Case definitions for acute myocardial infarction in administrative databases and their impact on in-hospital mortality rates

Risk Factors, Use of Revascularization, and Outcomes in Young Adults With ST-Elevation Myocardial Infarction

The incidence of acute myocardial infarction is increasing in younger age groups, with differences in treatment and outcomes based on gender. ST-elevation myocardial infarction (STEMI) in young adults, however, is incompletely understood as most of the current studies were performed in homogenous populations, did not focus on STEMI, and lack direct comparisons with older adults. We performed a retrospective observational study using the Statewide Planning And Research Cooperative System for all admissions in New York State with a principal diagnosis of STEMI from 2011 to 2018. There were 58,083 STEMIs with the majority being male (68.2%) and non-Hispanic White (64.8%), with an average age of 63.9 ± 13.9 years. Of these, 8,494 (14.6%) occurred in patients aged <50 years. The proportion of STEMIs in women increased with age, from 19.2% in the <50-year-old age group to 48.9% in the ≥70-year-old age group. Young adults with STEMI had greater prevalence of obesity, current tobacco use, other substance use, and major psychiatric disorders, were more likely to receive revascularization, and had lower 1-year mortality than older age groups. Revascularization was associated with at least a 3 times lower odds ratio of 1-year mortality in all age groups. In conclusion, young adults with STEMI had a unique set of risk factors and co-morbidities and were more likely to undergo revascularization than older age groups. In all age groups, female gender was associated with a higher burden of co-morbidities, decreased use of revascularization, and increased 1-year mortality.

Validated administrative data based ICD-10 algorithms for chronic conditions: A systematic review

OBJECTIVE

This systematic review aimed to identify ICD-10 based validated algorithms for chronic conditions using health administrative data.

METHODS

A comprehensive systematic literature search using Ovid MEDLINE, Embase, PsycINFO, Web of Science and CINAHL was performed to identify studies, published between 1983 and May 2023, on validated algorithms for chronic conditions using administrative health data. Two reviewers independently screened titles and abstracts and reviewed full text of selected studies to complete data extraction. A third reviewer resolved conflicts arising at the screening or study selection stages. The primary outcome was validated studies of ICD-10 based algorithms with both sensitivity and PPV of ≥70 %. Studies with either sensitivity or PPV <70 % were included as secondary outcomes.

RESULTS

Overall, the search identified 1686 studies of which 54 met the inclusion criteria. Combining a previously published literature search, a total of 61 studies were included for data extraction. The study identified 40 chronic conditions with high validity and 22 conditions with moderate validity. The validated algorithms were based on administrative data from different countries including Canada, USA, Australia, Japan, France, South Korea, and Taiwan. The algorithms identified included several types of cancers, cardiovascular conditions, kidney diseases, gastrointestinal disorders, and peripheral vascular diseases, amongst others.

CONCLUSION

With ICD-10 prominently used across the world, this up-to-date systematic review can prove to be a helpful resource for research and surveillance initiatives using administrative health data for identifying chronic conditions.

An Interrupted Time-Series Analysis of the Impact of COVID-19 on Hospitalizations for Vascular Events in 3 Canadian Provinces

Background

COVID-19 infection is associated with a pro-coagulable state, thrombosis, and cardiovascular events. However, its impact on population-based rates of vascular events is less well understood. We studied temporal trends in hospitalizations for stroke and myocardial infarction in 3 Canadian provinces (Alberta, Ontario, and Nova Scotia) between 2014 and 2022.

Methods

Linked administrative data from each province were used to identify admissions for ischemic stroke, intracerebral hemorrhage, cerebral venous thrombosis, and myocardial infarction. Event rates per 100,000/quarter, standardized to the 2016 Canadian population, were calculated. We assessed changes from quarterly rates pre-pandemic (2014-2020), compared to rates in the pandemic period (2020-2022), using interrupted time-series analysis with a jump discontinuity at pandemic onset. Age group- and sex-stratified analyses also were performed.

Results

We identified 162,497 strokes and 243,182 myocardial infarctions. At pandemic onset, no significant step change in strokesper 100,000/quarter was observed in any of the 3 provinces. During the pandemic, stroke rates were stable in Alberta and Ontario, but they increased in Nova Scotia (0.44 per 100,000/quarter, P = 0.004). At pandemic onset, a significant step decrease occurred in myocardial infarctions per 100,000/quarter in Alberta (4.72, P < 0.001) and Ontario (4.84, P < 0.001), but not in Nova Scotia. During the pandemic, myocardial infarctions per 100,000/quarter decreased in Alberta (-0.34, P = 0.01), but they remained stable in Ontario and Nova Scotia. No consistent patterns by age group or sex were noted.

Conclusions

Hospitalization rates for stroke or myocardial infarction across 3 Canadian provinces did not increase substantially during the first 2 years of the pandemic. Continued surveillance is warranted as the virus becomes endemic.

Assessment of the impact of resting heart rate on the risk of major adverse cardiovascular events after ischemic stroke: a retrospective observational study

BACKGROUND

Although elevated heart rate is a risk factor for cardiovascular morbidity and mortality in healthy people, the association between resting heart rate and major cardiovascular risk in patients after acute ischemic stroke remains debated. This study evaluated the association between heart rate and major adverse cardiovascular events after ischemic stroke.

METHODS

We conducted a retrospective cohort study analyzing data from the Chang Gung Research Database for 21,655 patients with recent ischemic stroke enrolled between January 1, 2010, and September 30, 2018. Initial in-hospital heart rates were averaged and categorized into 10-beats per minute (bpm) increments. The primary outcome was the composite of hospitalization for recurrent ischemic stroke, myocardial infarction, or all-cause mortality. Secondary outcomes were hospitalization for recurrent ischemic stroke, myocardial infarction, and heart failure. Hazard ratios and 95% confidence intervals (CIs) were estimated using Cox proportional hazards models, using the heart rate < 60 bpm subgroup as the reference.

RESULTS

After a median follow-up of 3.2 years, the adjusted hazard ratios for the primary outcome were 1.13 (95% CI: 1.01 to 1.26) for heart rate 60-69 bpm, 1.35 (95% CI: 1.22 to 1.50) for heart rate 70-79 bpm, 1.64 (95% CI: 1.47 to 1.83) for heart rate 80-89 bpm, and 2.08 (95% CI: 1.85 to 2.34) for heart rate ≥ 90 bpm compared with the reference group. Heart rate ≥ 70 bpm was associated with increased risk of all secondary outcomes compared with the reference group except heart failure.  CONCLUSIONS: Heart rate is a simple measurement with important prognostic implications. In patients with ischemic stroke, initial in-hospital heart rate was associated with major adverse cardiovascular events.

Trends and Outcomes of Acute Myocardial Infarction During the Early COVID-19 Pandemic in the United States: A National Inpatient Sample Study

BACKGROUND AND OBJECTIVES

There are limited national data on the trends and outcomes of patients hospitalized with acute myocardial infarction (AMI) during the coronavirus disease 2019 (COVID-19) pandemic. We aimed to evaluate the impact of early COVID-19 pandemic on the trends and outcomes of AMI using the National Inpatient Sample (NIS) database.

METHODS

The NIS database was queried from January 2019 to December 2020 to identify adult (age ≥18 years) AMI hospitalizations and were categorized into ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) based on International Classification of Diseases, Tenth Revision, Clinical Modification codes. In addition, the in-hospital mortality, revascularization, and resource utilization of AMI hospitalizations early in the COVID-19 pandemic (2020) were compared to those in the pre-pandemic period (2019) using multivariate logistic and linear regression analysis.

RESULTS

Amongst 1,709,480 AMI hospitalizations, 209,450 STEMI and 677,355 NSTEMI occurred in 2019 while 196,230 STEMI and 626,445 NSTEMI hospitalizations occurred in 2020. Compared with those in 2019, the AMI hospitalizations in 2020 had higher odds of in-hospital mortality (adjusted odds ratio [aOR], 1.27; 95% confidence interval [CI], [1.23-1.32]; p<0.01) and lower odds of percutaneous coronary intervention (aOR, 0.95 [0.92-0.99]; p=0.02), and coronary artery bypass graft (aOR, 0.90 [0.85-0.97]; p<0.01).

CONCLUSIONS

We found a significant decline in AMI hospitalizations and use of revascularization, with higher in-hospital mortality, during the early COVID-19 pandemic period (2020) compared with the pre-pandemic period (2019). Further research into the factors associated with increased mortality could help with preparedness in future pandemics.

Effect of Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers After Coronary Artery Bypass Graft Surgery: A Population-Based Cohort Study

BACKGROUND

The effect of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARBs) on major adverse cardiovascular events (MACE) in patients who undergo coronary artery bypass graft surgery is equivocal. This retrospective, population-based cohort study evaluated effect of exposure to an ACEI/ARB on MACE using linked administrative databases that included all cardiac revascularization procedures, hospitalizations, and prescriptions for the population of British Columbia, Canada.

METHODS AND RESULTS

All adults who underwent coronary artery bypass graft surgery between 2002 and 2020 were eligible. The primary outcome was time to MACE, defined as a composite of all-cause death, myocardial infarction, and ischemic stroke using Cox proportional hazards models with inverse probability treatment weighting. Included were 15 439 patients and 6191 (40%) were prescribed an ACEI/ARB. Mean age was 66 years, 83% were men, and 16% had heart failure (HF). Median exposure time was 40 months. Over the 5-year follow-up, 1623 MACE occurred. Impact of exposure was different for patients with and without HF (P <0.0001 for interaction). After probability-weighting and adjustment for relevant covariates, exposure to ACEI/ARBs was associated with a lower hazard of MACE in patients with HF at 1 year (hazard ratio, 0.13 [95% CI, 0.09-0.19]) and 5 years (hazard ratio, 0.36 [95% CI, 0.30-0.44]). In patients without HF, ACEI/ARBs had a lower hazard of MACE at 1 year (hazard ratio, 0.35 [95% CI, 0.27-0.46]) and 5 years (hazard ratio, 0.66 [95% CI, 0.58-0.76]).

CONCLUSIONS

In this population-based study, ACEI/ARBs were associated with a lower hazard of MACE in a cohort of patients post-coronary artery bypass graft surgery irrespective of HF status.

