion who saw a primary care physician decreased significantly (from 70.8% to 68.2%, p < 0.001), as did the proportion who visited an emergency department (from 20.6% to 19.2%, p < 0.001); the declines were seen in all subgroups examined. The proportion who saw a specialist as an outpatient increased from 31.9% to 33.2% (p < 0.001), and the proportion who received at least 1 medication dispensation increased from 54.9% to 60.2% (p < 0.001). The proportion admitted to an acute care hospital (5.6%-6.5%) or academic hospital (1.2%) was relatively stable over time. INTERPRETATION Despite implementation of 5 system-wide changes designed to affect the delivery of primary and specialty medical care as well as the use of pharmacist and nursing services in Alberta, patterns of health care delivery changed little between 2002/03 and 2016/17. Rather than searching for a policy "magic bullet," health care planners may be better served by focusing on upscaling and implementing interventions proven to be efficacious.
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Affiliation(s)
- Finlay A McAlister
- Division of General Internal Medicine (McAlister), Alberta SPOR Support Unit Data Platform (McAlister, Lin) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Lin), University of Alberta, Edmonton, Alta.; Departments of Medicine (Tonelli, Svenson) and Community Health Sciences (Tonelli, Svenson), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Nephrology (Wiebe), Department of Medicine, University of Alberta; Alberta Health (Svenson); Division of Preventive Medicine (Svenson) and School of Public Health (Svenson), University of Alberta, Edmonton, Alta.; Data Integration Measurement and Reporting (Dean), Alberta Health Services, Calgary, Alta.
| | - Marcello Tonelli
- Division of General Internal Medicine (McAlister), Alberta SPOR Support Unit Data Platform (McAlister, Lin) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Lin), University of Alberta, Edmonton, Alta.; Departments of Medicine (Tonelli, Svenson) and Community Health Sciences (Tonelli, Svenson), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Nephrology (Wiebe), Department of Medicine, University of Alberta; Alberta Health (Svenson); Division of Preventive Medicine (Svenson) and School of Public Health (Svenson), University of Alberta, Edmonton, Alta.; Data Integration Measurement and Reporting (Dean), Alberta Health Services, Calgary, Alta
| | - Natasha Wiebe
- Division of General Internal Medicine (McAlister), Alberta SPOR Support Unit Data Platform (McAlister, Lin) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Lin), University of Alberta, Edmonton, Alta.; Departments of Medicine (Tonelli, Svenson) and Community Health Sciences (Tonelli, Svenson), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Nephrology (Wiebe), Department of Medicine, University of Alberta; Alberta Health (Svenson); Division of Preventive Medicine (Svenson) and School of Public Health (Svenson), University of Alberta, Edmonton, Alta.; Data Integration Measurement and Reporting (Dean), Alberta Health Services, Calgary, Alta
| | - Meng Lin
- Division of General Internal Medicine (McAlister), Alberta SPOR Support Unit Data Platform (McAlister, Lin) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Lin), University of Alberta, Edmonton, Alta.; Departments of Medicine (Tonelli, Svenson) and Community Health Sciences (Tonelli, Svenson), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Nephrology (Wiebe), Department of Medicine, University of Alberta; Alberta Health (Svenson); Division of Preventive Medicine (Svenson) and School of Public Health (Svenson), University of Alberta, Edmonton, Alta.; Data Integration Measurement and Reporting (Dean), Alberta Health Services, Calgary, Alta
| | - Lawrence W Svenson
- Division of General Internal Medicine (McAlister), Alberta SPOR Support Unit Data Platform (McAlister, Lin) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Lin), University of Alberta, Edmonton, Alta.; Departments of Medicine (Tonelli, Svenson) and Community Health Sciences (Tonelli, Svenson), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Nephrology (Wiebe), Department of Medicine, University of Alberta; Alberta Health (Svenson); Division of Preventive Medicine (Svenson) and School of Public Health (Svenson), University of Alberta, Edmonton, Alta.; Data Integration Measurement and Reporting (Dean), Alberta Health Services, Calgary, Alta
| | - Stafford Dean
- Division of General Internal Medicine (McAlister), Alberta SPOR Support Unit Data Platform (McAlister, Lin) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Lin), University of Alberta, Edmonton, Alta.; Departments of Medicine (Tonelli, Svenson) and Community Health Sciences (Tonelli, Svenson), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Nephrology (Wiebe), Department of Medicine, University of Alberta; Alberta Health (Svenson); Division of Preventive Medicine (Svenson) and School of Public Health (Svenson), University of Alberta, Edmonton, Alta.; Data Integration Measurement and Reporting (Dean), Alberta Health Services, Calgary, Alta
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