Validity of myocardial infarction diagnoses in administrative databases: a systematic review

Risk of Atherosclerotic Cardiovascular Disease After Chronic Obstructive Pulmonary Disease Hospitalization among Primary and Secondary Prevention Older Adults

BACKGROUND

Meta-analyses have suggested that the risk of cardiovascular disease events is significantly higher after a chronic obstructive pulmonary disease (COPD) exacerbation, but the populations at highest risk have not been well characterized to date.

METHODS AND RESULTS

The authors analyzed the risk of atherosclerotic cardiovascular disease (ASCVD) hospitalizations after COPD hospitalization compared with before COPD hospitalization and patient factors associated with ASCVD hospitalizations after COPD hospitalization among 2 high-risk patient cohorts. The primary outcome was risk of an ASCVD hospitalization composite outcome (myocardial infarction, coronary artery bypass graft, percutaneous coronary intervention, stroke, transient ischemic accident) after COPD hospitalization relative to before COPD hospitalization. Additional analyses evaluated for risk factors associated with the composite ASCVD hospitalization outcome. In the high-risk primary prevention cohort, the hazard ratio (HR) estimate following adjustment for the composite ASCVD hospitalization outcome after COPD hospitalization versus before COPD hospitalization for 30 days was 0.74 (95% CI, 0.66-0.82; P≤0.0001); for 90 days, 0.69 (95% CI, 0.64-0.75; P≤0.0001); and for 1 year, 0.78 (95% CI, 0.73-0.82; P≤0.0001). In the secondary prevention cohort, the HR for 30-day hospitalization was 1.15 (95% CI, 1.05-1.26; P=0.0036); 90-day hospitalization, 1.08 (95% CI, 1.01-1.15; P=0.0178); and 1-year hospitalization, 1.07 (95% CI, 1.02-1.11; P=0.0026). Among the 19 characteristics evaluated, hyperlipidemia and history of acute ASCVD event were associated with the highest risk of ASCVD events 1 year after COPD hospitalization in the high-risk primary and secondary prevention cohorts.

CONCLUSIONS

The risk of ASCVD hospitalization was higher in patients with established ASCVD and lower among high-risk patients without established ASCVD after-COPD hospitalization relative to before hospitalization. We identified multiple risk factors for ASCVD hospitalization after COPD hospitalization.

Definitions of clinical study outcome measures for cardiovascular diseases: the European Unified Registries for Heart Care Evaluation and Randomized Trials (EuroHeart)

BACKGROUND AND AIMS

Standardized definitions for outcome measures in randomized clinical trials and observational studies are essential for robust and valid evaluation of medical products, interventions, care, and outcomes. The European Unified Registries for Heart Care Evaluation and Randomised Trials (EuroHeart) project of the European Society of Cardiology aimed to create international data standards for cardiovascular clinical study outcome measures.

METHODS

The EuroHeart methods for data standard development were used. From a Global Cardiovascular Outcomes Consortium of 82 experts, five Working Groups were formed to identify and define key outcome measures for: cardiovascular disease (generic outcomes), acute coronary syndrome and percutaneous coronary intervention (ACS/PCI), atrial fibrillation (AF), heart failure (HF) and transcatheter aortic valve implantation (TAVI). A systematic review of the literature informed a modified Delphi method to reach consensus on a final set of variables. For each variable, the Working Group provided a definition and categorized the variable as mandatory (Level 1) or optional (Level 2) based on its clinical importance and feasibility.

RESULTS

Across the five domains, 24 Level 1 (generic: 5, ACS/PCI: 8, AF: 2; HF: 5, TAVI: 4) and 48 Level 2 (generic: 18, ACS-PCI: 7, AF: 6, HF: 2, TAVI: 15) outcome measures were defined.

CONCLUSIONS

Internationally derived and endorsed definitions for outcome measures for a range of common cardiovascular diseases and interventions are presented. These may be used for data alignment to enable high-quality observational and randomized clinical research, audit, and quality improvement for patient benefit.

Cardiovascular Events During Pregnancy: Implications for Adverse Pregnancy Outcomes in Individuals With Autoimmune and Rheumatic Diseases

OBJECTIVE

This study examined maternal cardiovascular (CV) events relative to adverse pregnancy outcomes (APOs) among individuals with autoimmune rheumatic diseases (ARDs), primary antiphospholipid syndrome (APS), and those with neither.

METHODS

Using a California population-based birth cohort (2005-2020), we identified those with CV events (CVEs), ARDs, and APS through International Classification of Diseases, 9th and 10th revisions, Clinical Modification codes in maternal discharge records. Selected APOs identified from birth certificates were preterm birth (PTB; < 37 weeks' gestation), small-for-gestational-age infants (SGA; birth weight < 10th percentile for age and sex), and a composite of either outcome. Adjusted risk ratios (aRRs) for adverse outcomes and their 95% CIs were calculated.

RESULTS

CVEs occurred more frequently in individuals with ARDs (265 of 19,340 [1.4%]) and primary APS (428 of 7758 [5.5%]) than those without (17,130 of 7,004,334 [0.3%]). The presence vs absence of CVEs was associated with a greater incidence of adverse outcomes in ARD (53.2% vs 26.6%), APS (30.6% vs 20.7%), and non-ARD/APS pregnancies (28.2% vs 15.2%). CVEs were associated with increased risks of SGA in all groups (aRRs 1.2-1.5) and PTB in ARD (aRR 1.6, 95% CI 1.3-2.0) and non-ARD/APS (aRR 1.7, 95% CI 1.7-1.8) pregnancies.

CONCLUSION

CVEs were associated with modestly increased risks (20-70%) for PTB, SGA, or both across the groups. Notably, > 50% of ARD pregnancies with CVEs experienced APOs. Given that ARD and APS pregnancies have higher (although still low) rates of CVEs and have higher baseline risks of APOs than the general population, the additional burden conferred by CVEs is clinically important.

Healthcare utilization, mortality, and cardiovascular events following GLP1-RA initiation in chronic kidney disease

Treatment with glucagon-like peptide-1 receptor agonists (GLP1-RA) in patients with type 2 diabetes (T2D) and chronic kidney disease (CKD) may attenuate kidney disease progression and cardiovascular events but their real-world impact on healthcare utilization and mortality in this population are not well-defined. Here, we emulate a clinical trial that compares outcomes following initiation of GLP1-RA vs Dipeptidyl peptidase-4 inhibitors (DPP4i), as active comparators, in U.S. veterans aged 35 years of older with moderate to advanced CKD during fiscal years 2006 to 2021. Primary outcome was rate of acute healthcare utilization. Secondary outcomes were all-cause mortality and a composite of acute cardiovascular events. After propensity score matching (16,076 pairs) and 2.2 years mean follow-up duration, use of GLP1-RA in patients with moderate to advanced CKD was associated with lower annual rate of acute healthcare utilization and all-cause mortality. There was no significant difference in acute cardiovascular events.

Ticagrelor vs Prasugrel for Acute Coronary Syndrome in Routine Care

Importance

In patients with acute coronary syndrome (ACS) undergoing invasive treatment, ticagrelor and prasugrel are guideline-recommended P2Y12 receptor inhibitors. The ISAR-REACT5 randomized clinical trial demonstrated superiority for prasugrel, although concerns were raised about the generalizability of some underpowered subgroup analyses.

Objectives

To emulate a randomized clinical trial evaluating the safety and effectiveness of ticagrelor vs prasugrel under the conditions of routine care in individuals with ACS planned to undergo an invasive treatment strategy.

Design, Setting, and Participants

This new-user cohort study included secondary data from a German statutory health insurance claims database between January 2012 and December 2021, using 1:1 propensity score nearest-neighbor matching to emulate ISAR-REACT5. Individuals with ACS receiving either ticagrelor or prasugrel treatment after hospital discharge were followed up for 1 year. Eligibility criteria closely emulated those of ISAR-REACT5 and included age of 18 years or older and cardiovascular risk factors. Data were analyzed from May 2023 to May 2024.

Exposure

Outpatient prescription of ticagrelor or prasugrel.

Main Outcomes and Measures

The primary end point was the composite of all-cause mortality, myocardial infarction (MI), or stroke within 1 year of outpatient treatment initiation. Secondary end points included individual components of the primary end point and stent thrombosis. The safety end point was major bleeding. A Cox proportional hazards regression model was fitted to the overall cohort.

Results

Of 17 642 propensity score-matched individuals (mean [SD] age, 63.1 [10.9] years; 73.9% male), 8821 received ticagrelor and 8821 received prasugrel. Agreement was met in 11 of 12 predefined agreement metrics when comparing the results with ISAR-REACT5. The primary composite end point of all-cause mortality, MI, or stroke occurred in 815 individuals (9.2%) receiving ticagrelor and 663 (7.5%) receiving prasugrel (hazard ratio [HR], 1.24; 95% CI, 1.12-1.37). Myocardial infarction (HR, 1.20; 95% CI, 1.06-1.36) and stroke (HR, 1.33; 95% CI, 1.02-1.74) each occurred significantly more often in the ticagrelor group. Analysis of all-cause mortality (HR, 1.27; 95% CI, 0.99-1.64), stent thrombosis (HR, 1.11; 95% CI, 0.89-1.30), and major bleeding (HR, 1.12; 95% CI, 0.96-1.32) revealed no significant differences between treatment groups. Subgroup analysis showed that prasugrel was associated with the primary composite end point in fewer individuals with ST-segment elevation MI (338 of 4941 [6.8%] vs 451 of 4852 [9.3%]).

Conclusions and Relevance

This cohort study found that prasugrel was associated with lower rates of all-cause mortality, MI, or stroke compared with ticagrelor in individuals with ACS undergoing an invasive treatment strategy in routine care, particularly in individuals with ST-segment elevation MI. The findings suggest that carefully designed database studies can complement and extend findings from randomized clinical trials, informing guidelines and clinical decision-making.

Usefulness and caveats of real-world data for research on hypertension and its association with cardiovascular or renal disease in Japan

The role of real-world data, collected from clinical practice rather than clinical trials, has become increasingly important for investigating real-life situations, such as treatment effects. In Japan, evidence on hypertension, cardiovascular diseases, and kidney diseases using real-world data is increasing. These studies are mainly based on "the insurer-based real-world data" collected as electronic records, including data from health check-ups and medical claims such as JMDC database, DeSC database, the Japan Health Insurance Association (JHIA) database, or National Databases of Health Insurance Claims and Specific Health Checkups (NDB). Based on the insurer-based real-world data, traditional but finely stratified associations between hypertension and cardiovascular or kidney diseases can be explored. The insurer-based real-world data are also useful for pharmacoepidemiological studies that capture the distribution and trends of drug prescriptions; combined with annual health check-up data, the effectiveness of drugs can also be examined. Despite the usefulness of insurer-based real-world data collected as electronic records from a wide range of populations, we must be cautious about several points, including issues regarding population uncertainty, the validity of cardiovascular outcomes, the accuracy of blood pressure, traceability, and biases, such as indication and immortal biases. While a large sample size is considered a strength of real-world data, we must keep in mind that it does not overcome the problem of systematic error. This review discusses the usefulness and pitfalls of insurer-based real-world data in Japan through recent examples of Japanese research on hypertension and its association with cardiovascular or kidney disease.