Hydroxychloroquine use is associated with reduced mortality risk in older adults with rheumatoid arthritis

BACKGROUND

There is little robust data about the cardiovascular safety of hydroxychloroquine in patients with rheumatoid arthritis (RA), who often have cardiovascular comorbidities. We examined the association between use of hydroxychloroquine (HCQ) in patients with RA and major adverse cardiovascular events (MACE).

METHODS

In a retrospective cohort of Medicare beneficiaries aged ≥ 65 years with RA, we identified patients who initiated HCQ (users) and who did not initiate HCQ (non-users) between January 2015-June 2017. Each HCQ user was matched to 2 non-users of HCQ using propensity score derived from patient baseline characteristics. The primary outcome was the occurrence of MACE, defined as acute admissions for stroke, myocardial infarction, or heart failure. Secondary outcomes included all-cause mortality and the composite of MACE and all-cause mortality. Cox proportional hazards model was used to compare outcomes between HCQ users to non-users.

RESULTS

The study included 2380 RA patients with incident HCQ use and matched 4633 HCQ non-users over the study period. The mean follow-up duration was 1.67 and 1.63 years in HCQ non-users and users, respectively. In multivariable models, use of HCQ was not associated with the risk of MACE (hazard ratio 1.1; 95% CI: 0.832-1.33). However, use of HCQ was associated with a lower risk of all-cause mortality (HR: 0.54; 95% CI: 0.45-0.64) and the composite of all-cause mortality and MACE (HR 0.67; 95% CI: 0.58-0.78).

CONCLUSION

HCQ use was independently associated with a lower risk of mortality in older adults with RA but not with incidence of MACE events. Key Points • Using an incident user design (to avoid the biases of a prevalent user design) and a population-based approach, we examined the effect of hydroxychloroquine (HCQ) on the risk of major cardiovascular events (MACE) in older patients with RA. • We did not find an association between HCQ use and incident MACE. We did, however, find a significant association with the composite outcome (MACE and all-cause mortality) driven by a significant reduction in all-cause mortality with HCQ use.

Trends in acute myocardial infarction mortality in the European Union, 2012-2020

AIMS

To assess the sex- and age-specific trends in acute myocardial infarction (AMI) mortality in the modern European Union (EU-27) member states between years 2012 and 2020.

METHODS AND RESULTS

Data on cause-specific deaths and population numbers by sex for each country of the EU-27 were retrieved through a publicly available European Statistical Office (EUROSTAT) dataset for the years 2012 to 2020. AMI-related deaths were ascertained when codes for AMI (ICD-10 codes I21.0-I22.0) were listed as the underlying cause of death in the medical death certificate. Deaths occurring before the age of 65 years were defined as premature deaths. To calculate annual trends, we assessed the average annual percent change (AAPC) with relative 95% confidence intervals (CIs) using joinpoint regression. During the study period, 1 793 314 deaths (1 048 044 males and 745 270 females) occurred in the EU-27 due to of AMI. The proportion of AMI-related deaths per 1000 total deaths decline from 5.0% to 3.5% both in the entire population (P for trend < 0.001) and in males or females, separately. Joinpoint regression analysis revealed a continuous linear decrease in age-adjusted AMI-related mortality from 2012 to 2020 among EU-27 members [AAPC: -4.6% (95% CI: -5.1 to -4.0), P < 0.001]. The age-adjusted mortality rate showed a plateau in some Eastern European countries and was more pronounced in EU-27 females and in subjects aged ≥65 years.

CONCLUSION

Over the last decade, the age-adjusted AMI-related mortality has been continuously declining in most of the in EU-27 member states. However, some disparities still exist between western and eastern European countries.

Morbidity and healthcare use among mothers of children with cancer: A population-based study

BACKGROUND

The impact of a child's cancer diagnosis on subsequent maternal physical health is unclear.

METHODS

We identified all Ontario children diagnosed less than 18 years with cancer between 1992 and 2017. Linkage to administrative databases identified mothers who were matched to population controls. We identified physical health conditions, acute healthcare use, and preventive healthcare use through validated algorithms using healthcare data, and compared them between exposed (child with cancer) and unexposed mothers. Predictors of health outcomes were assessed among exposed mothers.

RESULTS

We identified 5311 exposed mothers and 19,516 matched unexposed mothers. For exposed mothers, median age at last follow-up was 48 years, (interquartile range: 42-53). Exposed mothers had an increased risk of cancer (hazard ratio [HR] 1.2, 95% confidence interval [95% CI]: 1.0-1.5, p = .03), but not of any other adverse physical outcomes or of increased acute healthcare use. Exposed mothers were more likely to receive influenza vaccinations (odds ratio 1.4, 95% CI: 1.3-1.5, p < .0001), and underwent cancer screening at the same rate as unexposed mothers. Among exposed mothers, bereavement was associated with a subsequent increased risk of cancer (HR 1.7, 95% CI: 1.2-2.5, p = .004) and death (HR 2.2, 95% CI: 1.2-4.1, p = .01).

CONCLUSION

Mothers of children with cancer are at increased risk of developing cancer, but not of other adverse physical health outcomes, and were equally or more likely to be adherent to preventive healthcare practices. Bereaved mothers were at increased risk of subsequent cancer and death. Interventions targeting specific subpopulations of mothers of children with cancer or focused on screening for specific cancers may be warranted.

Association of Blood Pressure Variability With Death and Discharge Destination Among Critically Ill Patients With and Without Stroke

BACKGROUND AND OBJECTIVES

It is unclear whether blood pressure variability's (BPV) association with worse outcomes is unique to patients with stroke or a risk factor among all critically ill patients. We (1) determined whether BPV differed between patients with stroke and nonstroke patients, (2) examined BPV's associations with in-hospital death and favorable discharge destination in patients with stroke and nonstroke patients, and (3) assessed how minimum mean arterial pressure (MAP)-a correlate of illness severity and cerebral perfusion-affects these associations.

METHODS

This is a retrospective analysis of adult intensive care unit patients hospitalized between 2001 and 2012 from the Medical Information Mart for Intensive Care III database. Confounder-adjusted logistic regressions determined associations between BPV, measured as SD and average real variability (ARV), and (1) in-hospital death and (2) favorable discharge, with testing of minimum MAP for effect modification.

RESULTS

BPV was higher in patients with stroke (N = 2,248) compared with nonstroke patients (N = 9,085) (SD mean difference 2.3, 95% CI 2.1-2.6, p < 0.01). After adjusting for minimum tertile of MAP and other confounders, higher SD remained significantly associated (p < 0.05) with higher odds of in-hospital death for patients with acute ischemic strokes (AISs, odds ratio [OR] 2.7, 95% CI 1.5-4.8), intracerebral hemorrhage (ICH, OR 2.6, 95% CI 1.6-4.3), subarachnoid hemorrhage (SAH, OR 3.4, 95% CI 1.2-9.3), and pneumonia (OR 1.9, 95% CI 1.1-3.3) and lower odds of favorable discharge destination in patients with ischemic stroke (OR 0.3, 95% CI 0.2-0.6) and ICH (OR 0.4, 95% CI 0.3-0.6). No interaction was found between minimum MAP tertile with SD (p > 0.05). Higher ARV was not significantly associated with increased risk of death in any condition when adjusting for illness severity but portended worse discharge destination in those with AIS (OR favorable discharge 0.4, 95% CI 0.3-0.7), ICH (OR favorable discharge 0.5, 95% CI 0.3-0.7), sepsis (OR favorable discharge 0.8, 95% CI 0.6-1.0), and pneumonia (OR favorable discharge 0.5, 95% CI 0.4-0.8).

DISCUSSION

BPV is higher and generally associated with worse outcomes among patients with stroke compared with nonstroke patients. BPV in patients with AIS and patients with ICH may be a marker of central autonomic network injury, although clinician-driven blood pressure goals likely contribute to the association between BPV and outcomes.

SGLT2 Inhibitors Are Associated With Reduced Cardiovascular Disease in Patients With Type 2 Diabetes: An Analysis of Real-World Data

OBJECTIVE

To assess the association between sodium-glucose cotransporter-2 (SGLT2) inhibitors and other second-line diabetes therapies with risk of cardiovascular disease (CVD), as well as conduct head-to-head comparisons between SGLT2 inhibitors.

PATIENTS AND METHODS

Using data from the MarketScan databases (January 1, 2013, through December 31, 2019), SGLT2 inhibitor users were matched with up to five other second-line therapy users by age, sex, date of enrollment, and date of second-line therapy initiation. The primary composite outcome included stroke, atrial fibrillation, myocardial infarction, and heart failure. Hazard ratios were estimated, adjusting for demographics and a propensity score reflecting comorbidities and medications.

RESULTS

In this study population of 313,396 patients (mean age 53±10 years; 47% female), 9787 incident CVD events occurred over a median follow-up of 1.36 years. After multivariable adjustments, SGLT2 inhibitor users had a lower risk of CVD than other second-line therapy users (HR, 0.66; 95% CI, 0.62 to 0.71). Significant associations were also observed when each CVD outcome was assessed separately. No differences were noted when comparing individual SGLT2 inhibitors.

CONCLUSION

SGLT2 inhibitors were associated with a clinically meaningfully lower CVD risk in the real-world setting. In head-to-head comparisons, the different SGLT2 inhibitors were consistent in their protective associations with CVD. This suggests that as a class, SGLT2 inhibitors may have widespread benefit in preventing CVD among patients with type 2 diabetes.

[Are Prevalence Rates Comparable in Survey and Routine Data? Prevalence of Myocardial Infarction in Claims Data of the AOK Lower Saxony and in Data of German Health Interview and Examination (DEGS1)]

AIMS OF THE STUDY

This study compared prevalences of myocardial infarction between data drawn from health interviews and claims data from statutory health insurance. Previous comparative studies have drawn comparisons without having considered possible differences in the sociodemographic structure of the underlying study populations. The approach applied here aimed to match the sociodemographic structure via available information in both datasets and to compare prevalences in parallelized samples.

