Cardiovascular disease recurrence and long-term mortality in a tri-ethnic British cohort

OBJECTIVE

Ethnic differences in cardiovascular disease incidence, but not cardiovascular disease recurrence, are reported. We characterised long-term risk of major adverse cardiovascular event (MACE) and mortality following a non-fatal cardiovascular event in a British cohort of South Asians, African Caribbeans and Europeans.

METHODS

We identified index and recurrent cardiovascular events and mortality between 1988 and 2017 using hospital records and death registry. Using multivariable hazards models, we separately calculated the adjusted HR of MACE and death following index event, adjusting for demographics, vascular and lifestyle risk factors. Using interaction terms, we evaluated if decade of index event modified the association between ethnicity and outcomes.

RESULTS

South Asians were younger at the index event (median age 66 years, n=396) than Europeans (69 years, n=335) and African Caribbeans (70 years, n=70). During 4228 person-years, of the 801 patients, 537 developed MACE and 338 died, with the highest crude rate of MACE in South Asians. On adjustment of baseline factors, compared with the Europeans, the higher risk of MACE (HR 0.97, 95% CI 0.77 to 1.21) and the lower risk of mortality (HR 0.95, 95% CI 0.72 to 1.26) in South Asians was eliminated. African Caribbeans had similar outcomes to Europeans (HR MACE 1.04, 95% CI 0.74 to 1.47; and HR death 1.07, 95% CI 0.70 to 1.64). Long-term survival following an index event improved in South Asians (ptrend 0.02) and African Caribbeans (ptrend 0.07) compared with Europeans.

CONCLUSIONS

Baseline vascular risk factors explained the observed ethnic variation in cardiovascular disease recurrence and long-term mortality, with a relative improvement in survival of minority ethnic groups over time.

Impact of cardiovascular disease and risk factors on fatal outcomes in patients with COVID-19 according to age: a systematic review and meta-analysis

OBJECTIVE

Previous studies that evaluated cardiovascular risk factors considered age as a potential confounder. We aimed to investigate the impact of cardiovascular disease (CVD) and its risk factors on fatal outcomes according to age in patients with COVID-19.

METHODS

A systematic literature review and meta-analysis was performed on data collected from PubMed and Embase databases up to 11 June 2020. All observational studies (case series or cohort studies) that assessed in-hospital patients were included, except those involving the paediatric population. Prevalence rates of comorbid diseases and clinical outcomes were stratified by mean patient age in each study (ranges: <50 years, 50-60 years and ≥60 years). The primary outcome measure was a composite fatal outcome of severe COVID-19 or death.

RESULTS

We included 51 studies with a total of 48 317 patients with confirmed COVID-19 infection. Overall, the relative risk of developing severe COVID-19 or death was significantly higher in patients with risk factors for CVD (hypertension: OR 2.50, 95% CI 2.15 to 2.90; diabetes: 2.25, 95% CI 1.89 to 2.69) and CVD (3.11, 95% 2.55 to 3.79). Younger patients had a lower prevalence of hypertension, diabetes and CVD compared with older patients; however, the relative risk of fatal outcomes was higher among the former.

CONCLUSIONS

The results of the meta-analysis suggest that CVD and its risk factors (hypertension and diabetes) were closely related to fatal outcomes in COVID-19 for patients across all ages. Although young patients had lower prevalence rates of cardiovascular comorbidities than elderly patients, relative risk of fatal outcome in young patients with hypertension, diabetes and CVD was higher than in elderly patients.

PROSPERO REGISTRATION NUMBER

CRD42020198152.

Influence of sex and phenotype on cardiac outcomes in patients with Fabry disease

Objective

This study describes the influence of sex and disease phenotype on the occurrence of cardiac events in Fabry disease (FD).

Methods

Cardiac events from birth to last visit (median age 50 years) were recorded for 213 patients with FD. Patients were categorised as follows : men with classical FD (n=57), men with non-classical FD (n=26), women with classical FD (n=98) and women with non-classical FD (n=32), based on the presence of classical FD symptoms, family history (men and women), biomarkers and residual enzyme activity (men). Event rates per 1000 patient-years after the age of 15 years and median event-free survival (EVS) age were presented. Influence of disease phenotype, sex and their interaction was studied using Firth’s penalised Cox regression.

Results

The event rates of major cardiovascular events (combined endpoint cardiovascular death (CVD), heart failure (HF) hospitalisation, sustained ventricular arrhythmias (SVAs) and myocardial infarction) were 11.0 (95% CI 6.6 to 17.3) in men with classical FD (EVS 55 years), 4.4 (95% CI 2.5 to 7.1) in women with classical FD (EVS 70 years) and 5.9 (95% CI 2.6 to 11.6) in men with non-classical FD (EVS 70 years). None of these events occurred in women with non-classical FD. Sex and phenotype significantly influenced the risk of major adverse cardiovascular event. CVD was the leading cause of death (75%) to which HF contributed most (42%). The overall rate of SVA was low (14 events in nine patients (4%)).