ECLIPSES: Early initiation of sodium glucose cotransporter-2 inhibitors for cardiovascular protection in patients with type 2 diabetes following acute coronary syndrome and subsequent coronary artery bypass graft surgery

INTRODUCTION

There is a paucity of data evaluating early initiation of sodium-glucose cotransporter-2 inhibitors (SGLT2i) in patients with diabetes following acute coronary syndrome (ACS) and coronary artery bypass graft surgery (CABG).

OBJECTIVES

To describe the efficacy and safety of SGLT2i initiated early after CABG in patients with type 2 diabetes who experienced ACS.

METHODS

This is a retrospective cohort study of patients with type 2 diabetes (T2DM) who experienced ACS and subsequent CABG with follow up at 3 and 12 months. Patients who filled a SGLT2i prescription within 14 days of discharge were allocated to the SGLT2i group and those who did not were included in the no SGLT2i group. The primary efficacy end point was first occurrence of a 4-point Major Adverse Cardiovascular Event (MACE), and the primary safety end point was a composite of hypoglycemia, hypotension, diabetic ketoacidosis, acute kidney injury, and urinary tract infection. Secondary end points included a comparative analysis of the primary outcome, 30-day readmission rates, and subgroup analyses of key populations.

RESULTS

A total of 1629 patients were included: 226 received a SGLT2i within 14 days of discharge and 1403 did not. At 12 months, 8.9% and 15.3% of patients experienced MACE in the SGLT2i and no SGLT2i groups, respectively (adjusted Hazard Ratio [aHR] 0.65, 95% confidence interval [CI] 0.41-1.04). The primary safety outcome occurred in 12.0% of the SGLT2i group and 19.1% of the no SGLT2i group at 12 months (aHR 0.68, 95% CI 0.45-1.01).

CONCLUSION

Early initiation of SGLT2i use was not associated with a reduction in MACE in patients with T2DM who experienced ACS and underwent subsequent CABG surgery. However, no apparent safety concerns were identified. Adequately powered trials are required to confirm this finding.

Risk of short-term cardiovascular disease in relation to the mode of delivery in singleton pregnancies: a retrospective cohort study

Background

Cardiovascular disease (CVD) is increasing in prevalence and affects up to 4% of pregnancies in otherwise healthy persons. The specific factors that drive the development of CVD in pregnant people are poorly characterised. This study aimed to determine whether the mode of delivery in singletons affects the risk of cardiovascular morbidity and mortality within one year in patients without prior CVD.

Methods

We designed a retrospective cohort study utilising the Nationwide Readmissions Database (NRD) to identify singleton delivery hospitalisations in the United States from Jan 1, 2010 to Nov 30, 2018. International Classification of Disease (ICD) versions 9 and 10 codes were used to identify patients with readmission for CVD within the calendar year of index delivery. Patients aged 15-54 who underwent a singleton vaginal or caesarean delivery were included. Patients with pre-existing CVD hospitalisations before or during delivery, ectopic pregnancies, or abortive outcomes were excluded. Participant data was retrieved from the NRD database. The primary outcome was hospital readmission, defined by ICD 9 and 10 codes for fatal or non-fatal CVD in the same calendar year as delivery. Cox proportional hazard regression models were used to adjust for confounders. These included maternal age, hospital bed size, hospital type, hospital teaching status, income quartile, insurance, and year of delivery. Additional sub-analyses were performed adjusting for hypertensive disorders of pregnancy and diabetes mellitus.

Findings

Of the 14,179,299 singleton deliveries, 32% (n = 4,553,492) underwent a caesarean. CVD readmissions occurred in 255.2 per 100,000 (n = 11,710) caesarean deliveries compared with 133.9 per 100,000 (n = 12,507) vaginal deliveries (rate difference [RD], 121.4, 95% confidence interval [CI], 114.8-127.9; hazard ratio [HR] adjusted for all confounders including hypertensive disorders of pregnancy and diabetes mellitus was 1.42, 95% CI 1.35-1.50). This association was highest in the first 0-29 days following delivery (HR 1.68, 95% CI 1.59-1.78). The risk of readmission for CVD persisted for one year.

Interpretation

These findings suggest that caesarean delivery of singletons is associated with a higher risk of cardiovascular morbidity in patients without pre-existing CVD. This risk was highest in the first month but remained elevated for one year after delivery. These findings add to the accumulating evidence that undergoing caesarean delivery may have long-standing health implications and support the extension of the post-partum surveillance period. Limitations of this study include the lack of adjustment for body mass index, race, and parity. We were also unable to determine the reason for the caesarean delivery.

Funding

None.

The Impact of Cardiac Arrhythmias on Total Knee Arthroplasty Outcomes

BACKGROUND

Cardiac comorbidities are common in patients undergoing total knee arthroplasty (TKA). While there is an abundance of research showing an association between cardiac abnormalities and poor postoperative outcomes, relatively little is published on specific pathologies. The aim of this study was to assess the impact of cardiac arrhythmias on postoperative outcomes in the setting of TKA.

METHODS

This retrospective cohort study included all patients undergoing TKA from a national database, from 2016 to 2019. Patients who had cardiac arrhythmias were identified via International Classification of Diseases, Tenth Revision, and Clinical Modification/Procedure Coding System codes and served as the cohort of interest. Multivariate regression was performed to compare postoperative outcomes. Gamma regression was performed to assess length of stay and total charges, while negative binomial regression was used to assess 30-day readmission and reoperation. Patient demographic variables and comorbidities, measured via the Elixhauser comorbidity index, were controlled in our regression analysis. Out of a total of 1,906,670 patients, 224,434 (11.76%) had a diagnosed arrhythmia and were included in our analyses.

RESULTS

Those who had arrhythmias had greater odds of both medical (odds ratio [OR] 1.52; P < .001) and surgical complications (OR 2.27; P < .001). They also had greater readmission (OR 2.49; P < .001) and reoperation (OR 1.93; P < .001) within 30 days, longer hospital stays (OR 1.07; P < .001), and greater total charges (OR 1.02; P < .001).

CONCLUSIONS

Cardiac arrhythmia is a common comorbidity in the TKA population and is associated with worse postoperative outcomes. Patients who had arrhythmias had greater odds of both medical and surgical complications requiring readmission or reoperation.

STUDY DESIGN

Level III; Retrospective Cohort Study.

Systemic infarcts among patients with atrial fibrillation

BACKGROUND

The epidemiology of atrial fibrillation (AF)-associated thromboembolic complications outside of ischemic strokes has not been thoroughly elucidated.

OBJECTIVE

The aim of this study was to describe the epidemiology of AF-associated systemic infarcts and relevant interactions by sex and race/ethnicity.

METHODS

Using the Office of Statewide Health Planning and Development, we performed a longitudinal analysis of patients aged ≥18 years who received ambulatory surgery, emergency, or inpatient medical care in California between 2005 and 2015. We determined the distribution of infarct locations and risks of systemic infarcts for patients with AF. Interaction analyses by sex and race/ethnicity were conducted.

RESULTS

Of 1,321,694 patients with AF, the average annual rate of systemic infarct was 2.1% ± 0.18% compared with 0.56% ± 0.06% in the 22,944,488 patients without AF. The increased frequency of these infarcts was observed for every body area investigated. After adjustment for potential confounders and mediators, patients with AF experienced a 45% increased risk of a systemic infarct (hazard ratio, 1.45; 95% confidence interval, 1.44-1.47; P < .001). Women, Asians, Blacks, and Hispanics each exhibited a statistically significant heightened relative risk of systemic infarcts in the presence of AF.

CONCLUSION

AF increases the risk of infarcts throughout the body. Susceptibility to these systemic infarcts varies by sex and race/ethnicity in patterns similar to differential risks for stroke. The presence of a systemic infarct in the absence of a clear cause should raise suspicion for AF, and the potential benefits of AF prevention and anticoagulation should be considered beyond only infarcts to the brain.

Mortality and major adverse cardiovascular events after glucagon-like peptide-1 receptor agonist initiation in patients with immune-mediated inflammatory diseases and type 2 diabetes: A population-based study

OBJECTIVE

To assess the risk of all-cause mortality and major adverse cardiovascular events (MACE) in patients with immune-mediated inflammatory diseases (IMIDs) and type 2 diabetes newly initiating glucagon-like peptide-1 receptor agonists (GLP-1-RAs) versus dipeptidyl peptidase-4 inhibitors (DPP-4is).

METHODS

We performed a population-based cohort study using administrative health data from British Columbia. Patients with an IMID (i.e., rheumatoid arthritis, psoriatic disease, ankylosing spondylitis, inflammatory bowel disease, or a systemic autoimmune rheumatic disease) and type 2 diabetes who newly initiated a GLP-1-RA or DPP-4i between January 1, 2010, and December 31, 2021 were identified using ICD-9/10 codes. The primary outcome was all-cause mortality. Secondary outcomes included MACE and its components (i.e., cardiovascular death, myocardial infarction, and ischemic stroke). Cox proportional hazard regressions were used with propensity score overlap weighting. The analysis was repeated in age- and sex-matched adults without IMIDs.

RESULTS

We identified 10,855 adults with IMIDs and type 2 diabetes who newly initiated a GLP-1-RA or DPP-4i. All-cause mortality rate was lower among initiators of GLP-1-RAs compared to initiators of DPP-4is, with a weighted hazard ratio (HR) of 0.48 (95% confidence interval [CI], 0.31-0.75) and rate difference (RD) of -9.4 (95% CI, -16.0 to -2.7) per 1000 person-years. Rate of MACE was also lower with GLP-1-RA exposure (HR 0.66 [0.50-0.88], RD -10.5 [-20.4 to -0.8]). Effect sizes were similar in adults without IMIDs.

CONCLUSION

In patients with IMIDs and type 2 diabetes, GLP-1-RA exposure is associated with a lower risk of all-cause mortality and MACE compared to a cardioneutral active comparator.

Validation Study of Cardiovascular International Statistical Classification of Diseases and Related Health Problems, Tenth Edition, Australian Modification (ICD-10-AM) Codes in Administrative Healthcare Databases (ANZACS-QI 77)

BACKGROUND

Administrative healthcare databases can be utilised for research. The accuracy of the International Statistical Classification of Diseases and Related Health Problems, Tenth Edition, Australian Modification (ICD-10-AM) coding of cardiovascular conditions in New Zealand is not known and requires validation.