METHODOLOGY

Data from the German Health Interview and Examination Study for Adults (DEGS1) and claims data from the AOK Lower Saxony (AOKN) were used. To match the sociodemographic structure of the two data sets, a parallelized sample was drawn from the AOKN data according to sex, age, and vocational training qualification. As part of a sensitivity analysis, additional samples were drawn and a mean overall prevalence was calculated from them.

RESULTS

Data from 5779 DEGS1 respondents and 22 534 AOKN insured persons were used for the analysis. After parallelization of the AOKN-sample by sex, age, and vocational training qualification, no significant differences in prevalence of myocardial infarction could be found between claims data from the AOKN and data from the DEGS1 Health Survey. In men, there were tendencies toward lower prevalence of myocardial infarction in the AOKN data. Possible explanations include the selection of less morbid insured persons by using the vocational education degree for parallelization or memory discrepancies in survey data.

CONCLUSION

Differences in sociodemographic structure may play a role the interpretation of disease prevalence from difference data sources. This can be compensated for by parallelizing the samples. Future comparative analyses should take into account characteristics of the socioeconomic status. Similar analyses of other diseases such as stroke, diabetes, and metabolic disorders would be desirable.

Personalized prediction of incident hospitalization for cardiovascular disease in patients with hypertension using machine learning

BACKGROUND

Prognostic information for patients with hypertension is largely based on population averages. The purpose of this study was to compare the performance of four machine learning approaches for personalized prediction of incident hospitalization for cardiovascular disease among newly diagnosed hypertensive patients.

METHODS

Using province-wide linked administrative health data in Alberta, we analyzed a cohort of 259,873 newly-diagnosed hypertensive patients from 2009 to 2015 who collectively had 11,863 incident hospitalizations for heart failure, myocardial infarction, and stroke. Linear multi-task logistic regression, neural multi-task logistic regression, random survival forest and Cox proportional hazard models were used to determine the number of event-free survivors at each time-point and to construct individual event-free survival probability curves. The predictive performance was evaluated by root mean squared error, mean absolute error, concordance index, and the Brier score.

RESULTS

The random survival forest model has the lowest root mean squared error value at 33.94 and lowest mean absolute error value at 28.37. Machine learning methods provide similar discrimination and calibration in the personalized survival prediction of hospitalizations for cardiovascular events in patients with hypertension. Neural multi-task logistic regression model has the highest concordance index at 0.8149 and lowest Brier score at 0.0242 for the personalized survival prediction.

CONCLUSIONS

This is the first personalized survival prediction for cardiovascular diseases among hypertensive patients using administrative data. The four models tested in this analysis exhibited a similar discrimination and calibration ability in predicting personalized survival prediction of hypertension patients.

Contributions of event rates, pre-hospital deaths, and deaths following hospitalisation to variations in myocardial infarction mortality in 326 districts in England: a spatial analysis of linked hospitalisation and mortality data

BACKGROUND

Myocardial infarction mortality varies substantially within high-income countries. There is limited guidance on what interventions-including primary and secondary prevention, or improvement of care pathways and quality-can reduce myocardial infarction mortality. Our aim was to understand the contributions of incidence (event rate), pre-hospital deaths, and hospital case fatality to the variations in myocardial infarction mortality within England.

METHODS

We used linked data from national databases on hospitalisations and deaths with acute myocardial infarction (ICD-10 codes I21 and I22) as a primary hospital diagnosis or underlying cause of death, from Jan 1, 2015, to Dec 31, 2018. We used geographical identifiers to estimate myocardial infarction event rate (number of events per 100 000 population), death rate (number of deaths per 100 000 population), total case fatality (proportion of events that resulted in death), pre-hospital fatality (proportion of events that resulted in pre-hospital death), and hospital case fatality (proportion of admissions due to myocardial infarction that resulted in death within 28 days of admission) for men and women aged 45 years and older across 326 districts in England. Data were analysed in a Bayesian spatial model that accounted for similarities and differences in spatial patterns of fatal and non-fatal myocardial infarction. Age-standardised rates were calculated by weighting age-specific rates by the corresponding national share of the appropriate denominator for each measure.

FINDINGS

From 2015 to 2018, national age-standardised death rates were 63 per 100 000 population in women and 126 per 100 000 in men, and event rates were 233 per 100 000 in women and 512 per 100 000 in men. After age-standardisation, 15·0% of events in women and 16·9% in men resulted in death before hospitalisation, and hospital case fatality was 10·8% in women and 10·6% in men. Across districts, the 99th-to-1st percentile ratio of age-standardised myocardial infarction death rates was 2·63 (95% credible interval 2·45-2·83) in women and 2·56 (2·37-2·76) in men, with death rates highest in parts of northern England. The main contributor to this variation was myocardial infarction event rate, with a 99th-to-1st percentile ratio of 2·55 (2·39-2·72) in women and 2·17 (2·08-2·27) in men across districts. Pre-hospital fatality was greater than hospital case fatality in every district. Pre-hospital fatality had a 99th-to-1st percentile ratio of 1·60 (1·50-1·70) in women and 1·75 (1·66-1·86) in men across districts, and made a greater contribution to variation in total case fatality than did hospital case fatality (99th-to-1st percentile ratio 1·39 [1·29-1·49] and 1·49 [1·39-1·60]). The contribution of case fatality to variation in deaths across districts was largest in women aged 55-64 and 65-74 years and in men aged 55-64, 65-74, and 75-84 years. Pre-hospital fatality was slightly higher in men than in women in most districts and age groups, whereas hospital case fatality was higher in women in virtually all districts at ages up to and including 65-74 years.

INTERPRETATION

Most of the variation in myocardial infarction mortality in England is due to variation in myocardial infarction event rate, with a smaller role for case fatality. Most variation in case fatality occurs before rather than after hospital admission. Reducing subnational variations in myocardial infarction mortality requires interventions that reduce event rate and pre-hospital deaths.

FUNDING

Wellcome Trust, British Heart Foundation, Medical Research Council (UK Research and Innovation), and National Institute for Health Research (UK).

Morbidity and health care use among siblings of children with cancer: A population-based study

BACKGROUND

Childhood cancer impacts the entire family unit. We sought to investigate its impact on the long-term physical health outcomes of siblings of children with cancer.

PROCEDURE

Pediatric cancer patients diagnosed in Ontario, Canada between 1988 and 2016 were linked to biological siblings. Sibling cases were matched to population controls based on sex, age, geographic location, and number of other children in the family. After individual linkage to health services data, we compared several outcomes between sibling cases and controls: (a) physical health conditions (such as diabetes, hypertension, and death); (b) acute health care use (hospitalization, low- and high-acuity emergency department [ED] visits); and (c) preventive health care use (periodic health checkups, influenza vaccinations). Cox proportional hazards, recurrent event, or logistic regression models were used as appropriate.

RESULTS

We identified 8529 sibling cases and 30,364 matched controls (median age at index: 6 years, median age at last follow-up 17 years). Compared to controls, siblings were at increased risk of hypertension (hazard ratio [HR] 1.8; 95% confidence interval [CI] 1.1-2.9; p = .01), had higher rates of low- and high-acuity ED visits (rate ratio 1.1; 95% CI 1.1-1.2; p < .001), and increased risk of hospitalization (HR 1.1; 95% CI 1.1-1.2; p < .001). Sibling cases were also more likely to receive preventive health care (p < .05).

CONCLUSION

Increased risk of hypertension, high-acuity ED visits, and hospitalizations suggest that siblings may experience poorer health compared to controls. Counseling families about this potential increased risk and long-term follow-up of siblings to monitor their physical health may be justified.

AlzEye: longitudinal record-level linkage of ophthalmic imaging and hospital admissions of 353 157 patients in London, UK

PURPOSE

Retinal signatures of systemic disease ('oculomics') are increasingly being revealed through a combination of high-resolution ophthalmic imaging and sophisticated modelling strategies. Progress is currently limited not mainly by technical issues, but by the lack of large labelled datasets, a sine qua non for deep learning. Such data are derived from prospective epidemiological studies, in which retinal imaging is typically unimodal, cross-sectional, of modest number and relates to cohorts, which are not enriched with subpopulations of interest, such as those with systemic disease. We thus linked longitudinal multimodal retinal imaging from routinely collected National Health Service (NHS) data with systemic disease data from hospital admissions using a privacy-by-design third-party linkage approach.

PARTICIPANTS

Between 1 January 2008 and 1 April 2018, 353 157 participants aged 40 years or older, who attended Moorfields Eye Hospital NHS Foundation Trust, a tertiary ophthalmic institution incorporating a principal central site, four district hubs and five satellite clinics in and around London, UK serving a catchment population of approximately six million people.

FINDINGS TO DATE

Among the 353 157 individuals, 186 651 had a total of 1 337 711 Hospital Episode Statistics admitted patient care episodes. Systemic diagnoses recorded at these episodes include 12 022 patients with myocardial infarction, 11 735 with all-cause stroke and 13 363 with all-cause dementia. A total of 6 261 931 retinal images of seven different modalities and across three manufacturers were acquired from 1 54 830 patients. The majority of retinal images were retinal photographs (n=1 874 175) followed by optical coherence tomography (n=1 567 358).

FUTURE PLANS

AlzEye combines the world's largest single institution retinal imaging database with nationally collected systemic data to create an exceptional large-scale, enriched cohort that reflects the diversity of the population served. First analyses will address cardiovascular diseases and dementia, with a view to identifying hidden retinal signatures that may lead to earlier detection and risk management of these life-threatening conditions.