Conclusions

Sex and phenotype greatly influence the risk and age of onset of cardiac events in FD. This indicates the need for patient group-specific follow-up and treatment.

Single high-sensitivity troponin levels to assess patients with potential acute coronary syndromes

OBJECTIVE

We tested the hypothesis that patients with a potential acute coronary syndrome (ACS) and very low levels of high-sensitivity cardiac troponin I can be efficiently and safely discharged from the emergency department after a single troponin measurement.

METHODS

This prospective cohort study recruited 2255 consecutive patients aged ≥18 years presenting to the Emergency Department, Royal Perth Hospital, Western Australia, with chest pain without high-risk features but requiring the exclusion of ACS. Patients were managed using a guideline-recommended pathway or our novel Single Troponin Accelerated Triage (STAT) pathway. The primary outcome was the percentage of patients discharged in <3 hours. Secondary outcomes included the duration of observation and death or acute myocardial infarction in the next 30 days.

RESULTS

The study enrolled 1131 patients to the standard cohort and 1124 to the STAT cohort. Thirty-eight per cent of the standard cohort were discharged directly from emergency department compared with 63% of the STAT cohort (p<0.001). The median duration of observation was 4.3 (IQR 3.3-7.1) hours in the standard cohort and 3.6 (2.6-5.4) hours in the STAT cohort (p<0.001), with 21% and 38% discharged in <3 hours, respectively (p<0.001). No patients discharged directly from the emergency department died or suffered an acute myocardial infarction within 30 days in either cohort.

CONCLUSIONS

Among low-risk patients with a potential ACS, a pathway which incorporates early discharge based on a single very low level of high-sensitivity cardiac troponin increases the proportion of patients discharged directly from the emergency department, reduces length of stay and is safe.

TRIAL REGISTRATION NUMBER

ACTRN12618000797279.

Socioeconomic disparities in prehospital factors and survival after out-of-hospital cardiac arrest

OBJECTIVE

It remains unknown whether patient socioeconomic factors affect interventions and survival after out-of-hospital cardiac arrest (OHCA), and whether a socioeconomic effect on bystander interventions affects survival. Therefore, this study examined patient socioeconomic disparities in prehospital factors and survival.

METHODS

From the Danish Cardiac Arrest Registry, patients with OHCA ≥30 years were identified, 2001-2014, and divided into quartiles of household income (highest, high, low, lowest). Associations between income and bystander cardiopulmonary resuscitation (CPR) and 30-day survival with bystander CPR as mediator were analysed by logistic regression and mediation analysis in private witnessed, public witnessed, private unwitnessed and public unwitnessed arrests, adjusted for confounders.

RESULTS

We included 21 480 patients. Highest income patients were younger, had higher education and were less comorbid relative to lowest income patients. They had higher odds for bystander CPR with the biggest difference in private unwitnessed arrests (OR 1.74, 95% CI 1.47 to 2.05). For 30-day survival, the biggest differences were in public witnessed arrests with 26.0% (95% CI 22.4% to 29.7%) higher survival in highest income compared with lowest income patients. Had bystander CPR been the same for lowest income as for highest income patients, then survival would be 25.3% (95% CI 21.5% to 29.0%) higher in highest income compared with lowest income patients, resulting in elimination of 0.79% (95% CI 0.08% to 1.50%) of the income disparity in survival. Similar trends but smaller were observed in low and high-income patients, the other three subgroups and with education instead of income. From 2002 to 2014, increases were observed in both CPR and survival in all income groups.

CONCLUSION

Overall, lower socioeconomic status was associated with poorer prehospital factors and survival after OHCA that was not explained by patient or cardiac arrest-related factors.

N-terminal pro-brain natriuretic peptide and sudden cardiac death in hypertrophic cardiomyopathy

OBJECTIVE

Elevated levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) are associated with heart failure-related death in hypertrophic cardiomyopathy (HCM), but the relationship between NT-proBNP level and sudden cardiac death (SCD) in HCM remains undefined.

METHODS

The study prospectively enrolled 977 unrelated patients with HCM with available NT-proBNP results who were prospectively enrolled and followed for 3.0±2.1 years. The Harrell's C-statistic under the receiver operating characteristic curve was calculated to evaluate discrimination performance. A combination model was constructed by adding NT-proBNP tertiles to the HCM Risk-SCD model. The correlation between log NT-proBNP level and cardiac fibrosis as measured by late gadolinium enhancement (LGE) or Masson's staining was analysed.