METHOD

International Statistical Classification of Diseases and Related Health Problems, Tenth Edition, Australian Modification coded discharges for acute coronary syndrome (ACS), heart failure (HF) and atrial fibrillation (AF), in both primary and secondary diagnostic positions, were identified from four district health boards between 1 January 2019 and 31 June 2019. A sample was randomly selected for retrospective clinician review for evidence of the coded diagnosis according to contemporary diagnostic criteria. Positive predictive values (PPVs) for ICD-10-AM coding vs clinician review were calculated. This study is also known as All of New Zealand, Acute Coronary Syndrome-Quality Improvement (ANZACS-QI) 77.

RESULTS

A total of 600 cases (200 for each diagnosis, 5.0% of total identified cases) were reviewed. The PPV of ACS was 93% (95% confidence interval [CI] 89%-96%), HF was 93% (95% CI 89%-96%) and AF was 96% (95% CI 92%-98%). There were no differences in PPV between district health boards. PPV for ACS were lower in Māori vs non-Māori (72% vs 96%; p=0.004), discharge from non-Cardiology vs Cardiology services (89% vs 96%; p=0.048) and ICD-10-AM coding for unstable angina vs myocardial infarction (81% vs 95%; p=0.011). PPV for HF were higher in the primary vs secondary diagnostic position (100% vs 89%; p=0.001).

CONCLUSIONS

The PPVs of ICD-10-AM coding for ACS, HF, and AF were high in this validation study. ICD-10-AM coding can be used to identify these diagnoses in administrative databases for the purposes of healthcare evaluation and research.

A Capture-Recapture-based Ascertainment Probability Weighting Method for Effect Estimation With Under-ascertained Outcomes

Outcome under-ascertainment, characterized by the incomplete identification or reporting of cases, poses a substantial challenge in epidemiologic research. While capture-recapture methods can estimate unknown case numbers, their role in estimating exposure effects in observational studies is not well established. This paper presents an ascertainment probability weighting framework that integrates capture-recapture and propensity score weighting. We propose a nonparametric estimator of effects on binary outcomes that combines exposure propensity scores with data from two conditionally independent outcome measurements to simultaneously adjust for confounding and under-ascertainment. Demonstrating its practical application, we apply the method to estimate the relationship between health care work and coronavirus disease 2019 testing in a Swedish region. We find that ascertainment probability weighting greatly influences the estimated association compared to conventional inverse probability weighting, underscoring the importance of accounting for under-ascertainment in studies with limited outcome data coverage. We conclude with practical guidelines for the method's implementation, discussing its strengths, limitations, and suitable scenarios for application.

The influence of diagnostic subgroups, patient- and hospital characteristics for the validity of cardiovascular diagnoses-Data from a Norwegian hospital trust

BACKGROUND

Cardiovascular discharge diagnoses may serve as endpoints in epidemiological studies if they have a high validity. Aim was to study if diagnoses-specific characteristics like type, sub-categories, and position of cardiovascular diagnoses affected diagnostic accuracy.

METHODS

Patients (n = 7,164) with a discharge diagnosis of acute myocardial infarction, heart failure or cerebrovascular disease were included. Data were presented as positive predictive values (PPV) and sensitivity.

RESULTS

PPV was high (≥88%) for acute myocardial infarction (n = 2,189) (except for outpatients). For heart failure (n = 4,026) PPV was 67% overall, but higher (>99%) when etiology or echocardiography was included. For hemorrhagic (n = 257) and ischemic (n = 1,034) strokes PPVs were 87% and 80%, respectively, with sensitivity of 79% and 75%. Transient ischemic attacks (n = 926) had PPV 56%, but sensitivity 86%. Primary diagnoses showed higher validity than subsequent diagnoses and inpatient diagnoses were more valid than outpatient diagnoses (except for transient ischemic attack). The diagnoses of acute myocardial infarction and heart failure where most valid when placed at cardiology units, while ischemic stroke when discharged from an internal medicine unit.

CONCLUSIONS

The diagnoses of acute myocardial infarction and stroke had excellent validity when placed during hospital stays. Similarly, heart failure diagnoses had excellent validity when echocardiography was performed before placing the diagnosis, while overall the diagnoses of heart failure and transient ischemic attack were less valid. In conclusion, the results indicate that cardiovascular diagnoses based on objective findings such as acute myocardial infarction and stroke have excellent validity and may be used as endpoints in clinical epidemiological studies with less rigid validation.

Validity and reliability International Classification of Diseases-10 codes for all forms of injury: A systematic review

BACKGROUND

Intentional and unintentional injuries are a leading cause of death and disability globally. International Classification of Diseases (ICD), Tenth Revision (ICD-10) codes are used to classify injuries in administrative health data and are widely used for health care planning and delivery, research, and policy. However, a systematic review of their overall validity and reliability has not yet been done.

OBJECTIVE

To conduct a systematic review of the validity and reliability of external cause injury ICD-10 codes.

METHODS

MEDLINE, EMBASE, COCHRANE, and SCOPUS were searched (inception to April 2023) for validity and/or reliability studies of ICD-10 external cause injury codes in all countries for all ages. We examined all available data for external cause injuries and injuries related to specific body regions. Validity was defined by sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Reliability was defined by inter-rater reliability (IRR), measured by Krippendorff's alpha, Cohen's Kappa, and/or Fleiss' kappa.

RESULTS

Twenty-seven published studies from 2006 to 2023 were included. Across all injuries, the mean outcome values and ranges were sensitivity: 61.6% (35.5%-96.0%), specificity: 91.6% (85.8%-100%), PPV: 74.9% (58.6%-96.5%), NPV: 80.2% (44.6%-94.4%), Cohen's kappa: 0.672 (0.480-0.928), Krippendorff's alpha: 0.453, and Fleiss' kappa: 0.630. Poisoning and hand and wrist injuries had higher mean sensitivity (84.4% and 96.0%, respectively), while self-harm and spinal cord injuries were lower (35.5% and 36.4%, respectively). Transport and pedestrian injuries and hand and wrist injuries had high PPVs (96.5% and 92.0%, respectively). Specificity and NPV were generally high, except for abuse (NPV 44.6%).

CONCLUSIONS AND SIGNIFICANCE

The validity and reliability of ICD-10 external cause injury codes vary based on the injury types coded and the outcomes examined, and overall, they only perform moderately well. Future work, potentially utilizing artificial intelligence, may improve the validity and reliability of ICD codes used to document injuries.

Disease incidence and not case fatality drives the rural disadvantage in myocardial-infarction-related mortality in Germany

OBJECTIVE

Demographic and infrastructural developments might compromise medical care provision in rural regions, particularly for acute health conditions. Studying the case of myocardial infarction (MI), we investigated how MI-related mortality at ages 65+ varies between rural and urban regions in Germany and to what extent differences are driven by varying case fatality and disease incidence.

METHODS

The study relies on data containing all hospitalizations, cause-specific deaths and population counts for the total German population between years 2012-2018 and ages 65+. MI-related mortality, MI incidence and case fatality are compared between urban and rural regions in a population-wide analysis. The impacts of changing incidence and case fatality on rural-urban MI-related mortality differences are assessed using a counterfactual approach.

RESULTS

Rural regions in Germany show systematically higher MI-related death rates and MI incidence at ages 65+ compared to urban regions. Higher mortality is primarily the result of higher MI incidence in rural regions, while case fatality is largely similar. The rural excess in MI-related death rates would be nullified and 1 out of 6 MI-related deaths in rural regions could be prevented if rural regions in Germany would have at least the median MI incidence of urban regions.

CONCLUSIONS

MI incidence and not case fatality drives the rural disadvantage in MI-related mortality in Germany. Higher MI incidence points towards potential regional variation in the effectiveness of disease prevention. The findings highlight that improving disease prevention at the patient level carries larger opportunities for reducing regional MI-related mortality inequalities in Germany.

Burden of serious harms from diagnostic error in the USA

BACKGROUND

Diagnostic errors cause substantial preventable harms worldwide, but rigorous estimates for total burden are lacking. We previously estimated diagnostic error and serious harm rates for key dangerous diseases in major disease categories and validated plausible ranges using clinical experts.

OBJECTIVE

We sought to estimate the annual US burden of serious misdiagnosis-related harms (permanent morbidity, mortality) by combining prior results with rigorous estimates of disease incidence.

METHODS

Cross-sectional analysis of US-based nationally representative observational data. We estimated annual incident vascular events and infections from 21.5 million (M) sampled US hospital discharges (2012-2014). Annual new cancers were taken from US-based registries (2014). Years were selected for coding consistency with prior literature. Disease-specific incidences for 15 major vascular events, infections and cancers ('Big Three' categories) were multiplied by literature-based rates to derive diagnostic errors and serious harms. We calculated uncertainty estimates using Monte Carlo simulations. Validity checks included sensitivity analyses and comparison with prior published estimates.

RESULTS

Annual US incidence was 6.0 M vascular events, 6.2 M infections and 1.5 M cancers. Per 'Big Three' dangerous disease case, weighted mean error and serious harm rates were 11.1% and 4.4%, respectively. Extrapolating to all diseases (including non-'Big Three' dangerous disease categories), we estimated total serious harms annually in the USA to be 795 000 (plausible range 598 000-1 023 000). Sensitivity analyses using more conservative assumptions estimated 549 000 serious harms. Results were compatible with setting-specific serious harm estimates from inpatient, emergency department and ambulatory care. The 15 dangerous diseases accounted for 50.7% of total serious harms and the top 5 (stroke, sepsis, pneumonia, venous thromboembolism and lung cancer) accounted for 38.7%.

CONCLUSION

An estimated 795 000 Americans become permanently disabled or die annually across care settings because dangerous diseases are misdiagnosed. Just 15 diseases account for about half of all serious harms, so the problem may be more tractable than previously imagined.

Stratified analysis in comparative effectiveness studies that emulate randomized trials

PURPOSE

For observational cohort studies that employ matching by propensity scores (PS), preliminary stratification by consequential predictors of outcome better emulates stratified randomization and potentially reduces variance and bias through relaxed dependence on modeling assumptions. We assessed the impact of pre-stratification in two real-life examples. For both, prior evidence from placebo-controlled randomized clinical trials (RCTs) suggested small or no risk reduction, but observational analysis suggested protection, presumably the result of confounding bias.

STUDY DESIGN AND SETTING

The study populations consisted of Medicare beneficiaries (2014-18) with type 2 diabetes initiating either (i) empagliflozin versus dipeptidyl peptidase-4 inhibitors (DPP-4i) or (ii) empagliflozin versus glucagon-like peptide-1 receptor agonists (GLP-1RA). The outcome was myocardial infarction or stroke. We estimated hazard ratios (HR) and rate differences (RD) after controlling for 143 pre-exposure covariates via 1:1 PS matching after (1) PS estimation in the total cohort (total-cohort PS-matching) and (2) PS estimation separately by baseline cardiovascular disease (stratified PS matching).