Outcomes of Acute Coronary Syndrome in Hospitalized Patients with Celiac Disease, a United States Nationwide Experience

Background: Cardiovascular disease remains the leading cause of death in the United States. Coronary artery disease alone accounted for approximately 13% of deaths in the US in 2016. Some studies have suggested an increased prevalence of coronary artery disease (CAD) in chronic inflammatory conditions, such as celiac disease (CD). Chronic subclinical systemic inflammation, decreased absorption of cardio-protective nutrients and drugs have all been postulated as the driving mechanisms for this increased risk of CAD. Methods: We reviewed a Nationwide Inpatient Sample from 2007 to 2017, using Acute Coronary syndrome as a principal diagnosis with CD as the secondary diagnosis, utilizing validated ICD-9-CM and ICD-10 codes. We examined the annual trends in the number of cases and hospitalization charges yearly and used survey regression to calculate adjusted odds ratios (aOR) for hospital mortality and other outcomes. Results: We identified a total of 8,036,307 ACS hospitalizations from 2007 to 2017, of which 5917 (0.07%) had a diagnosis for CD. The proportion of patients with CD in ACS hospitalizations increased from 0.015% in 2007 to 0.076% in 2017. These patients were significantly older (70.3 vs. 67.4 years, p < 0.02), more likely female (51.9% vs. 39.5%, p < 0.01), and more likely to be white (93.8% vs. 76.6%; p < 0.01) than ACS patients without CD. After adjusting for age, gender, race, Charlson Comorbidity index and hospital level characteristics, ACS hospitalizations for CD patients had a lower odds ratio for hospital mortality (aOR = 0.39; 95% CI = 0.23–0.67; p < 0.01). Additionally, length of stay in this patient population was shorter (4.53 vs. 4.84 days, p < 0.01) but the mean hospitalization charges were higher (USD 64,058 vs. USD 60,223, p < 0.01). Conclusion: We found that the number of ACS-related admissions in CD patients has risen more than five-fold between 2007 and 2017. However, the odds of in-hospital mortality in these patients is not higher than patients without CD. The results of our study demonstrate that although the systemic inflammation related to CD is associated with an increasing prevalence of ACS hospitalizations, on the contrary, the mortality rate is significantly higher in patients without celiac disease.

Cardiovascular and major bleeding outcomes with antiplatelet and direct oral anticoagulants in patients with acute coronary syndrome and atrial fibrillation: A population-based analysis

BACKGROUND

Direct oral anticoagulants (DOACs) are replacing warfarin for stroke prevention in patients with atrial fibrillation (AF).

OBJECTIVE

To assess the effectiveness and safety of concomitant treatment with antiplatelet-DOAC compared to antiplatelet-warfarin in patients with acute coronary syndrome (ACS) and AF.

DESIGN

Retrospective propensity score-matched cohort study using United States-based commercial healthcare database from January 2016 to June 2019.

PARTICIPANTS

New-users of antiplatelet-DOAC and antiplatelet-warfarin who initiated the combined therapy within 30 days following incident ACS diagnosis.

MEASUREMENTS

Primary study outcomes were recurrent cardiovascular diseases (CVD) (ie, a composite of stroke and myocardial infarction) and major bleeding events identified via discharge diagnoses. We controlled for potential confounders via propensity score matching (PSM). We generated marginal hazard ratios (HRs) via Cox proportional hazards regression using a robust variance estimator while adjusting for calendar time.

RESULTS

After PSM, a total of 2,472 persons were included (1,236 users of antiplatelet-DOAC and 1,236 users of antiplatelet-warfarin). The use of antiplatelet-DOAC (vs. antiplatelet-warfarin) was associated with a reduced rate of recurrent CVD (adjusted HR 0.72, 95% confidence interval [CI], 0.56-0.92) and major bleeding events (adjusted HR, 0.49, 95% CI 0.33-0.72).

LIMITATIONS

Residual confounding.

CONCLUSIONS

In real-world data of AF patients with concurrent ACS, the use of antiplatelet-DOAC following ACS diagnosis was associated with a lower rate of recurrent CVD and major bleeding events compared with antiplatelet-warfarin. These findings highlight a potential promising role for DOACs in patients with ACS and AF requiring combined antiplatelet therapy.

Coding Variation and Adherence to Methodological Standards in Cardiac Research Using the National Inpatient Sample

Background: Code selection is crucial to the accuracy and reproducibility of studies using administrative data, however a comprehensive assessment of coding trends for major cardiac diagnoses and procedures is lacking. We aimed to evaluate trends in administrative code utilization for major cardiac diagnoses and procedures, and adherence to required methodological practices in cardiac research using the National Inpatient Sample (NIS).

Methods: In this observational study of 445 articles, ICD-9-CM codes corresponding to acute myocardial infarction (AMI), heart failure, atrial fibrillation, percutaneous coronary intervention, and coronary artery bypass grafting were collected and analyzed. The NIS was used to compare the number of hospitalizations between the most frequently encountered AMI case definitions. Key elements were abstracted from each article to evaluate adherence to required methodological practices.

Results: Variation in code utilization was observed for each diagnosis and procedure assessed, and the number of unique case definitions published per year increased throughout the study period (P < 0.001), driven largely by the significant increase in articles per year (P < 0.001). Off-target codes were observed in 39 (8.8%) studies. Upon reintroduction into the NIS for 2008–2012, the most commonly encountered case definitions for AMI were found to yield significantly different estimates of AMI hospitalizations and hospitalization trends over time. Three hundred and ninety-nine articles (84%) did not adhere to one or more required research practices. Overall adherence was superior for publications in higher-impact journals (P = 0.002).

Conclusions: Substantial variation in code selection exists for major cardiac diagnoses and procedures, and non-adherence to methodological standards is widespread. These data have important implications for the accuracy and generalizability of analyses using the NIS.

Readmission for cardiac and non-cardiac causes among adults with epilepsy or multiple sclerosis - A nationwide analysis

PURPOSE

The aim of this study was to determine proportions of 30-day cardiac readmissions in adults with epilepsy compared to multiple sclerosis (MS) or those with neither condition. Predictors and causes of readmissions were also examined.

METHODS

We used the 2014 Nationwide Readmissions Database and ICD-9-CM codes to identify people with epilepsy, MS, and without epilepsy or MS. Multinomial logistic regressions were fitted to: (1) examine association between 30-day readmissions and epilepsy, MS or neither, and (2) to describe causes and predictors of 30-day readmission for cardiac readmissions in epilepsy.

RESULTS

Out of 6,870,508 adults admitted in 2014, 202,938 (2.98%) had epilepsy and 29,556 (0.45%) had MS. The proportion of 30-day readmission for epilepsy and MS were, respectively: (1) due to cardiac causes (0.17% vs. 0.13%); (2) due to other causes (13.89% vs. 10.61%). The odds of 30-day cardiac readmission in those with epilepsy and MS were lower compared to those without either condition (OR = 0.64, 95% CI 0.57-0.73, p < 0.0001; OR = 0.60, 95% CI 0.43-0.84, p = 0.003). Among those with epilepsy, increasing age (OR = 1.03, 95% CI 1.02-1.04, p < 0.0001) and a Charlson comorbidity index ≥1 (OR = 1.79, 95% CI 1.24-2.60, p = 0.002) were associated with higher odds of 30-day cardiac readmission. A higher proportion of those with epilepsy readmitted within 30-days due to cardiac causes died in hospital (10.09%) compared to those with MS (not reportable due to cell frequency <10) or without epilepsy or MS (5.61%).

CONCLUSION

Those admitted to a hospital and living with epilepsy had a higher proportion of cardiac readmissions and death in hospital when compared to those living with MS, and the determinants are likely multifactorial. These findings are important and need to be further explored to identify strategies to prevent readmissions due to any cause and treatments that could reduce mortality.

Systematic Undercoding of Diagnostic Procedures in National Inpatient Sample (NIS): A Threat to Validity Due to Surveillance Bias

BACKGROUND AND OBJECTIVES

Health services research often relies on readily available data, originally collected for administrative purposes and used for public reporting and pay-for-performance initiatives. We examined the prevalence of underreporting of diagnostic procedures for acute myocardial infarction (AMI), deep venous thrombosis (DVT), and pulmonary embolism (PE), used for public reporting and pay-for-performance initiatives.

METHOD

We retrospectively identified procedures for AMI, DVT, and PE in the National Inpatient Sample (NIS) database between 2012 and 2016. From January 1, 2012, through September 30, 2015, the NIS used the International Classification of Diseases, Ninth Revision (ICD-9) coding scheme. From October 1, 2015, through December 31, 2016, the NIS used the International Classification of Diseases, Tenth Revision (ICD-10) coding scheme. We grouped the data by ICD code definitions (ICD-9 or ICD-10) to reflect these code changes and to prevent any confounding or misclassification. In addition, we used survey weighting to examine the utilization of venous duplex ultrasound scan for DVT, electrocardiogram (ECG) for AMI, and chest computed tomography (CT) scan, pulmonary angiography, echocardiography, and nuclear medicine ventilation/perfusion () scan for PE.

RESULTS

In the ICD-9 period, by primary diagnosis, only 0.26% (n = 5930) of patients with reported AMI had an ECG. Just 2.13% (n = 7455) of patients with reported DVT had a peripheral vascular ultrasound scan. For patients with PE diagnosis, 1.92% (n = 12 885) had pulmonary angiography, 3.92% (n = 26 325) had CT scan, 5.31% (n = 35 645) had cardiac ultrasound scan, and 0.45% (n = 3025) had scan. In the ICD-10 period, by primary diagnosis, 0.04% (n = 345) of reported AMI events had an ECG and 0.91% (n = 920) of DVT events had a peripheral vascular ultrasound scan. For patients with PE diagnosis, 2.08% (n = 4805) had pulmonary angiography, 0.63% (n = 1460) had CT scan, 1.68% (n = 3890) had cardiac ultrasound scan, and 0.06% (n = 140) had scan. Small proportions of diagnostic procedures were observed for any diagnoses of AMI, DVT, or PE.

CONCLUSIONS

Our findings question the validity of using NIS and other administrative databases for health services and outcomes research that rely on certain diagnostic procedures. Unfortunately, the NIS does not provide granular data that can control for differences in diagnostic procedure use, which can lead to surveillance bias. Researchers and policy makers must understand and acknowledge the limitations inherent in these databases, when used for pay-for-performance initiatives and hospital benchmarking.

Perioperative cardiovascular outcomes among older adults undergoing in-hospital noncardiac surgery

BACKGROUND

Older adults undergoing noncardiac surgery have a high risk of major adverse cardiovascular events (MACE). This study aims to estimate the magnitude of increased perioperative risk, and examine national trends in perioperative MACE following in-hospital noncardiac surgery in older adults compared to middle-aged adults.

DESIGN

Time-series analysis of retrospective longitudinal data.

SETTING

The United States Agency for Healthcare Research and Quality National Inpatient Sample (NIS).