RESULTS

During follow-up, 29 patients had SCD. Increased log NT-proBNP levels were associated with an increased risk of SCD events (adjusted HR 22.27, 95% CI 10.93 to 65.63, p<0.001). The C-statistic of NT-proBNP in predicting SCD events was 0.80 (p<0.001). The combined model significantly improved the predictive efficiency of the HCM Risk-SCD model from 0.72 to 0.81 (p<0.05), with a relative integrated discrimination improvement of 0.002 (p<0.001) and net reclassification improvement of 0.67 (p<0.001). Furthermore, log NT-proBNP levels were significantly correlated with cardiac fibrosis as detected either by LGE (r=0.257, p<0.001) or by Masson's trichrome staining in the myocardium (r=0.198, p<0.05).

CONCLUSION

NT-proBNP is an independent predictor of SCD in patients with HCM and may help with risk stratification of this disease.

Risk for cardiovascular events following 'microsize' versus usual myocardial infarctions

BACKGROUND

Microsize myocardial infarction (MI) is a recently described phenomenon that meets rigorous criteria for MI with very low peak troponin elevations. We aim to compare the risk for cardiovascular events and mortality following microsize versus usual MIs.

METHODS AND RESULTS

Prospective cohort analysis of REasons for Geographic And Racial Differences in Stroke (REGARDS) study participants without a history of coronary heart disease (CHD) who had an incident MI between 2003 and 2015. Incident MIs were classified as microsize MI (peak troponin <0.5 ng/mL) or usual MI (peak troponin ≥0.5 ng/mL). Participants were followed for a composite of cardiovascular events that included recurrent MI, coronary revascularisation, fatal CHD and heart failure, and all-cause mortality. Overall, 1024 participants with an incident MI were included in the analysis (328 with microsize MI and 696 with usual MI). Participants with microsize MI were more likely to be older and black. The multivariable-adjusted adjustment HR for cardiovascular events among participants with microsize versus usual MI after a median follow-up of 1.7 years was 1.11 (95% CI 0.86 to 1.44). The multivariable-adjusted HR for all-cause mortality after 28 days from incident MI among participants with microsize versus usual MI after a median follow-up of 3.6 years was 1.09 (95% CI 0.81 to 1.45).

CONCLUSION

Microsize MIs have a prognostic value for future cardiovascular events and mortality comparable to usual MIs. These findings should encourage clinicians to initiate secondary prevention strategies in patients with microsize MI until this emerging clinical entity is better understood.

Prognostic significance of natriuretic peptide levels in atrial fibrillation without heart failure

OBJECTIVES

Natriuretic peptides are an important prognostic marker in patients with heart failure (HF). However, little is known regarding their prognostic significance in patients with atrial fibrillation (AF) without HF and natriuretic peptides levels are underused in these patients in daily practice.

METHODS

The Fushimi AF Registry is a community-based prospective survey of patients with AF in Fushimi-ku, Kyoto, Japan. We investigated patients with AF without HF (defined as prior HF hospitalisation, New York Heart Association functional class≥2 or left ventricular ejection fraction<40%) using the data of B-type natriuretic peptide (BNP, n=388) or N-terminal pro-B-type natriuretic peptide (NT-proBNP, n=771) at enrolment. BNPs were converted to NT-proBNP using a conversion formula. We divided the patients according to quartiles of NT-proBNP levels and compared the backgrounds and outcomes.

RESULTS

Of 1159 patients (mean age: 72.1±10.2 years, median CHA₂DS₂-VASc score: 3 and oral anticoagulant (OAC) prescription: 671 (56%)), the median NT-proBNP level was 488 (IQR 169-1015) ng/L. Patients with high NT-proBNP levels were older, had higher CHA₂DS₂-VASc scores and had more OAC prescription (all p<0.001). Kaplan-Meier curves demonstrated that NT-proBNP levels were significantly associated with higher incidences of stroke/systemic embolism, all-cause death and HF hospitalisation during a median follow-up period of 5.0 years (log rank, all p<0.001). Multivariable Cox regression analyses revealed that NT-proBNP levels were an independent predictor of adverse outcomes even after adjustment by various confounders.

CONCLUSION

NT-proBNP levels are a significant prognostic marker for adverse outcomes in patients with AF without HF and may have clinical value.

TRIAL REGISTRATION NUMBER

UMIN000005834.

Association of cardiac rehabilitation and health-related quality of life following acute myocardial infarction

OBJECTIVE

To study the association of cardiac rehabilitation and physical activity with temporal changes in health-related quality of life (HRQoL) following acute myocardial infarction (AMI).