RESULTS

Stratified PS matching resulted in HRs that exceeded those from total-cohort PS-matching by 13% and 9%, respectively, for the comparisons of empagliflozin to DPP-4i and GLP-1RA. Against both comparators, HRs and RDs after stratified PS matching were closer to the null, with slightly higher variances (2%-3%) than those after total-cohort PS matching.

CONCLUSION

Stratified PS matching produced effect estimates closer to the expected trial findings than total-cohort PS matching. The price paid in increased variance was minimal.

The clinical characteristics, managements, and outcomes of acute myocardial infarction in osteoarthritis patients; a cross-sectional analysis of 6.5 million patients

OBJECTIVES

The prevalence of osteoarthritis (OA) and cardiovascular disease are increasing and both conditions share similar risk factors. We investigated the association between OA and receipt of invasive managements and clinical outcomes in patients with acute myocardial infarction (AMI).

METHODS

Using the National Inpatient Sample, adjusted binary logistic regression determined the association between OA and each outcome variable.

RESULTS

Of 6,561,940 AMI hospitalizations, 6.3% had OA. OA patients were older and more likely to be female. OA was associated with a decreased odds of coronary angiography (adjusted odds ratio 0.91; 95% confidence interval 0.90, 0.92), PCI (0.87; 0.87, 0.88), and coronary artery bypass grafting (0.98; 0.97, 1.00). OA was associated with a decreased odds of adverse outcomes (in-hospital mortality: 0.68; 0.67, 0.69; major acute cardiovascular and cerebrovascular events: 0.71; 0.70, 0.72; all-cause bleeding: 0.76; 0.74, 0.77; and stroke/TIA: 0.84; 0.82, 0.87).

CONCLUSIONS

This study of a representative sample of the US population highlights that OA patients are less likely to be offered invasive interventions following AMI. OA was also associated with better outcomes post-AMI, possibly attributed to a misclassification bias where unwell patients with OA were less likely to receive an OA code because codes for serious illness took precedence.

Cardiovascular Outcomes of α-Blockers vs 5-α Reductase Inhibitors for Benign Prostatic Hyperplasia

Importance

The most prescribed class of medications for benign prostatic hyperplasia (BPH) is α-blockers (ABs). However, the cardiovascular safety profile of these medications among patients with BPH is not well understood.

Objective

To compare the safety of ABs vs 5-α reductase inhibitors (5-ARIs) for risk of adverse cardiovascular outcomes.

Design, Setting, and Participants

This active comparator, new-user cohort study was conducted using insurance claims data from a 20% random sample of Medicare beneficiaries from 2007 to 2019 to evaluate the 1-year risk of adverse cardiovascular outcomes. Males aged 66 to 90 years were indexed into the cohort at new use of an AB or 5-ARI. Twelve months of continuous enrollment and at least 1 diagnosis code for BPH within 12 months prior to initiation were required. Data were analyzed from January 2007 through December 2019.

Exposures

Exposure was defined by a qualifying prescription fill for an AB or 5-ARI after at least 12 months without a prescription for these drug classes.

Main Outcomes and Measures

Follow-up began at a qualified refill for the study drug. Primary study outcomes were hospitalization for heart failure (HF), composite major adverse cardiovascular events (MACE; hospitalization for stroke, myocardial infarction, or death), composite MACE or hospitalization for HF, and death. Inverse probability of treatment and censoring-weighted 1-year risks, risk ratios (RRs), and risk differences (RDs) were estimated for each outcome.

Results

Among 189 868 older adult males, there were 163 829 patients initiating ABs (mean [SD] age, 74.6 [6.2] years; 579 American Indian or Alaska Native [0.4%], 5890 Asian or Pacific Islander [3.6%], 9179 Black [5.6%], 10 610 Hispanic [6.5%], and 133 510 non-Hispanic White [81.5%]) and 26 039 patients initiating 5-ARIs (mean [SD] age, 75.3 [6.4] years; 76 American Indian or Alaska Native [0.3%], 827 Asian or Pacific Islander [3.2%], 1339 Black [5.1%], 1656 Hispanic [6.4%], and 21 605 non-Hispanic White [83.0%]). ABs compared with 5-ARIs were associated with an increased 1-year risk of MACE (8.95% [95% CI, 8.81%-9.09%] vs 8.32% [95% CI, 7.92%-8.72%]; RR = 1.08 [95% CI, 1.02-1.13]; RD per 1000 individuals = 6.26 [95% CI, 2.15-10.37]), composite MACE and HF (RR = 1.07; [95% CI, 1.03-1.12]; RD per 1000 individuals = 7.40 [95% CI, 2.88-11.93 ]), and death (RR = 1.07; [95% CI, 1.01-1.14]; RD per 1000 individuals = 3.85 [95% CI, 0.40-7.29]). There was no difference in risk for HF hospitalization alone.

Conclusions and Relevance

These results suggest that ABs may be associated with an increased risk of adverse cardiovascular outcomes compared with 5-ARIs. If replicated with more detailed confounder data, these results may have important public health implications given these medications' widespread use.

Impact of Successive Office Blood Pressure Measurements During a Single Visit on Cardiovascular Risk Prediction: Analysis of CARTaGENE

BACKGROUND

Multiple office blood pressure (BP) readings correlate more closely with ambulatory BP than single readings. Whether they are associated with long-term outcomes and improve cardiovascular risk prediction is unknown. Our objective was to assess the long-term impact of multiple office BP readings.

METHODS

We used data from CARTaGENE, a population-based survey comprising individuals aged 40 to 70 years. Three BP readings (BP1, BP2, and BP3) at 2-minute intervals were obtained using a semiautomated device. They were averaged to generate BP1-2, BP2-3, and BP1-2-3 for systolic BP (SBP) and diastolic BP. Cardiovascular events (major adverse cardiovascular event [MACE]: cardiovascular death, stroke, and myocardial infarction) during a 10-year follow-up were recorded. Associations with MACE were obtained using adjusted Cox models. Predictive performance was assessed with 10-year atherosclerotic cardiovascular disease scores and their associated C statistics.

RESULTS

In the 17 966 eligible individuals, 2378 experienced a MACE during follow-up. Crude SBP values ranged from 122.5 to 126.5 mm Hg. SBP3 had the strongest association with MACE incidence (hazard ratio, 1.10 [1.05-1.15] per SD) and SBP1 the weakest (hazard ratio, 1.06 [1.01-1.10]). All models including SBP1 (SBP1, SBP1-2, and SBP1-2-3) were underperformed. At a given SBP value, the excess MACE risk conferred by SBP3 was 2× greater than SBP1. In atherosclerotic cardiovascular disease scores, SBP3 yielded the highest C statistic, significantly higher than most other SBP measures. In contrast to SBP, all diastolic BP readings yielded similar results.

CONCLUSIONS

Cardiovascular risk prediction is improved by successive office SBP values, especially when the first reading is discarded. These findings reinforce the necessity of using multiple office BP readings.

Fibrosis-4 Index Score Predicts Concomitant Coronary Artery Diseases Across the Spectrum of Fatty Liver Disease

BACKGROUND

25% of US adults have nonalcoholic fatty liver disease (NAFLD). The independent association between hepatic fibrosis and cardiovascular disease remains controversial. Metabolic dysfunction-associated fatty liver disease (MAFLD) precisely characterizes hepatic steatosis.

AIM

We aimed to determine if degree of hepatic fibrosis, with differing metabolic risk factors, is associated with presence of coronary artery disease (CAD).

METHODS

Retrospective review of patients with hepatic steatosis at a single center from January 2016-October 2020 was performed. MAFLD diagnosis was based on presence of fatty liver disease and metabolic factors. Descriptive statistics and stepwise multivariable logistic regression were performed.

RESULTS

5288 patients with hepatic steatosis were included. 2821 patients with steatosis and metabolic risks were classified as NAFLD-MAFLD. 1245 patients with steatosis without metabolic risks were classified as non-MAFLD NAFLD. 812 patients with metabolic risks and other liver disease and were classified as non-NAFLD MAFLD. On Multivariate analysis, Fib-4 ≥ 2.67 was an independent risk factor for CAD in the overall fatty liver disease and NAFLD-MAFLD groups. Fib-4 as a continuous variable showed linear association with CAD risk in the overall fatty liver disease, Non-MAFLD NAFLD and NAFLD-MAFLD groups, at Fib-4 values below 2.67.

CONCLUSION

Fib-4 ≥ 2.67 is independently predicts concomitant CAD in patients with hepatic steatosis. Fib-4, at levels below 2.67, is significantly associated with concomitant CAD in the all fatty liver disease, Non-MAFLD NAFLD, and NAFLD-MAFLD groups. Emphasizing clinical phenotypes and Fib-4 levels may help target those with an increased risk for CAD.

Can traffic-related air pollution trigger myocardial infarction within a few hours of exposure? Identifying hourly hazard periods

INTRODUCTION

Traffic-related air pollution can trigger myocardial infarction (MI). However, the hourly hazard period of exposure to nitrogen dioxide (NO2), a common traffic tracer, for incident MI has not been fully evaluated. Thus, the current hourly US national air quality standard (100 ppb) is based on limited hourly-level effect estimates, which may not adequately protect cardiovascular health.

OBJECTIVES

We characterized the hourly hazard period of NO2 exposure for MI in New York state (NYS), USA, from 2000 to 2015.

METHODS

For nine cities in NYS, we obtained data on MI hospitalizations from the NYS Department of Health Statewide Planning and Research Cooperative System and hourly NO2 concentrations from the US Environmental Protection Agency's Air Quality System database. We used city-wide exposures and a case-crossover study design with distributed lag non-linear terms to assess the relationship between hourly NO2 concentrations over 24 h and MI, adjusting for hourly temperature and relative humidity.

RESULTS

The mean NO2 concentration was 23.2 ppb (standard deviation: 12.6 ppb). In the six hours preceding MI, we found linearly increased risk with increasing NO2 concentrations. At lag hour 0, a 10 ppb increase in NO2 was associated with 0.2 % increased risk of MI (Rate Ratio [RR]: 1.002; 95 % Confidence Interval [CI]: 1.000, 1.004). We estimated a cumulative RR of 1.015 (95 % CI: 1.008, 1.021) for all 24 lag hours per 10 ppb increase in NO2. Lag hours 2-3 had consistently elevated risk ratios in sensitivity analyses.

CONCLUSIONS

We found robust associations between hourly NO2 exposure and MI risk at concentrations far lower than current hourly NO2 national standards. Risk of MI was most elevated in the six hours after exposure, consistent with prior studies and experimental work evaluating physiologic responses after acute traffic exposure. Our findings suggest that current hourly standards may be insufficient to protect cardiovascular health.