PARTICIPANTS

Hospitalizations for major noncardiac surgery among adults age ≥45 years between January 2004 and December 2014.

MEASUREMENTS

Inpatient perioperative MACE was defined as a composite of in-hospital death, myocardial infarction (MI), and ischemic stroke. In hospital death was determined from the NIS discharge disposition. MI and ischemic stroke were defined by International Classification of Diseases, Ninth Revision codes.

RESULTS

Of an estimated 55,349,978 surgical hospitalizations, 26,423,039 (47.7%) were for adults age 45-64, 14,231,386 (25.7%) age 65-74, 10,621,029 (19.2%) age 75-84 years, and 4,074,523 (7.4%) age ≥85 years. MACE occurred in 1,601,022 surgical hospitalizations (2.9%). Adults 65-74 (2.8%; aOR 1.16, 95% CI 1.14-1.17), 75-84 years (4.5%; aOR 1.30, 95% CI 1.28-1.32), and ≥85 years (6.9%; aOR 1.55, 95% CI 1.52-1.57) had greater risk of MACE than those 45-64 years (1.7%). From 2004 to 2014, MACE declined among adults 65-74 (3.1-2.5%, p < 0.001), 75-85 years (4.9-3.9%, p < 0.001), and ≥85 years (7.7-6.1%, p < 0.001), but was unchanged for adults age 45-64. Declines in MACE were driven by decreased MI and mortality despite increased stroke.

CONCLUSION

Older adults accounted for half of hospitalizations, but experienced the majority of MACE. Older adults had greater adjusted odds of MACE than younger individuals. The proportion of perioperative MACE declined over time, despite increases in ischemic stroke. These data highlight risks of noncardiac surgery in older adults that warrant increased attention to improve perioperative outcomes.

Association of hepatitis C infection and acute coronary syndrome: A case-control study

ABSTRACT

Infections with hepatitis C virus (HCV) represent a substantial national and international public health burden. HCV has been associated with numerous extrahepatic conditions and can lead to metabolic derangements that are associated with atherosclerosis and cardiovascular disease. We investigated whether HCV infection is associated with an increased number of acute coronary syndrome (ACS) events among hospitalized patients in an inner-city tertiary hospital.We performed a matched (age, sex, and race/ethnicity) case-control study on patients at least 18 years old admitted to inpatient medical and cardiac services at the University of Maryland Medical Center from 2015 through 2018. The primary outcome was ACS and the primary exposure was HCV infection. Covariates of interest included: alcohol use, tobacco use, illicit drug use, hypertension, diabetes mellitus, human immunodeficiency virus infection, body mass index, dyslipidemia, and family history of coronary heart disease. Covariates with significant associations with both exposure and outcome in bivariate analyses were included in the multivariable analyses of the final adjusted model.There were 1555 cases and 3110 controls included in the final sample. Almost 2% of cases and 2.4% of controls were HCV infected. In adjusted models, there was no significant association found between experiencing an ACS event in those with HCV infection compared to those without HCV infection (odds ratio 0.71, 95% confidence interval 0.45-1.11).We found no significant association between HCV infection and ACS in our study population. However, given the mixed existing literature, the association between HCV and ACS warrants further investigation in future prospective cohort and/or interventional studies.

Incidence of acute myocardial infarction in the workforce: Findings from the Occupational Disease Surveillance System

BACKGROUND

Increased risks of acute myocardial infarction (AMI) may be attributable to the workplace, however, associations are not well-established. Using the Occupational Disease Surveillance System (ODSS), we sought to estimate associations between occupation and industry of employment and AMI risk among workers in Ontario, Canada.

METHODS

The study population was derived by linking provincial accepted lost-time workers' compensation claims data, to inpatient hospitalization records. Workers aged 15-65 years with an accepted non-AMI compensation claim were followed for an AMI event between 2007 and 2016. Adjusted Cox proportional hazard models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for each industry and occupation group, compared to all other workers in the cohort. Sex-stratified analyses were also performed.

RESULTS

In all, 24,514 incident cases of AMI were identified among 1,502,072 Ontario workers. Increased incidence rates of AMI were found across forestry (HR 1.37, 95% CI 1.19-1.58) and wood processing (HR 1.50, 1.27-1.77) job-titles. Elevated rates were also detected within industries and occupations both broadly related to mining and quarrying (HR 1.52, 1.17-1.97), trucking (HR 1.32, 1.27-1.38), construction (HR 1.32, 1.14-1.54), and the manufacturing and processing of metal (HR 1.41, 1.19-1.68), textile (HR 1.41, 1.07-1.88), non-metallic mineral (HR 1.30, 0.82-2.07), and rubber and plastic (HR 1.42, 1.27-1.60) products. Female food service workers also had elevated AMI rates (HR 1.36, 1.23-1.51).

CONCLUSION

This study found occupational variation in AMI incidence. Future studies should examine work-related hazards possibly contributing to such excess risks, like noise, vibration, occupational physical activity, shift work, and chemical and particulate exposures.

Validation of an International Classification of Disease, 10th revision coding adaptation for the Charlson Comorbidity Index in United States healthcare claims data

PURPOSE

An International Classification of Disease (ICD-10) Charlson Comorbidity Index (CCI) adaptation had not been previously developed and validated for United States (US) healthcare claims data. Many researchers use the Canadian adaption by Quan et al (2005), not validated in US data. We sought to evaluate the predictive validity of a US ICD-10 CCI adaptation in US claims and compare it with the Canadian standard.

METHODS

Diverse patient cohorts (rheumatoid arthritis, hip/knee replacement, lumbar spine surgery, acute myocardial infarction [AMI], stroke, pneumonia) in the IBM® MarketScan® Research Databases were linked with the IBM MarketScan Mortality file. Predictive performance was measured using c-statistics for binary outcomes (1-year and postoperative mortality, in-hospital complications) and root mean square prediction error (RMSE) for continuous outcomes (1-year all-cause medical costs, index hospitalization costs, length of stay [LOS]), after adjusting for age and sex. C-statistics were compared by the method of DeLong and colleagues (1988); RMSEs, by resampling.

RESULTS

C-statistics were generally high (≥ ~ 0.8) for mortality but lower for in-hospital complications (~0.6-0.7). RMSEs for costs and hospitalization LOS were relatively large and comparable to standard deviations. Results were similar overall between the US and Canadian adaptations, with relative differences typically <1%.

CONCLUSIONS

This US-based coding adaptation and a previously published Canadian adaptation resulted in similar predictive ability for all outcomes evaluated but may have different construct validity (not evaluated in our study). We recommend using adaptations specific to the country of data origin based on good research practice.

Logistic regression and machine learning predicted patient mortality from large sets of diagnosis codes comparably

OBJECTIVE

The objective of the study was to compare the performance of logistic regression and boosted trees for predicting patient mortality from large sets of diagnosis codes in electronic healthcare records.

STUDY DESIGN AND SETTING

We analyzed national hospital records and official death records for patients with myocardial infarction (n = 200,119), hip fracture (n = 169,646), or colorectal cancer surgery (n = 56,515) in England in 2015-2017. One-year mortality was predicted from patient age, sex, and socioeconomic status, and 202 to 257 International Classification of Diseases 10th Revision codes recorded in the preceding year or not (binary predictors). Performance measures included the c-statistic, scaled Brier score, and several measures of calibration.

RESULTS

One-year mortality was 17.2% (34,520) after myocardial infarction, 27.2% (46,115) after hip fracture, and 9.3% (5,273) after colorectal surgery. Optimism-adjusted c-statistics for the logistic regression models were 0.884 (95% confidence interval [CI]: 0.882, 0.886), 0.798 (0.796, 0.800), and 0.811 (0.805, 0.817). The equivalent c-statistics for the boosted tree models were 0.891 (95% CI: 0.889, 0.892), 0.804 (0.802, 0.806), and 0.803 (0.797, 0.809). Model performance was also similar when measured using scaled Brier scores. All models were well calibrated overall.

CONCLUSION

In large datasets of electronic healthcare records, logistic regression and boosted tree models of numerous diagnosis codes predicted patient mortality comparably.

Outcomes of Hospitalizations for Cardiogenic Shock at Left Ventricular Assist Device Versus Non-Left Ventricular Assist Device Centers

Background Cardiogenic shock (CS) is a complex syndrome associated with high morbidity and mortality. In recent years, many US hospitals have formed multidisciplinary shock teams capable of rapid diagnosis and triage. Because of preexisting collaborative systems of care, hospitals with left ventricular assist device (LVAD) programs may also represent "centers of excellence" for CS care. However, the outcomes of patients with CS at LVAD centers have not been previously evaluated. Methods and Results Patients with CS were identified in the 2012 to 2014 National Inpatient Sample. Clinical characteristics, revascularization rates, and use of mechanical circulatory support were analyzed in LVAD versus non-LVAD centers. The association between hospital type and in-hospital mortality was examined using multivariable logistic regression models. Of 272 075 hospitalizations, 26.0% were in LVAD centers. CS attributable to causes other than acute myocardial infarction represented most cases. In-hospital mortality was lower in LVAD centers (38.9% versus 43.3%; P<0.001). In multivariable analysis, the odds of mortality remained significantly lower for hospitalizations in LVAD centers (odds ratio, 0.89; P<0.001). In patients with CS secondary to acute myocardial infarction, revascularization rates were similar between LVAD and non-LVAD centers. The use of intra-aortic balloon pump (18.7% versus 18.8%) and Impella/TandemHeart (2.6% versus 1.9%) was similar between hospital types, whereas extracorporeal membrane oxygenation was used more frequently in LVAD centers (4.3% versus 0.2%; P<0.001). Conclusions Risk-adjusted mortality was lower in patients with CS who were hospitalized at LVAD centers. These centers likely represent specialized, shock team capable institutions across the country that may be best suited to manage patients with CS.

Maternal, pregnancy, and neonatal outcomes for women with Marfan syndrome

BACKGROUND

Marfan syndrome (MFS) is an autosomal dominant hereditary disorder which affects cardiovascular structure and function. With medical advances, more women with MFS experience pregnancy, which may increase maternal and neonatal risk. Existing research has been limited by small or clinical samples. This study examines the association of MFS and adverse maternal, neonatal, and obstetric outcomes.