Validation of diagnosis of acute myocardial infarction and stroke in electronic medical records: a primary care cross-sectional study in Madrid, Spain (the e-MADVEVA Study)

OBJECTIVES

To validate the diagnoses of acute myocardial infarction (AMI) and stroke recorded in electronic medical records (EMR) and to estimate the population prevalence of both diseases in people aged ≥18 years.

DESIGN

Cross-sectional validation study.

SETTING

45 primary care centres.

PARTICIPANTS

Simple random sampling of diagnoses of AMI and stroke (International Classification of Primary Care-2 codes K75 and K90, respectively) registered by 55 physicians and random age-matched and sex-matched sampling of the records that included in primary care EMRs in Madrid (Spain).

PRIMARY AND SECONDARY OUTCOME MEASURES

Sensitivity, specificity, positive and negative predictive values and overall agreement were calculated using the kappa statistic. Applied gold standards were ECGs, brain imaging studies, hospital discharge reports, cardiology reports and neurology reports. In the case of AMI, the ESC/ACCF/AHA/WHF Expert Consensus Document was also used. Secondary outcomes were the estimated prevalence of both diseases considering the sensitivity and specificity obtained (true prevalence).

RESULTS

The sensitivity of a diagnosis of AMI was 98.11% (95% CI, 96.29 to 99.03), and the specificity was 97.42% (95% CI, 95.44 to 98.55). The sensitivity of a diagnosis of stroke was 97.56% (95% CI, 95.56 to 98.68), and the specificity was 94.51% (95% CI, 91.96 to 96.28). No differences in the results were found after stratification by age and sex (both diseases). The prevalence of AMI and stroke was 1.38% and 1.27%, respectively.

CONCLUSION

The validation results show that diagnoses of AMI and stroke in primary care EMRs constitute a helpful tool in epidemiological studies. The prevalence of AMI and stroke was lower than 2% in the population aged over 18 years.

Cardiovascular Disease-Related Emergency Department Visits and Hospitalization among Women with Hypertensive Disorders of Pregnancy

INTRODUCTION

The risk of developing cardiovascular disease is higher for women who had hypertensive disorders of pregnancy than for women without a history of hypertensive disorders of pregnancy. However, it is unknown whether the emergency department visits and hospitalization differ between women with a history of hypertensive disorders of pregnancy and women without hypertensive disorders of pregnancy. The objective of this study was to characterize and compare cardiovascular disease-related emergency department visits, hospitalization rates, and diagnoses in women with a history of hypertensive disorders of pregnancy with those in women without.

METHODS

This study included participants from the California Teachers Study (N=58,718) with a history of pregnancy and data from 1995 through 2020. Incidence of cardiovascular disease-related emergency department visits and hospitalizations based on linkages with hospital records were modeled using multivariable negative binomial regression. Data were analyzed in 2022.

RESULTS

A total of 5% of the women had a history of hypertensive disorders of pregnancy (5.4%, 95% CI=5.2%, 5.6). A total of 31% of women had 1 or more cardiovascular disease-related emergency department visits (30.9%), and 30.1% had 1 or more hospitalizations. The incidence of cardiovascular disease-related emergency department visits (adjusted incident rate ratio=8.96, p<0.001) and hospitalizations (adjusted incident rate ratio=8.88, p<0.001) were significantly higher for women with hypertensive disorders of pregnancy than for those without, adjusting for other related characteristics of the women.

CONCLUSIONS

History of hypertensive disorders of pregnancy is associated with higher cardiovascular disease-related emergency department visits and hospitalizations. These findings underscore the potential burden on women and the healthcare system of managing complications associated with hypertensive disorders of pregnancy. Evaluating and managing cardiovascular disease risk factors in women with a history of hypertensive disorders of pregnancy is necessary to avoid cardiovascular disease-related emergency department visits and hospitalizations in this group.

Associations of free sugars from solid and liquid sources with cardiovascular disease: a retrospective cohort analysis

BACKGROUND

The World Health Organization recommends a 10% total energy (TE%) limit for free sugars (i.e., added sugars and naturally occurring sugars in fruit juice, honey, and syrups) based on evidence linking higher intakes with overweight and dental caries. Evidence for cardiovascular disease (CVD) is limited. Impacts may differ by sex, age group, and solid vs. liquid sources; liquids may stimulate more adverse CVD profiles (due to their rapid absorption in the body along along with triggering less satiety). We examined associations of consuming total free sugars ≥ 10 TE% with CVD within four sex and age-defined groups. Given roughly equal free sugar intakes from solid and liquid sources, we also evaluated source-specific associations of free sugars ≥ 5 TE% thresholds.

METHODS

In this retrospective cohort study, we estimated free sugars from 24-h dietary recall (Canadian Community Health Survey, 2004-2005) in relationship to nonfatal and fatal CVD (Discharge Abstract and Canadian Mortality Databases, 2004-2017; International Disease Classification-10 codes for ischemic heart disease and stroke) through multivariable Cox proportional hazards models adjusted for overweight/obesity, health behaviours, dietary factors, and food insecurity. We conducted analyses in separate models for men 55 to 75 years, women 55 to 75 years, men 35 to 55 years, and women 35 to 55 years. We dichotomized total free sugars at 10 TE% and source-specific free sugars at 5 TE%.

RESULTS

Men 55 to 75 years of age had 34% higher CVD hazards with intakes of free sugars from solid sources ≥ 5 TE% vs. below (adjusted HR 1.34, 95% CI 1.05- 1.70). The other three age and sex-specific groups did not demonstrate conclusive associations with CVD.

CONCLUSIONS

Our findings suggest that from a CVD prevention standpoint in men 55 to 75 years of age, there may be benefits from consuming less than 5 TE% as free sugars from solid sources.

Cardiovascular outcomes in children with Kawasaki disease: a population-based cohort study

BACKGROUND

The risk of cardiovascular events after Kawasaki disease (KD) remains uncertain. Our objective was to determine the risk of cardiovascular events and mortality after KD.

METHODS

Population-based retrospective cohort study using Ontario health administrative databases (0-18 years; 1995-2018).

EXPOSURE

pediatric KD hospitalizations. Each case was matched to 100 non-exposed controls.

PRIMARY OUTCOME

major adverse cardiac events (MACE; cardiovascular death, myocardial infarction, or stroke composite).

SECONDARY OUTCOMES

composite cardiovascular events and mortality. We determined incidence rates and adjusted hazard ratios (aHR) using multivariable Cox models.

RESULTS

Among 4597 KD survivors, 79 (1.7%) experienced MACE, 632 (13.8%) composite cardiovascular events, and 9 (0.2%) died during 11-year median follow-up. The most frequent cardiovascular events among KD survivors were ischemic heart disease (4.6 events/1000 person-years) and arrhythmias (4.5/1000 person-years). KD survivors were at increased risk of MACE between 0-1 and 5-10 years, and composite cardiovascular events at all time periods post-discharge. KD survivors had a lower mortality risk throughout follow-up (aHR 0.36, 95% CI 0.19-0.70).

CONCLUSION

KD survivors are at increased risk of post-discharge cardiovascular events but have a lower risk of death, which justifies enhanced cardiovascular disease surveillance in these patients.

IMPACT

Among 4597 Kawasaki disease (KD) survivors, 79 (1.7%) experienced major adverse cardiac events (MACE) and 632 (13.8%) had composite cardiovascular events during 11-year median follow-up. KD survivors had significantly higher risks of post-discharge MACE and cardiovascular events versus non-exposed children. Only nine KD survivors (0.2%) died during follow-up, and the risk of mortality was significantly lower among KD survivors versus non-exposed children. Childhood KD survivors should receive preventative counseling and cardiovascular surveillance, aiming to mitigate adult cardiovascular disease.

Suboptimal oral health and the risk of cardiovascular disease in the presence of competing death: a data linkage analysis

OBJECTIVE

The objective of this study is to simultaneously assess the associations between suboptimal oral health (SOH) and cardiovascular disease (CVD) and competing death (CD).

METHODS

Ontario residents aged 40 years and over who participated in the Canadian Community Health Survey 2003 and 2007-2008 were followed until December 31, 2016 for the incidence of CVD or CD. SOH was assessed based on self-rated oral health and inability to chew. Multivariable competing risk analysis was adjusted for socioeconomic characteristics, behavioural factors and intermediate health outcomes.

RESULTS

The study sample included 36,176 participants. Over a median follow-up of 9.61 years, there were 2077 CVD events and 3180 CD events. The fully adjusted models indicate 35% (HR = 1.35, 95% CI: 1.12-1.64) increase in the risk of CVD and 57% (HR = 1.57, 95% CI: 1.33-1.85) increase in the risk of CD among those who reported poor oral health as compared to those who reported excellent oral health. The fully adjusted models also indicate 11% (HR = 1.11, 95% CI: 0.97-1.27) increase in the hazard of CVD and 37% (HR = 1.37, 95% CI: 1.24-1.52) increase in the hazard of CD among those who reported inability to chew.

CONCLUSION

This study provides important information to contextualize CVD risk among those with SOH. The competing risk analysis indicates that those with SOH may benefit from additional interventions to prevent CVD and CD. Accordingly, managing the risk of CVD among those with SOH should fall under a more comprehensive approach that aims at improving their overall health and well-being.

Real-world data in primary care: validation of diagnosis of atrial fibrillation in primary care electronic medical records and estimated prevalence among consulting patients'

BACKGROUND

Primary care electronic medical records contain clinical-administrative information on a high percentage of the population. Before this information can be used for epidemiological purposes, its quality must be verified. This study aims to validate diagnoses of atrial fibrillation (AF) recorded in primary care electronic medical records and to estimate the prevalence of AF in the population attending primary care consultations.

METHODS

We performed a cross-sectional validation study of all diagnoses of AF recorded in primary care electronic medical records in Madrid (Spain). We also performed simple random sampling of diagnoses of AF (ICPC-2 code K78) registered by 55 physicians and random age- and sex-matched sampling of the records that included a diagnosis of AF. Electrocardiograms, echocardiograms, and hospital discharge or cardiology clinic reports were matched. Sensitivity, specificity, positive and negative predictive values (PPV and NPV), and overall agreement were calculated using the kappa statistic (κ). The prevalence of AF in the community of Madrid was estimated considering the sensitivity and specificity obtained in the validation. All calculations were performed overall and by sex and age groups.

RESULTS

The degree of agreement was very high (κ = 0.952), with a sensitivity of 97.84%, specificity of 97.39%, PPV of 97.37%, and NPV of 97.85%. The prevalence of AF in the population aged over 18 years was 2.41% (95%CI 2.39-2.42% [2.25% in women and 2.58% in men]). This increased progressively with age, reaching 16.95% in those over 80 years of age (15.5% in women and 19.44% in men).

CONCLUSIONS

The validation results obtained enable diagnosis of AF recorded in primary care to be used as a tool for epidemiological studies. A high prevalence of AF was found, especially in older patients.

Lipid-Lowering Therapy Use and Intensification Among United States Veterans Following Myocardial Infarction or Coronary Revascularization Between 2015 and 2019

BACKGROUND

Understanding how statins, ezetimibe, and PCSK9i (proprotein convertase subtilisin/kexin type 9 serine protease inhibitors) are prescribed after a myocardial infarction (MI) or elective coronary revascularization may improve lipid-lowering therapy (LLT) intensification and reduce recurrent atherosclerotic cardiovascular disease events. We described the use and intensification of LLT among US veterans who had a MI or elective coronary revascularization between July 24, 2015, and December 9, 2019, within 12 months of hospital discharge.

METHODS

LLT intensification was defined as increasing statin dose, or initiating a statin, ezetimibe, or a PCSK9i, overall and among those with an LDL-C (low-density lipoprotein cholesterol) ≥70 or 100 mg/dL. Poisson regression was used to determine patient characteristics associated with a greater likelihood of LLT intensification following hospitalization for MI or elective coronary revascularization.

RESULTS

Among 81 372 index events (mean age, 69.0 years, 2.3% female, mean LDL-C 89.6 mg/dL, 33.8% with LDL-C <70 mg/dL), 39.7% were not taking any LLT, and 22.0%, 37.2%, and 0.6% were taking a low-moderate intensity statin, a high-intensity statin, and ezetimibe, respectively, before MI/coronary revascularization during the study period. Within 14 days, 3 months, and 12 months posthospitalization, 33.3%, 41.9%, and 47.3%, respectively, of veterans received LLT intensification. LLT intensification was most common among veterans taking no LLT (82.5%, n=26 637) before MI/coronary revascularization. Higher baseline LDL-C, having a lipid test, and attending a cardiology visit were each associated with a greater likelihood of LLT intensification, while age ≥75 versus <65 years was associated with a lower likelihood of LLT intensification within 12 months posthospitalization.

CONCLUSIONS

Less than half of veterans received LLT intensification in the year after MI or coronary revascularization suggesting a missed opportunity to reduce atherosclerotic cardiovascular disease risk.

Validation of Algorithms to Identify Acute Myocardial Infarction, Stroke, and Cardiovascular Death in German Health Insurance Data

Purpose

Validation of outcomes allows measurement of and correction for potential misclassification and targeted adjustment of algorithms for case definition. The purpose of our study was to validate algorithms for identifying cases of acute myocardial infarction (AMI), stroke, and cardiovascular (CV) death using patient profiles, ie, chronological tabular summaries of relevant available information on a patient, extracted from pseudonymized German claims data.

Patients and Methods

Based on the German Pharmacoepidemiological Research Database (GePaRD), 250 cases were randomly selected (50% males) for each outcome between 2016 and 2017 based on the inclusion criteria age ≥50 years and continuous insurance ≥1 year and applying the following algorithms: hospitalization with a main diagnosis of AMI (ICD-10-GM codes I21.- and I22.-) or stroke (I63, I61, I64) or death with a hospitalization in the 60 days before with a main diagnosis of CV disease. Patient profiles were built including (i) age and sex, (ii) hospitalizations incl. diagnoses, procedures, discharge reasons, (iii) outpatient diagnoses incl. diagnostic certainty, physician specialty, (iv) outpatient encounters, and (v) outpatient dispensings. Using adjudication criteria based on clinical guidelines and risk factors, two trained physicians independently classified cases as “certain”, “probable”, “unlikely” or “not assessable”. Positive predictive values (PPVs) were calculated as percentage of confirmed cases among all assessable cases.

Results

For AMI, the overall PPV was 97.6% [95% confidence interval 94.8–99.1]. The PPV for any stroke was 94.8% [91.3–97.2] and higher for ischemic (98.3% [95.0–99.6]) than for hemorrhagic stroke (86.5% [76.5–93.3]). The PPV for CV death was 79.9% [74.4–84.4]. It increased to 91.7% [87.2–95.0] after excluding 32 cases with data insufficient for a decision.

Conclusion

Algorithms based on hospital diagnoses can identify AMI, stroke, and CV death from German claims data with high PPV. This was the first study to show that German claims data contain information suitable for outcome validation.

Prognostic implication of premature ventricular contractions in patients without structural heart disease

AIMS

Premature ventricular contractions (PVCs) are a common form of arrhythmia associated with an unfavourable prognosis in patients with structural heart disease. However, the prognostic significance in absence of heart disease is debated. With this study, we aim to investigate whether subjects with PVC, without structural heart disease, have a worse prognosis than the general population.

METHODS AND RESULTS

Patients evaluated for PVC at a secondary care centre in Stockholm County from January 2010 to December 2016 were identified. We included patients without history of previous heart disease who had undergone echocardiography and exercise test with normal findings. Based on sex and age, we matched the PVC cohort to a four times bigger control group from the general population and compared the outcome in terms of mortality and cardiovascular morbidity during a median follow-up time of 5.2 years. We included 820 patients and 3,264 controls. Based on a non-inferiority analysis, the PVC group did not have a higher mortality than the control group (0.44, CI 0.27-0.72). Sensitivity analysis with propensity score matching confirmed this result.

CONCLUSIONS

PVC patients, who after thorough evaluation showed no signs of structural heart disease, did not have a worse prognosis when compared to an age- and sex- control group based on the general population.

Does a Code for Acute Myocardial Infarction Mean the Same in All Norwegian Hospitals? A Likelihood Approach to a Medical Record Review

Objective

Health registries are important data sources for epidemiology, quality monitoring, and improvement. Acute myocardial infarction (AMI) is a common, serious condition. Little is known about variation in the positive predictive value (PPV) of a coded AMI diagnosis and its association with hospital quality indicators. The present study aimed to investigate the relationship between PPV and registry-based 30-day mortality after AMI admission and between-hospital variation in PPV.

Study Design and Setting

An electronic record review was performed in a nationwide sample of Norwegian hospitals. Clinical signs and cardiac troponin measurements were abstracted and analyzed using a mixture model for likelihood ratios and parametric bootstrapping.

Results

The overall PPV was estimated to be 97%. We found no statistically significant association between hospital PPV and the classification of hospitals into low, intermediate, and high registry-based 30-day mortality. There was significant variation between hospitals, with a PPV range of 91–100%.

Conclusion

We found no evidence that variation in PPV of AMI diagnosis can explain variation between hospitals in registry-based 30-day mortality after admission. However, PPV varied significantly between hospitals. We were able to use a very efficient statistical approach to the analysis and handling of various sources of uncertainty.

Comparative Effectiveness of Empagliflozin vs Liraglutide or Sitagliptin in Older Adults With Diverse Patient Characteristics

IMPORTANCE

Limited evidence is available on the comparative effectiveness of empagliflozin vs alternative second-line glucose-lowering agents in patients with type 2 diabetes (T2D) receiving routine care who have a broad spectrum of cardiorenal risk.

OBJECTIVE

To evaluate the association of empagliflozin with cardiovascular outcomes relative to liraglutide and sitagliptin, stratified by age, sex, baseline atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), and chronic kidney disease (CKD).

DESIGN, SETTING, AND PARTICIPANTS

This retrospective comparative effectiveness cohort study used deidentified Medicare claims data from August 1, 2014, to September 30, 2018, with follow-up from drug initiation until treatment changes, death, or gap in Medicare enrollment (>30 days). Data analysis was performed from October 1, 2021, to April 30, 2022. Medicare fee-for-service beneficiaries older than 65 years with T2D were included. A total of 45 788 patients (22 894 propensity score-matched pairs initiating treatment with either empagliflozin or liraglutide) were included in cohort 1, and 45 624 patients (22 812 propensity score-matched pairs initiating treatment with either empagliflozin or sitagliptin) were included in cohort 2.

EXPOSURES

Empagliflozin vs liraglutide (cohort 1) or empagliflozin vs sitagliptin (cohort 2).

MAIN OUTCOMES AND MEASURES

Primary outcomes were (1) modified major adverse cardiovascular events (MACEs), including a composite of myocardial infarction, stroke, and all-cause mortality, and (2) hospitalization for heart failure (HHF). Hazard ratios (HRs) and rate differences (RDs) per 1000 person-years were estimated, adjusting for 143 baseline covariates using 1:1 propensity score matching.

RESULTS

Among 45 788 patients in cohort 1, the mean (SD) age was 71.9 (5.1) years; 23 396 patients (51.1%) were female, 22 392 (48.9%) were male, and 38 049 (83.1%) were White. Among 45 624 patients in cohort 2, the mean (SD) age was 72.1 (5.1) years; 21 418 patients (46.9%) were female, 24 206 (53.1%) were male, and 37 814 (82.9%) were White. Relative to patients initiating liraglutide, those initiating empagliflozin had a similar risk of the modified MACE outcome (HR, 0.90; 95% CI, 0.79-1.03) and a reduced risk of HHF (HR, 0.66; 95% CI, 0.52-0.82). Across subgroups, empagliflozin was associated with a lower risk of the modified MACE outcome in patients with a history of ASCVD (HR, 0.83; 95% CI, 0.71-0.98) and HF (HR, 0.77; 95% CI, 0.60-1.00) compared with liraglutide, and potential heterogeneity in estimates was observed by sex (male: HR, 0.85 [95% CI, 0.71-1.01]; female: HR, 1.16 [95% CI, 0.94-1.42]; P = .02 for homogeneity). However, reductions in the risk of HHF were observed across most subgroups (eg, ASCVD: HR, 0.66 [95% CI, 0.51-0.85]; HF: HR, 0.66 [95% CI, 0.49-0.88]). Compared with sitagliptin, empagliflozin was associated with reduced risks of the modified MACE outcome (HR, 0.68; 95% CI, 0.60-0.77) and HHF (HR, 0.45; 95% CI, 0.36-0.56), which were consistent across all subgroups. Absolute benefits of empagliflozin vs sitagliptin were larger in patients with a history of ASCVD (modified MACE: RD, -17.6 [95% CI, -24.9 to -10.4]; HHF: RD, -16.7 [95% CI, -21.7 to -11.9]), HF (modified MACE: RD, -41.1 [95% CI, -59.9 to -22.6]; HHF: RD, -50.4 [95% CI, -67.5 to -33.9]), or CKD (modified MACE: RD, -26.7 [95% CI, -41.3 to -12.3]; HHF: RD, -31.9 [95% CI, -43.5 to -20.8]).

CONCLUSIONS AND RELEVANCE

In this comparative effectiveness study of older adults, empagliflozin was associated with a lower risk of HHF (relative to both liraglutide and sitagliptin) and the modified MACE outcome (relative to sitagliptin), with larger absolute benefits in patients with established cardiorenal diseases. These findings suggest that older adults with T2D might benefit more from empagliflozin vs liraglutide or sitagliptin with respect to the risk of HHF; with respect to the risk of MACEs, empagliflozin might be preferable to liraglutide only in patients with cardiovascular disease history and to sitagliptin across all patient subgroups.