METHODS

We conducted a cross-sectional study using the discharge abstract database, containing all labor and delivery hospitalizations in Canada (excluding Quebec) from fiscal years 2004-2015 where women delivered a live- or stillbirth. We measured maternal and neonatal morbidity, preterm births (<37 weeks), small-for-gestational-age births, perinatal mortality, and adverse maternal cardiovascular events. For each outcome, we calculated the absolute risk for women with and without MFS and used generalized estimating equations with a logit function to calculate odds.

RESULTS

Overall, 2,682,461 women delivered a live or stillborn infant in Canada during the study period, with 135 birth events to women with MFS. Women with MFS did not have significantly higher odds of severe maternal morbidity during their delivery (aOR:1.3; 95%CI: 0.4-4.0). Similarly, their infants did not have significantly higher odds of neonatal morbidity. However, infants born to women with MFS were significantly more likely to be born preterm (aOR:2.6; 95%CI: 1.6-4.3) and to be small-for-gestational-age (aOR:1.8; 95%CI:1.0-3.1).

CONCLUSIONS

This population-based study indicates that, although some women with MFS may experience higher odds of maternal and/or neonatal morbidity during labor and delivery, the majority of women with MFS can have healthy births with proper clinical management.

Risk of Acute Myocardial Infarction, Heart Failure, and Death in Migraine Patients Treated with Triptans

OBJECTIVE

The goal of this study is to determine the strength of association between treatment with triptans and acute myocardial infarction, heart failure, and death.

BACKGROUND

Case reports in the literature have raised concerns over an association between treatment of migraine headaches with triptans and cardiovascular events. This study aims to systematically evaluate this association in a contemporary population-based cohort. We hypothesized that triptan exposure is not associated with increased cardiovascular events.

METHODS

A retrospective cohort study was conducted within an integrated healthcare delivery system in Southern California. From January 2009 to December 2018, 189,684 patients age ≥18 years had a diagnosis of migraine. In this group, 130,656 were exposed to triptans. Patients treated with triptans were matched 1:1 to those not exposed to triptans by using a propensity score. The primary outcome was acute myocardial infarction; secondary outcomes were heart failure, all-cause death, and combined acute myocardial infarction, heart failure, and death.

RESULTS

The incidence rate of acute myocardial infarction was 0.67 per 1000 person-year in triptan-exposed vs 1.44 per 1000 person-year in not exposed patients. In propensity-matched analyses, the adjusted hazard ratio for triptan exposure was 0.95 (95% confidence interval [CI] 0.84-1.08) for acute myocardial infarction; 1.00 (95% CI 0.93-1.08) for all-cause death; 0.93 (95% CI 0.81-1.08) for heart failure; and 0.99 (95% CI 0.93-1.06) for a composite of acute myocardial infarction, heart failure, or death. Sensitivity analyses focusing on stratified subgroups based on age, gender, ethnicity, and several cardiac risk factors also revealed no significant association between triptan exposure and cardiovascular events.

CONCLUSIONS

No association was found between exposure to triptans and an increased risk of cardiovascular events. These data provide reassurance regarding the cardiovascular safety of utilizing triptans for the medical management of migraine headaches.

Maternal, pregnancy, and neonatal outcomes for women with Turner syndrome

BACKGROUND

Turner syndrome (TS) occurs in approximately 1 in 2500 live female births and is caused by the partial or complete loss of one of the X chromosomes, resulting in abnormalities such as ovarian failure and infertility. However, pregnancy in women with TS may still occur via spontaneous pregnancy or through oocyte donation. Limited data exists on pregnancy in women with TS that could aid in clinical care.

METHODS

We conducted a population-based cross-sectional study using data from the Discharge Abstract Database (2004-2015), which contains all labor and delivery hospitalizations across Canada (excluding Quebec) where women delivered a live or stillborn infant. The odds of adverse maternal and neonatal outcomes for women with and without TS were calculated using backwards multivariable logistic regression with generalized estimating equations, adjusting for the Obstetric Comorbidity Index, mode of delivery, and year.

RESULTS

Overall, 2,682,284 women delivered a live or stillborn infant during the study period and 44 birth events occurred for women with TS. No severe maternal morbidity or adverse cardiovascular events occurred for women with TS at their labor and delivery hospitalization. However, infants born to women with TS were 3.6 times more likely (95% CI: 1.7-7.8) to experience neonatal morbidity than those born to women without TS. These infants also were more likely to have had a preterm birth (aOR: 2.9, 95% CI: 1.6-5.4) and to be small-for-gestational-age (aOR: 4.5, 95% CI: 2.4-8.4).

CONCLUSION

This study adds further understanding of the likelihood of adverse outcomes for pregnant women with TS.

Spatial distribution of in- and out-of-hospital mortality one year after acute myocardial infarction in France

OBJECTIVE

To describe the spatial distribution of acute myocardial infarction (AMI) mortality in France in association with the socio-economic characteristics of the patient's place of residence.

METHODS

In this population-based study, we included patients hospitalized for AMI identified according to ICD-10 codes, using data from the national health insurance database from January 1, 2013 to December 31, 2014. In- and out-of-hospital deaths were identified over a period of 1 year following the first hospital stay for AMI.An exploratory analysis was performed to classify area profiles. The spatial analysis of AMI mortality was performed using a principal component analysis followed by an ascending hierarchical classification taking into account socio-economic data, access-time by road to coronary angiography, standardized in-hospital prevalence, and 1 year mortality.

RESULTS

Over the 2 years, 115,418 patients were hospitalized with a diagnosis of AMI. Patients were a mean of 68 ​± ​15 years and most were men (68.5%). The overall mortality rate was 12.2% after 1 year. More than half of patients (65.5%) underwent an early revascularization procedure. The map of standardized 1 year mortality showed a geographic area of high mortality extending diagonally from north-east to south-west France. We identified 6 different area profiles with standardized mortality varying from 15.9 to 54.4 per 100,000 inhabitants. The spatial distribution of higher mortality was associated with lower socioeconomic levels. These findings were not associated with a lower access to coronary angiography.

CONCLUSION

There are considerable geographical differences in the prevalence of AMI and 1 year mortality. The spatial distribution of lower healthcare indicators follows the distribution of social inequalities. This study highlights the importance of focusing national policies on universally accessible prevention programs such as the promotion cardiac rehabilitation and healthy lifestyles.

Novel glucose lowering agents are associated with a lower risk of cardiovascular and adverse events in type 2 diabetes: A population based analysis

BACKGROUND

Recent randomized control trials have described a protective cardiovascular effect of novel glucose lowering drugs in patients at high cardiovascular risk. Whether these second-line agents have similar effects in the general population is unknown. We aimed to compare the risk of major cardiovascular and adverse events in new users of sodium-glucose cotransporter-2 inhibitors (SGLT-2i), dipeptidyl peptidase-4 inhibitor (DPP-4i), glucagon-like peptide 1 agonist (GLP-1a), and sulfonylurea in T2DM patients not controlled on metformin therapy.

METHODS

Retrospective cohort study using the MarketScan database (2011-2015). We selected T2DM individuals who were newly dispensed sulfonylureas, SGLT-2i, DPP-4i, or GLP-1a, as second-line therapy, added to metformin. Cohort entry was defined by date of first prescription of the second-line agent. Time to first non-fatal cardiovascular or adverse event was compared using Cox regression models adjusted for confounders.

RESULTS

Among 118,341 T2DM patients using metformin (mean age: 56), most were at low cardiovascular risk (4% with previous cardiovascular or cerebrovascular event). During a median follow-up of 10 months compared with sulfonylureas users, cardiovascular risk was lower in users of SGLT-2i (aHR = 0.61; 95% CI: 0.40-0.97), DPP-4i (aHR = 0.79; 95% CI: 0.69-0.90) and GLP-1a (aHR = 0.65; 95% CI: 0.48-0.89). Serious adverse events were rare but compared with sulfonylurea, the risk was lower in new users of novel glucose lowering agents.

CONCLUSION

In our analyses, which included patients with and without prior cardiovascular disease, initiating novel glucose lowering drugs as second-line therapy for T2DM was associated with a lower risk of cardiovascular and adverse events than sulfonylurea initiation.

Sex Differences in Cardiovascular Effectiveness of Newer Glucose-Lowering Drugs Added to Metformin in Type 2 Diabetes Mellitus

Background

Randomized controlled trials showed that newer glucose‐lowering agents are cardioprotective, but most participants were men. It is unknown whether benefits are similar in women.

Methods and Results

Among adults with type 2 diabetes mellitus not controlled with metformin with no prior use of insulin, we assessed for sex differences in the cardiovascular effectiveness and safety of sodium‐glucose‐like transport‐2 inhibitors (SGLT‐2i), glucagon‐like peptide‐1 receptor agonists (GLP‐1RA), dipeptidyl peptidase‐4 inhibitors, initiated as second‐line agents relative to sulfonylureas (reference‐group). We studied type 2 diabetes mellitus American adults with newly dispensed sulfonylureas, SGLT‐2i, GLP‐1RA, or dipeptidyl peptidase‐4 inhibitors (Marketscan‐Database: 2011–2017). We used multivariable Cox proportional hazards models with time‐varying exposure to compare time to first nonfatal cardiovascular event (myocardial infarction/unstable angina, stroke, and heart failure), and safety outcomes between drugs users, and tested for sex–drug interactions. Among 167 254 type 2 diabetes mellitus metformin users (46% women, median age 59 years, at low cardiovascular risk), during a median 4.5‐year follow‐up, cardiovascular events incidence was lower in women than men (14.7 versus 16.7 per 1000‐person‐year). Compared with sulfonylureas, hazard ratios (HRs) for cardiovascular events were lower with GLP‐1RA (adjusted HR‐women: 0.57, 95% CI: 0.48–0.68; aHR‐men: 0.82, 0.71–0.95), dipeptidyl peptidase‐4 inhibitors (aHR‐women: 0.83, 0.77–0.89; aHR‐men: 0.85, 0.79–0.91) and SGLT‐2i (aHR‐women: 0.58, 0.46–0.74; aHR‐men: 0.69, 0.57–0.83). A sex‐by‐drug interaction was statistically significant only for GLP‐1RA (P=0.002), suggesting greater cardiovascular effectiveness in women. Compared with sulfonylureas, risks of adverse events were similarly lower in both sexes for GLP‐1RA (aHR‐women: 0.81, 0.73–0.89; aHR‐men: 0.80, 0.71–0.89), dipeptidyl peptidase‐4 inhibitors (aHR‐women: 0.82, 0.78–0.87; aHR‐men: 0.83, 0.78–0.87) and SGLT‐2i (aHR‐women: 0.68, 0.59–0.78; aHR‐men: 0.67, 0.59–0.78) (all sex–drug interactions for adverse events P>0.05).