Racial Disparities in Hospitalization Among Patients Who Receive a Diagnosis of Acute Coronary Syndrome in the Emergency Department

Background Timely hospitalization of patients who are diagnosed with an acute coronary syndrome (ACS) at the emergency department (ED) is a crucial step to lower the risk of ACS mortality. We examined whether there are racial and ethnic differences in the risk of being discharged home among patients who received a diagnostic code of ACS at the ED and whether having health insurance plays a role. Methods and Results We examined 51 022 910 discharge records of ED visits in Florida, New York, and Utah in the years 2008, 2011, 2014, and 2016/2017 using state-specific data from the Healthcare Cost and Utilization Project. We identified ED admissions for acute myocardial infarction or unstable angina using the International Classification of Diseases, Ninth Revision (ICD-9)/International Statistical Classification of Diseases, Tenth Revision (ICD-10) diagnostic codes. We used generalized estimating equation models to compare the risk of being discharged home across racial and ethnic groups. We used Poisson marginal structural models to estimate the mediating role of health insurance status. The proportion discharged home with a diagnostic code of ACS was 12% among Black patients, 6% among White patients, 9% among Hispanic patients, and 9% among Asian/Pacific Islander patients. The incidence risk ratio for being discharged home was 1.26 (95% CI, 1.18-1.34) in Black patients, 1.23 (95% CI, 1.15-1.32) in Hispanic patients, and 1.11 (95% CI, 0.93-1.31) in Asian/Pacific Islander patients compared with White patients. Race and ethnicity were marginally associated with discharge home via pathways not mediated by health insurance. Conclusions Racial and ethnic disparities exist in the hospitalization of patients who received a diagnostic code of ACS in the ED. Possible causes need to be investigated.

Prediction of Cardiovascular Events by Pulse Waveform Parameters: Analysis of CARTaGENE

Background Waveform parameters provide approximate data about aortic wave reflection. However, their association with cardiovascular events remains controversial and their role in cardiovascular prediction is unknown. Methods and Results We analyzed participants aged between 40 and 69 from the population-based CARTaGENE cohort. Baseline pulse wave analysis (central pulse pressure, augmentation index) and wave separation analysis (forward pressure, backward pressure, reflection magnitude) parameters were derived from radial artery tonometry. Associations between each parameter and major adverse atherosclerotic events (MACE; cardiovascular death, stroke, myocardial infarction) were obtained using adjusted Cox models. The incremental predictive value of each parameter compared with the 10-year atherosclerotic cardiovascular disease score alone was assessed using hazard ratios, c-index differences, continuous net reclassification indexes, and integrated discrimination indexes. From 17 561 eligible patients, 2315 patients had a MACE during a median follow-up of 10.1 years. Central pulse pressure, forward pressure, and backward pressure, but not augmentation index and reflection magnitude, were significantly associated with MACE after full adjustment. All parameters except forward pressure statistically improved MACE prediction compared with the atherosclerotic cardiovascular disease score alone. The greatest prediction improvement was seen with augmentation index and reflection magnitude but remained small in magnitude. These 2 parameters enhanced predictive performance more strongly in patients with low baseline atherosclerotic cardiovascular disease scores. Up to 5.7% of individuals were reclassified into a different risk stratum by adding waveform parameters to atherosclerotic cardiovascular disease scores. Conclusions Some waveform parameters are independently associated with MACEs in a population-based cohort. Augmentation index and reflection magnitude slightly improve risk prediction, especially in patients at low cardiovascular risk.

An artificial intelligence-based risk prediction model of myocardial infarction

BACKGROUND

Myocardial infarction can lead to malignant arrhythmia, heart failure, and sudden death. Clinical studies have shown that early identification of and timely intervention for acute MI can significantly reduce mortality. The traditional MI risk assessment models are subjective, and the data that go into them are difficult to obtain. Generally, the assessment is only conducted among high-risk patient groups.

OBJECTIVE

To construct an artificial intelligence-based risk prediction model of myocardial infarction (MI) for continuous and active monitoring of inpatients, especially those in noncardiovascular departments, and early warning of MI.

METHODS

The imbalanced data contain 59 features, which were constructed into a specific dataset through proportional division, upsampling, downsampling, easy ensemble, and w-easy ensemble. Then, the dataset was traversed using supervised machine learning, with recursive feature elimination as the top-layer algorithm and random forest, gradient boosting decision tree (GBDT), logistic regression, and support vector machine as the bottom-layer algorithms, to select the best model out of many through a variety of evaluation indices.

RESULTS

GBDT was the best bottom-layer algorithm, and downsampling was the best dataset construction method. In the validation set, the F1 score and accuracy of the 24-feature downsampling GBDT model were both 0.84. In the test set, the F1 score and accuracy of the 24-feature downsampling GBDT model were both 0.83, and the area under the curve was 0.91.

CONCLUSION

Compared with traditional models, artificial intelligence-based machine learning models have better accuracy and real-time performance and can reduce the occurrence of in-hospital MI from a data-driven perspective, thereby increasing the cure rate of patients and improving their prognosis.

Event Rates and Risk Factors for Recurrent Cardiovascular Events and Mortality in a Contemporary Post Acute Coronary Syndrome Population Representing 239 234 Patients During 2005 to 2018 in the United States

Background

Patients with acute coronary syndrome (ACS) are recognized by guidelines as remaining at high risk for adverse outcomes. Evidence from contemporary, representative ACS populations in a clinical practice setting is necessary to identify subgroups and strategies for improving patient outcomes. We aimed to describe event rates and risk factors in an ACS population over prolonged follow‐up for cardiovascular end points.

Methods and Results

We identified 239 234 patients in the Optum Research Database (57.2% men; mean [standard deviation] age, 69.2 [12.2] years) with evidence of an ACS hospitalization (index ACS) during January 1, 2005 through December 30, 2018. Subgroups were based on index ACS event (myocardial infarction/unstable angina and revascularization status) and the Thrombolysis In Myocardial Infarction Risk Score for Secondary Prevention. The 5‐year event rate for the primary end point representing nonfatal myocardial infarction, nonfatal ischemic stroke, and cardiovascular death was 33.4% (95% CI, 33.1%–33.7%; P<0.001). The risk of experiencing the primary end point was ≈6‐fold higher immediately after discharge (≈40.9% annualized risk) as compared with the period 1+ years after hospitalization (≈6.4% annualized risk). Among subgroups, the 5‐year primary end point event rate was highest for myocardial infarction without revascularization and a Thrombolysis In Myocardial Infarction Risk Score for Secondary Prevention ≥4, at 47.9% (95% CI, 47.3%–48.4%; P<0.001) and 56.7% (95% CI, 55.9%–57.4%; P<0.001), respectively.

Conclusions

Patients with ACS remain at very high risk of experiencing recurrent cardiovascular events, particularly early after discharge, with identifiable subgroups at multifold higher risk of specific clinical end points.

Association of tramadol with all-cause mortality, cardiovascular diseases, venous thromboembolism, and hip fractures among patients with osteoarthritis: a population-based study

Background

The use of tramadol among osteoarthritis (OA) patients has been increasing rapidly around the world, but population-based studies on its safety profile among OA patients are scarce. We sought to determine if tramadol use in OA patients is associated with increased risks of all-cause mortality, cardiovascular diseases (CVD), venous thromboembolism (VTE), and hip fractures compared with commonly prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) or codeine.

Methods

Using administrative health datasets from British Columbia, Canada, we conducted a sequential propensity score-matched cohort study among all OA patients between 2005 and 2013. The tramadol cohort (i.e., tramadol initiation) was matched with four comparator cohorts (i.e., initiation of naproxen, diclofenac, cyclooxygenase-2 [Cox-2] inhibitors, or codeine). Outcomes are all-cause mortality, first-ever CVD, VTE, and hip fractures within the year after the treatment initiation. Patients were followed until they either experienced an event, left the province, or the 1-year follow-up period ended, whichever occurred first. Cox proportional hazard models were used to estimate hazard ratios after adjusting for competing risk of death.

Results

Overall, 100,358 OA patients were included (mean age: 68 years, 63% females). All-cause mortality was higher for tramadol compared to NSAIDs with rate differences (RDs/1000 person-years, 95% CI) ranging from 3.3 (0.0–6.7) to 8.1 (4.9–11.4) and hazard ratios (HRs, 95% CI) ranging from 1.2 (1.0–1.4) to 1.5 (1.3–1.8). For CVD, no differences were observed between tramadol and NSAIDs. Tramadol had a higher risk of VTE compared to diclofenac, with RD/1000 person-years (95% CI) of 2.2 (0.7–3.7) and HR (95% CI) of 1.7 (1.3–2.2). Tramadol also had a higher risk of hip fractures compared to diclofenac and Cox-2 inhibitors with RDs/1000 person-years (95% CI) of 1.9 (0.4–3.4) and 1.7 (0.2–3.3), respectively, and HRs (95% CI) of 1.6 (1.2–2.0) and 1.4 (1.1–1.9), respectively. No differences were observed between tramadol and NSAIDs for all events.

Conclusions

OA patients initiating tramadol have an increased risk of mortality, VTE, and hip fractures within 1 year compared with commonly prescribed NSAIDs, but not with codeine.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-022-02764-3.

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.

Trends in the occurrence of ischaemic heart disease over time in rheumatoid arthritis: 1821 patients from 1972 to 2017

OBJECTIVE

To evaluate trends of acute myocardial infarction (AMI) and ischaemic heart disease (IHD) in rheumatoid arthritis (RA) patients compared with the general population over time.

METHOD

We performed a retrospective cohort study of 1821 RA patients diagnosed from 1972 to 2013. Aggregated counts of the total population of the same county (Hordaland, Norway) and period were used for comparison. Information on AMI and IHD events was obtained from hospital patient administrative systems or cardiovascular registries. We estimated incidence rates and excess of events [standardized event ratio (SER) with 95% confidence interval (CI)] compared with the general population by Poisson regression.

RESULTS

There was an average annual decline of 1.6% in age- and gender-adjusted AMI incidence rates from 1972 to 2017 (p < 0.035). The difference in events (excess events) in RA patients compared with the general population declined on average by 1.3% per year for AMI and by 2.3% for IHD from 1972 to 2014. There were no significant excess AMI (SER 1.05, 95% CI 0.82-1.35) or IHD events (SER 1.02, 95% CI 0.89-1.16) for RA patients diagnosed after 1998 compared with the general population.

CONCLUSION

Incidence rates and excess events of AMI and IHD in RA patients declined from 1972 to 2017. There were no excess AMI or IHD events in RA patients diagnosed after 1998 compared with the general population.

Systematic review: development of a consensus code set to identify cirrhosis in electronic health records

BACKGROUND

Electronic health records (EHRs) collate longitudinal data that can be used to facilitate large-scale research in patients with cirrhosis. However, there is no consensus code set to define the presence of cirrhosis in EHR. This systematic review aims to evaluate the validity of diagnostic coding in cirrhosis and to synthesise a comprehensive set of ICD-10 codes for future EHR research.

METHOD

MEDLINE and EMBASE databases were searched for studies that used EHR to identify cirrhosis and cirrhosis-related complications. Validated code sets were summarised, and the performance characteristics were extracted. Citation analysis was done to inform development of a consensus code set. This was then validated in a cohort of patients.

RESULTS

One thousand six hundred twenty-six records were screened, and 18 studies were identified. The positive predictive value (PPV) was the most frequently reported statistical estimate and was ≥80% in 17/18 studies. Citation analyses showed continued variation in those used in contemporary research practice. Nine codes were identified as those most frequently used in the literature and these formed the consensus code set. This was validated in diverse patient populations from Europe and North America and showed high PPV (83%-89%) and greater sensitivity for the identification of cirrhosis than the most often used code set in the recent literature.

CONCLUSION

There is variation in code sets used to identify cirrhosis in contemporary research practice. A consensus set has been developed and validated, showing improved performance, and is proposed to align EHR study designs in cirrhosis to facilitate international collaboration and comparisons.

Cardiovascular Effectiveness of Sodium-Glucose Cotransporter 2 Inhibitors and Glucagon-Like Peptide-1 Receptor Agonists in Older Patients in Routine Clinical Care With or Without History of Atherosclerotic Cardiovascular Diseases or Heart Failure

Background Randomized trials demonstrate the cardioprotective effects of sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA). We evaluated their relative cardiovascular effectiveness in routine care populations with a broad spectrum of atherosclerotic cardiovascular diseases (CVDs) or heart failure (HF). Methods and Results We identified Medicare beneficiaries from 2013 to 2017, aged >65 years, initiating SGLT2i (n=24 747) or GLP-1RA (n=22 596) after a 1-year baseline. On the basis of diagnoses during baseline, we classified patients into: (1) no HF or CVD, (2) HF but no CVD, (3) no HF but CVD, and (4) both HF and CVD. We identified hospitalized HF and atherosclerotic CVD outcomes from drug initiation until treatment changes, death, or disenrollment. We estimated propensity score-weighted 2-year risk ratios (RRs) and risk differences, accounting for measured confounding, informative censoring, and competing risk. In patients with no CVD or HF, SGLT2i reduced the hospitalized HF risk compared with GLP-1RA (propensity score-weighted RR, 0.65; 95% CI, 0.43-0.96). The association was strongest in those who had HF but no CVD (RR, 0.48; 95% CI, 0.25-0.85). The combined myocardial infarction, stroke, and mortality outcome risk was slightly higher for SGLT2i compared with GLP-1RA in those without CVD or HF (RR, 1.31; 95% CI, 1.09-1.56). The association was favorable toward SGLT2i in subgroups with a history of HF. Conclusions SGLT2i reduced the cardiovascular risk versus GLP-1RA in patients with a history of HF but no CVD. Atherosclerotic CVD events were less frequent with GLP-1RA in those without prior CVD or HF.

Use of diagnostic likelihood ratio of outcome to evaluate misclassification bias in the planning of database studies

Background

The diagnostic likelihood ratio (DLR) and its utility are well-known in the field of medical diagnostic testing. However, its use has been limited in the context of an outcome validation study. We considered that wider recognition of the utility of DLR would enhance the practices surrounding database studies. This is particularly timely and important since the use of healthcare-related databases for pharmacoepidemiology research has greatly expanded in recent years. In this paper, we aimed to advance the use of DLR, focusing on the planning of a new database study.

Methods

Theoretical frameworks were developed for an outcome validation study and a comparative cohort database study; these two were combined to form the overall relationship. Graphical presentations based on these relationships were used to examine the implications of validation study results on the planning of a database study. Additionally, novel uses of graphical presentations were explored using some examples.

Results

Positive DLR was identified as a pivotal parameter that connects the expected positive-predictive value (PPV) with the disease prevalence in the planned database study, where the positive DLR is equal to sensitivity/(1-specificity). Moreover, positive DLR emerged as a pivotal parameter that links the expected risk ratio with the disease risk of the control group in the planned database study. In one example, graphical presentations based on these relationships provided a transparent and informative summary of multiple validation study results. In another example, the potential use of a graphical presentation was demonstrated in selecting a range of positive DLR values that best represented the relevant validation studies.

Conclusions

Inclusion of the DLR in the results section of a validation study would benefit potential users of the study results. Furthermore, investigators planning a database study can utilize the DLR to their benefit. Wider recognition of the full utility of the DLR in the context of a validation study would contribute meaningfully to the promotion of good practice in planning, conducting, analyzing, and interpreting database studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01757-1.

Evidence of large systematic differences between countries in assigning ischaemic heart disease deaths to myocardial infarction: the contrasting examples of Russia and Norway

BACKGROUND

There is considerable variation in mortality rates from myocardial infarction (MI) across high-income countries, some of which may be artefactual.

METHODS

Time trends in mortality rates from ischaemic heart disease (IHD) and MI were analysed for a set of high-income countries from the end of the 1970s. Using individual-level mortality data from Russia (2005-2017) and Norway (2005-2016), we investigated factors associated with the proportion of total IHD deaths certified as due to MI.

RESULTS

In most countries, MI mortality rates have dramatically declined from the 1970s. However, the share of MI in total IHD deaths varies substantially across countries. In Russia, only 12% of IHD deaths had MI assigned as the underlying cause vs 63% in Norway. IHD deaths occurring outside of hospital without autopsy were far less likely to be assigned as MI in Russia (2%) than in Norway (59%).

CONCLUSIONS

Although established international criteria for MI require specific clinical or post-mortem evidence, it appears that certifying specialists in different countries may interpret these criteria differently. At one extreme, Russian doctors may only assign MI as a cause of death when there is specific pathophysiological evidence. At the other extreme, their counterparts in Norway may be willing to specify MI as the cause even when this evidence is not available. Internationally established criteria for MI diagnosis are challenging to apply for out-of-hospital deaths. Differences between countries in how certifiers interpret these criteria may account for at least some of the international variation in MI mortality rates.

Retrospective validation of a machine learning clinical decision support tool for myocardial infarction risk stratification

Diagnosis and appropriate intervention for myocardial infarction (MI) are time-sensitive but rely on clinical measures that can be progressive and initially inconclusive, underscoring the need for an accurate and early predictor of MI to support diagnostic and clinical management decisions. The objective of this study was to develop a machine learning algorithm (MLA) to predict MI diagnosis based on electronic health record data (EHR) readily available during Emergency Department assessment. An MLA was developed using retrospective patient data. The MLA used patient data as they became available in the first 3 h of care to predict MI diagnosis (defined by International Classification of Diseases, 10th revision code) at any time during the encounter. The MLA obtained an area under the receiver operating characteristic curve of 0.87, sensitivity of 87% and specificity of 70%, outperforming the comparator scoring systems TIMI and GRACE on all metrics. An MLA can synthesize complex EHR data to serve as a clinically relevant risk stratification tool for MI.

Comparative Risk of Incident Coronary Heart Disease Across Chronic Inflammatory Diseases

Background: Chronic inflammatory diseases (CIDs) are considered risk enhancing factors for coronary heart disease (CHD). However, sparse data exist regarding relative CHD risks across CIDs. Objective: Determine relative differences in CHD risk across multiple CIDs: psoriasis, rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), human immunodeficiency virus (HIV), systemic sclerosis (SSc), and inflammatory bowel disease (IBD). Methods: The cohort included patients with CIDs and controls without CID in an urban medical system from 2000 to 2019. Patients with CIDs were frequency-matched with non-CID controls on demographics, hypertension, and diabetes. CHD was defined as myocardial infarction (MI), ischemic heart disease, and/or coronary revascularization based on validated administrative codes. Multivariable-adjusted Cox models were used to determine the risk of incident CHD and MI for each CID relative to non-CID controls. In secondary analyses, we compared CHD risk by disease severity within each CID. Results: Of 17,049 patients included for analysis, 619 had incident CHD (202 MI) over an average of 4.4 years of follow-up. The multivariable-adjusted risk of CHD was significantly higher for SLE [hazard ratio (HR) 1.9, 95% confidence interval (CI) 1.2, 3.2] and SSc (HR 2.1, 95% CI 1.2, 3.9). Patients with SLE also had a significantly higher risk of MI (HR 3.6, 95% CI 1.9, 6.8). When CIDs were categorized by markers of disease severity (C-reactive protein for all CIDs except HIV, for which CD4 T cell count was used), greater disease severity was associated with higher CHD risk across CIDs. Conclusions: Patients with SLE and SSc have a higher risk of CHD. CHD risk with HIV, RA, psoriasis, and IBD may only be elevated in those with greater disease severity. Clinicians should personalize CHD risk and treatment based on type and severity of CID.

Major adverse cardiovascular event definitions used in observational analysis of administrative databases: a systematic review

Background

Major adverse cardiovascular events (MACE) are increasingly used as composite outcomes in randomized controlled trials (RCTs) and observational studies. However, it is unclear how observational studies most commonly define MACE in the literature when using administrative data.

Methods

We identified peer-reviewed articles published in MEDLINE and EMBASE between January 1, 2010 to October 9, 2020. Studies utilizing administrative data to assess the MACE composite outcome using International Classification of Diseases 9th or 10th Revision diagnosis codes were included. Reviews, abstracts, and studies not providing outcome code definitions were excluded. Data extracted included data source, timeframe, MACE components, code definitions, code positions, and outcome validation.

Results

A total of 920 articles were screened, 412 were retained for full-text review, and 58 were included. Only 8.6% (n = 5/58) matched the traditional three-point MACE RCT definition of acute myocardial infarction (AMI), stroke, or cardiovascular death. None matched four-point (+unstable angina) or five-point MACE (+unstable angina and heart failure). The most common MACE components were: AMI and stroke, 15.5% (n = 9/58); AMI, stroke, and all-cause death, 13.8% (n = 8/58); and AMI, stroke and cardiovascular death 8.6% (n = 5/58). Further, 67% (n = 39/58) did not validate outcomes or cite validation studies. Additionally, 70.7% (n = 41/58) did not report code positions of endpoints, 20.7% (n = 12/58) used the primary position, and 8.6% (n = 5/58) used any position.

Conclusions

Components of MACE endpoints and diagnostic codes used varied widely across observational studies. Variability in the MACE definitions used and information reported across observational studies prohibit the comparison, replication, and aggregation of findings. Studies should transparently report the administrative codes used and code positions, as well as utilize validated outcome definitions when possible.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01440-5.