Conclusions

Newer glucose‐lowering drugs were associated with lower risk of cardiovascular events than sulfonylureas, with greater effectiveness of GLP‐1RA in women than men. Overall, they appeared safe, with a better safety profile for SGLT‐2i than for GLP‐1RA regardless of sex.

Impact of immune thrombocytopenic purpura on clinical outcomes in patients with acute myocardial infarction

Background

Patients with immune thrombocytopenic purpura (ITP) admitted with acute myocardial infarction (AMI) may be challenging to manage given their increased risk of bleeding complications. There is limited evidence in the literature guiding appropriate interventions in this population. The objective of this study is to determine the difference in clinical outcomes in AMI patients with and without ITP.

Methods

Using the United States national inpatient sample database, adults aged ≥18 years, who were hospitalized between 2007 and 2014 for AMI, were identified. Among those, patients with ITP were selected. A propensity‐matched cohort analysis was performed. The primary outcome was in‐hospital mortality. Secondary outcomes were coronary revascularization procedures, bleeding and cardiovascular complications, and length of stay (LOS).

Results

The propensity‐matched cohort included 851 ITP and 851 non‐ITP hospitalizations for AMI. There was no difference in mortality between ITP and non‐ITP patients with AMI (6% vs7.3%, OR:0.81; 95% CI:0.55‐1.19; P = .3). When compared to non‐ITP patients, ITP patients with AMI underwent fewer revascularization procedures (40.9% vs 45.9%, OR:0.81; 95% CI:0.67‐0.98; P = .03), but had a higher use of bare metal stents (15.4% vs 11.3%, OR:1.43; 95% CI:1.08‐1.90; P = .01), increased risk of bleeding complications (OR:1.80; CI:1.36‐2.38; P < .0001) and increased length of hospital stay (6.14 vs 5.4 days; mean ratio: 1.14; CI:1.05‐1.23; P = .002). More cardiovascular complications were observed in patients requiring transfusions.

Conclusions

Patients with ITP admitted for AMI had a similar in‐hospital mortality risk, but a significantly higher risk of bleeding complications and a longer LOS compared to those without ITP. Further studies are needed to assess optimal management strategies of AMI that minimize complications while improving outcomes in this population.

Quality Through Coopetition: An Empiric Approach to Measure Population Outcomes for Emergency Care-Sensitive Conditions

STUDY OBJECTIVE

We develop a novel approach for measuring regional outcomes for emergency care-sensitive conditions.

METHODS

We used statewide inpatient hospital discharge data from the Pennsylvania Healthcare Cost Containment Council. This cross-sectional, retrospective, population-based analysis used International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes to identify admissions for emergency care-sensitive conditions (ischemic stroke, ST-segment elevation myocardial infarction, out-of-hospital cardiac arrest, severe sepsis, and trauma). We analyzed the origin and destination patterns of patients, grouped hospitals with a hierarchical cluster analysis, and defined boundary shapefiles for emergency care service regions.

RESULTS

Optimal clustering configurations determined 10 emergency care service regions for Pennsylvania.

CONCLUSION

We used cluster analysis to empirically identify regional use patterns for emergency conditions requiring a communitywide system response. This method of attribution allows regional performance to be benchmarked and could be used to develop population-based outcome measures after life-threatening illness and injury.

A diagnostic accuracy study validating cardiovascular ICD-9-CM codes in healthcare administrative databases. The Umbria Data-Value Project

BACKGROUND

Administrative healthcare databases are useful and inexpensive tools that can provide a comprehensive assessment of the burden of diseases in terms of major outcomes, such as mortality, hospital readmissions, and use of healthcare resources. However, a crucial issue is the reliability of information gathered. The aim of this study was to validate ICD-9 codes for several major cardiovascular conditions, i.e., acute myocardial infarction (AMI), atrial fibrillation/flutter (AF), and heart failure (HF), in order to use them for epidemiological, outcome, and health services research.

METHODS

Data from the centralised administrative database of the Umbria Region (890,000 residents, located in Central Italy) were considered. Patients with a first hospital discharge for AMI, AF/flutter, and HF, between 2012 and 2014, were identified using ICD-9-CM codes in primary position. A sample of cases and non-cases was randomly selected, and the corresponding medical charts reviewed by specifically trained investigators. For each disease, case ascertainment was based on all clinical, laboratory, and instrumental examinations available in medical charts. Sensitivity, specificity, and predictive values with 95% confidence intervals (CIs), were calculated.

RESULTS

We reviewed 458 medical charts, 128 for AMI, 127 for AF/flutter, 127 for HF, and 76 of non-cases for each condition. Diagnostic accuracy measures of the original discharge diagnosis were as follows. AMI: sensitivity 98% (95% CI, 94-100%), specificity 91% (95% CI, 83-97%), positive predictive value (PPV) 95% (95% CI, 89-98%), negative predictive value (NPV) 97% (95% CI, 91-100%). AF/flutter: sensitivity 95% (95% CI, 90-98%), specificity 95% (95% CI, 87-99%), PPV 97% (95% CI, 92-99%), NPV 92% (95% CI, 84-97%). HF: sensitivity 96% (95% CI, 91-99%), specificity 90% (95% CI, 81-96%), PPV 94% (95% CI, 88-97%), NPV 93% (95% CI, 85-98%).

CONCLUSION

The case ascertainment for AMI, AF and flutter, and HF, showed a high level of accuracy (≥ 90%). The healthcare administrative database of the Umbria Region can be confidently used for epidemiological, outcome, and health services research.

Traditional risk factors may not explain increased incidence of myocardial infarction in MS

Objective

To compare the risk of incident acute myocardial infarction (AMI) in the multiple sclerosis (MS) population and a matched population without MS, controlling for traditional vascular risk factors.

Methods

We conducted a retrospective matched cohort study using population-based administrative (health claims) data in 2 Canadian provinces, British Columbia and Manitoba. We identified incident MS cases using a validated case definition. For each case, we identified up to 5 controls without MS matched on age, sex, and region. We compared the incidence of AMI between cohorts using incidence rate ratios (IRR). We used Cox proportional hazards regression to compare the hazard of AMI between cohorts adjusting for sociodemographic factors, diabetes, hypertension, and hyperlipidemia. We pooled the provincial findings using meta-analysis.

Results

We identified 14,565 persons with MS and 72,825 matched controls. The crude incidence of AMI per 100,000 population was 146.2 (95% confidence interval [CI] 129.0–163.5) in the MS population and 128.8 (95% CI 121.8–135.8) in the matched population. After age standardization, the incidence of AMI was higher in the MS population than in the matched population (IRR 1.18; 95% CI 1.03–1.36). After adjustment, the hazard of AMI was 60% higher in the MS population than in the matched population (hazard ratio 1.63; 95% CI 1.43–1.87).

Conclusion

The risk of AMI is elevated in MS, and this risk may not be accounted for by traditional vascular risk factors.

The association of pre- and posthospital medication adherence in myocardial infarction patients

BACKGROUND

Nonadherence to optimal medical therapy following myocardial infarction (MI) is associated with adverse clinical outcomes such as stent thrombosis, recurrent cardiovascular events, and death. Whether adherence to medications prior to MI predicts post-MI medication adherence is unknown.

METHODS

We assessed adherence to P2Y₁₂ inhibitors and statins before and after admission for MI among 8,147 MI patients who had Medicare insurance with Part D prescription coverage. Adherence was defined as a proportion of days covered with medication fills ≥80%. Multivariable logistic regression was used to assess the association between pre- and post-MI P2Y₁₂ inhibitor adherence. As few patients were on P2Y₁₂ inhibitors pre-MI, we also examined the association of pre-MI statin adherence with post-MI P2Y₁₂ inhibitor and statin adherence.

RESULTS

Pre-MI medication nonadherence was observed in 427 of 2,633 (16%) patients on preadmission P2Y₁₂ inhibitors and 1,233 of 6,934 (18%) patients on preadmission statins. Nonadherent patients were more likely to be of nonwhite race and have multiple prior hospital admissions. Patients who were nonadherent to P2Y₁₂ inhibitors pre-MI were substantially less likely to adhere to P2Y₁₂ inhibitors at 90 days (adjusted odds ratio [OR] 0.33, 95% CI 0.25-0.43) and 1 year post-MI (adjusted OR 0.29, 95% CI 0.21-0.39) compared with patients who were adherent pre-MI. Pre-MI statin nonadherence was also associated with lower post-MI adherence to P2Y₁₂ inhibitors at 90 days (adjusted OR 0.65, 95% CI 0.53-0.79) and 1 year (adjusted OR 0.37, 95% CI 0.29-0.54).

CONCLUSIONS

Prior medication adherence predicts post-MI adherence to P2Y₁₂ inhibitors. Increasing accessibility of medication adherence data in the medical record may be an important tool to identify patients at higher risk for post-MI medication nonadherence and target efforts to improve adherence.

Association of Body Mass Index With Risk Factor Optimization and Guideline-Directed Medical Therapy in US Veterans With Cardiovascular Disease

BACKGROUND

Obesity is a growing epidemic that has been linked to the development of cardiovascular disease (CVD). Guideline-directed medications for secondary prevention and risk factor control are recommended for patients with all forms of CVD. The association of body mass index (BMI) with use of medications for secondary prevention and risk factor control in patients with CVD are poorly understood.

METHODS AND RESULTS

We identified 1 122 567 patients with CVD receiving care in 130 Veterans Affairs facilities from October 1, 2013, to September 30, 2014. Five groups were stratified by BMI-underweight (BMI, <18.5 kg/m²), normal (BMI, 18.5-24.9 kg/m²), overweight (BMI, 25-29.9 kg/m²), obese (BMI, 30-39.9 kg/m²), and extremely obese (BMI, ≥40 kg/m²). A composite of 4 measures-blood pressure <140/90 mm Hg, hemoglobin A1c ≤9% in diabetic patients, statin use, and antiplatelet use-termed optimal medial therapy (OMT) was compared among groups. Multivariable logistic regression was performed with normal BMI as the referent category. Underweight patients comprised 12 623 (1.1%), normal BMI 230 471 (20.5%), overweight 413 590 (36.8%), obese 404 105 (36%), and extremely obese 61 778 (5.5%) of the cohort. Only 43.7% of the entire cohort received OMT, and this was the highest in the overweight group. Adjusted odds ratios for receiving OMT were 0.81 (95% CI, 0.77-0.85), 1.11 (95% CI, 1.10-1.13), 1.08 (95% CI, 1.06-1.09), and 0.87 (95% CI, 0.85-0.89), for patients who were underweight, overweight, obese, and extremely obese, respectively, compared with normal BMI.

CONCLUSIONS

OMT was low in the entire cohort. There is an inverse U-shaped relationship between OMT and BMI with patients who are underweight and extremely obese less likely to receive OMT compared with patients with normal BMI.

Incidence, Risk Factors, and Outcomes Associated With In-Hospital Acute Myocardial Infarction

IMPORTANCE

Studies of acute myocardial infarction (AMI) occurring outside the hospital have informed approaches to addressing risk, treatment, and patient outcomes. Similar insights for in-hospital AMI are lacking.

OBJECTIVE

To determine the incidence, risk factors, and outcomes associated with in-hospital AMI.

DESIGN, SETTING, AND PARTICIPANTS

Cohort, nested case-control, and matched cohort study of patients hospitalized in US Veterans Health Administration facilities between July 2007 and September 2009. The incidence of in-hospital AMI was determined from a complete cohort of in-hospital AMI relative to the total number of inpatient admissions. From the in-hospital AMI cohort, detailed medical record review was performed on 687 cases and 687 individually matched controls. Risk factors and outcomes associated with in-hospital AMI were determined from matched comparison of in-hospital AMI cases to hospitalized controls.

EXPOSURES

Candidate risk factors for in-hospital AMI included characteristics at the time of admission and in-hospital variables prior to the index date.

MAIN OUTCOMES AND MEASURES

In the determination of the incidence and risk factors associated with in-hospital AMI, the outcome of interest was in-hospital AMI. All-cause mortality was the main outcome of interest following in-hospital AMI.

RESULTS

A total of 5556 patients with in-hospital AMI (mean [SD] age, 73 [10] years; 5456 [98.2%] male) were identified among 1.3 million admissions, with an incidence of 4.27 in-hospital AMI events per 1000 admissions. Independent risk factors associated with in-hospital AMI included intensive care unit setting, history of coronary artery disease, heart rate greater than 100 beats/min, hemoglobin level less than 8 g/dL, and white blood cell count 14 000/μL or greater. Compared with the matched control group, mortality was significantly higher for patients with in-hospital AMI (in-hospital mortality, 26.4% vs 4.2%; 30-day mortality, 33.0% vs 10.0%; 1-year mortality, 59.2% vs 34.4%).

CONCLUSIONS AND RELEVANCE

In-hospital AMI was common and associated with common cardiovascular risk factors and markers of acute illness. Patient outcomes following in-hospital AMI were poor, with 1-year mortality approaching 60%. Further study of in-hospital AMI may yield opportunities to reduce in-hospital AMI risk and improve patient outcomes.

Cardiovascular outcomes of sodium glucose cotransporter-2 inhibitors in patients with type 2 diabetes

AIMS

To determine the association between cardiovascular diseases (CVD) and SGLT2 inhibitors compared to sulfonylureas and dipeptidyl peptidase-4 (DPP4) inhibitors and to examine within-class effects of SGLT2 inhibitors.

METHODS

A retrospective cohort analysis was conducted using Truven Health MarketScan. New users of SGLT2 inhibitors, sulfonylureas or DPP-4 inhibitors were included. Primary outcome was incident CVD, defined as non-fatal myocardial infarction or non-fatal stroke; secondary outcomes were hospitalization because of heart failure and lower extremity amputation. Proportional hazards models, after propensity score matching, were used to obtain hazard ratios (HR) and 95% confidence intervals (CI).

RESULTS

In fully adjusted models, use of SGLT2 inhibitors was associated with a decreased risk of developing CVD compared with use of sulfonylureas (HR, 0.50; 95% CI, 0.45, 0.55) and DPP-4 inhibitors (HR, 0.57; 95% CI, 0.52, 0.62), respectively. Analyses revealed no evidence of within-class effects: dapagliflozin vs sulfonylureas (HR, 0.55; 95% CI, 0.43, 0.70) or DPP-4 inhibitors (HR, 0.57; 95% CI, 0.46, 0.70); and canagliflozin vs sulfonylureas (HR, 0.61; 95% CI, 0.54, 0.69) or DPP-4 inhibitors (HR, 0.66; 95% CI, 0.54, 0.71). Additionally, SGLT2 inhibitors were associated with lower risk of hospitalization because of heart failure compared to both sulfonylureas and DPP-4 inhibitors, as well as lower risk of lower extremity amputation compared to sulfonylureas.

CONCLUSION

Using population-based data, incident use of SGLT-2 inhibitors was associated with a decreased incidence of CVD compared to use of sulfonylureas and DPP-4 inhibitors. These findings were consistent between dapagliflozin and canagliflozin, suggesting that CVD reduction is a class effect for SGLT2 inhibitors. In addition, SGLT2 inhibitors portended lower risk of hospitalization because of heart failure (vs sulfonylureas and DPP-4 inhibitors) and lower risk of lower extremity amputation (vs sulfonylureas).

Trends of Cardiovascular Risk Factors in Patients With Acute Myocardial Infarction: Soroka Acute Myocardial Infarction II (SAMI II) Project

CONCLUSIONS

The last decade, patients with AMI became older with increased burden of CVRFs. Framingham risk score increased among patients with NSTEMI and decreased in patients with STEMI. These trends impact on risk stratification and secondary prevention programs.

Effectiveness, Complications, and Costs of Rheumatoid Arthritis Treatment with Biologics in Alberta: Experience of Indigenous and Non-indigenous Patients

OBJECTIVE

To examine clinical effectiveness, treatment complications, and healthcare costs for indigenous and non-indigenous Albertans with rheumatoid arthritis (RA) participating in the Alberta Biologics Pharmacosurveillance program.

METHODS

Patients initiating biologic therapy in Alberta (2004-2012) were characterized for disease severity and treatment response. Provincial hospitalization separations, physician claims, outpatient department data, and emergency department data were used to estimate treatment complication event rates and healthcare costs.

RESULTS

Indigenous patients (n = 90) presented with higher disease activity [mean 28-joint count Disease Activity Score (DAS28) 6.11] than non-indigenous patients (n = 1400, mean DAS28 5.19, p < 0.0001). Improvements in DAS28, function, swollen joint count, CRP, and patient and physician global evaluation scores were comparable to non-indigenous patients, but indigenous patients did not have a significant improvement in erythrocyte sedimentation rate (-0.31 per month, 95% CI -0.79 to 0.16, p = 0.199). At the end of study followup, 13% (12/90) of indigenous and 33% (455/1400) of non-indigenous patients were in DAS28 remission (p < 0.001). Indigenous patients had a 40% increased risk of all-cause hospitalization [adjusted incidence rate ratio (IRR) 1.4, 95% CI 1.1-1.8, p = 0.01] and a 4-fold increase in serious infection rate (adjusted IRR 4.0, 95% CI 2.3-7.0, p < 0.001). Non-indigenous patients incurred higher costs for RA-related hospitalizations (difference $896, 95% CI 520-1273, p < 0.001), and outpatient department visits (difference $128, 95% CI 2-255, p = 0.047).

CONCLUSION

We identified disparities in treatment outcomes, safety profiles, and patient-experienced effects of RA for the indigenous population in Alberta. These disparities are critical to address to facilitate and achieve desired RA outcomes from individual and population perspectives.

Geographic Variations in In‐Hospital Mortality and Use of Percutaneous Coronary Intervention Following Acute Myocardial Infarction in China: A Nationwide Cross‐Sectional Analysis

Background

Prevalence of acute myocardial infarction (AMI) is increasing in China, and AMI has become a major cause of mortality; however, information is very limited about the nationwide geographic and hospital variation in in‐hospital mortality (IHM) and the use of percutaneous coronary intervention (PCI) after AMI.

Methods and Results

From the Nationwide Hospital Discharge Database of China, we identified 242 866 adult admissions with AMI in 2015 from 1055 tertiary hospitals. We used multivariable logistic regressions to analyze the associations between geographic or hospital characteristics with IHM or PCI use. The national IHM rate was 4.71% (95% confidence interval, 4.62–4.79%). There was a greater risk of mortality in the Northeast (odds ratio [OR]: 1.86), West (OR: 1.73), South (OR: 1.32), and North (OR: 1.14) regions than in the East region of China. Non–teaching hospitals (OR: 1.18) and tertiary level B hospitals (OR: 1.06) were associated with higher IHM rates. The national PCI use rate was 45.3% (95% confidence interval, 45.1–45.5%). Compared with the East region of China, PCI use was lower in the Northeast (OR: 0.50), West (OR: 0.64), North (OR: 0.84), and South (OR: 0.88) regions. Non–teaching hospitals (OR: 0.83) and tertiary level B hospitals (OR: 0.55) were also associated with lower usage rates. There was a significant negative correlation between IHM and PCI use (r=−0.955), and IHM rates for patients with and without PCI both differed by geographic regions.

Conclusions

There were significant differences in IHM and PCI use among China's tertiary hospitals, linked to both geographic and hospital characteristics. More targeted intervention at national and regional levels is needed to improve access to effective health technologies and, eventually, outcomes following AMI.