METHODS

Evaluation of the Methods and Management of Acute Coronary Events-3 is a nationwide longitudinal prospective cohort study of 4570 patients admitted with an AMI between 1 November 2011 and 17 September 2013. HRQoL was estimated using EuroQol 5-Dimension-3 Level Questionnaire at hospitalisation, 30 days, and 6 and 12 months following hospital discharge. The association of cardiac rehabilitation and self-reported physical activity on temporal changes in HRQoL was quantified using inverse probability of treatment weighting propensity score and multilevel regression analyses.

RESULTS

Cardiac rehabilitation attendees had higher HRQoL scores than non-attendees at 30 days (mean EuroQol 5-Visual Analogue Scale (EQ-VAS) scores: 71.0 (SD 16.8) vs 68.6 (SD 19.8)), 6 months (76.0 (SD 16.4) vs 70.2 (SD 19.0)) and 12 months (76.9 (SD 16.8) vs 70.4 (SD 20.4)). Attendees who were physically active ≥150 min/week had higher HRQoL scores compared with those who only attended cardiac rehabilitation at 30 days (mean EQ-VAS scores: 79.3 (SD 14.6) vs 70.2 (SD 17.0)), 6 months (82.2 (SD 13.9) vs 74.9 (SD 16.7)) and 12 months (84.1 (SD 12.1) vs 75.6 (SD 17.0)). Cardiac rehabilitation and self-reported physical activity of ≥150 min/week were each positively associated with temporal improvements in HRQoL (coefficient: 2.12 (95% CI 0.68 to 3.55) and 4.75 (95% CI 3.16 to 6.34), respectively).

CONCLUSIONS

Cardiac rehabilitation was independently associated with temporal improvements in HRQoL at up to 12 months following hospitalisation, with such changes further improved in patients who were physically active.

Impact of opioid use disorders on outcomes and readmission following cardiac operations

OBJECTIVE

While opioid use disorder (OUD) has been previously associated with increased morbidity and resource use in cardiac operations, its impact on readmissions is understudied.

METHODS

Patients undergoing coronary artery bypass grafting and valve repair or replacement, excluding infective endocarditis, were identified in the 2010-16 Nationwide Readmissions Database. Using International Classification of Diseases 9/10, we tabulated OUD and other characteristics. Multivariable regression was used to adjust for differences.

RESULTS

Of an estimated 1 978 276 patients who had cardiac surgery, 5707 (0.3%) had OUD. During the study period, the prevalence of OUD increased threefold (0.15% in 2010 vs 0.53% in 2016, parametric trend<0.001). Patients with OUD were more likely to be younger (54.0 vs 66.0 years, p<0.001), insured by Medicaid (28.2 vs 6.2%, p<0.001) and of the lowest income quartile (33.6 vs 27.1%, p<0.001). After multivariable adjustment, OUD was associated with decreased mortality (1.5 vs 2.7%, p=0.001). Although these patients had similar rates of overall complications (36.1 vs 35.1%, p=0.363), they had increased thromboembolic (1.3 vs 0.8%, p<0.001) and infectious (4.1 vs 2.8%, p<0.001) events, as well as readmission at 30 days (19.0 vs 13.2%, p<0.001). While patients with OUD had similar hospitalisation costs ($50 766 vs $50 759, p=0.994), they did have longer hospitalisations (11.4 vs 10.3 days, p<0.001).

CONCLUSION

The prevalence of OUD among cardiac surgical patients has steeply increased over the past decade. Although the presence of OUD was not associated with excess mortality at index hospitalisation, it was predictive of 30-day readmission. Increased attention to predischarge interventions and care coordination may improve outcomes in this population.

Newly diagnosed diabetes and outcomes after acute myocardial infarction in young adults

Objective

To examine prevalence and characteristics of newly diagnosed diabetes (NDD) in younger adults hospitalised with acute myocardial infarction (AMI) and investigate whether NDD is associated with health status and clinical outcomes over 12-month post-AMI.

Methods

In individuals (18–55 years) admitted with AMI, without established diabetes, we defined NDD as (1) baseline or 1-month HbA1c≥6.5%; (2) discharge diabetes diagnosis or (3) diabetes medication initiation within 1 month. We compared baseline characteristics of NDD, established diabetes and no diabetes, and their associations with baseline, 1-month and 12-month health status (angina-specific and non-disease specific), mortality and in-hospital complications.

Results

Among 3501 patients in Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients study, 14.5% met NDD criteria. Among 508 patients with NDD, 35 (6.9%) received discharge diagnosis, 91 (17.9%) received discharge diabetes education and 14 (2.8%) initiated pharmacological treatment within 1 month. NDD was more common in non-White (OR 1.58, 95% CI 1.23 to 2.03), obese (OR 1.72, 95% CI 1.39 to 2.12), financially stressed patients (OR 1.27, 95% CI 1.02 to 1.58). Compared with established diabetes, NDD was independently associated with better disease-specific health status and quality of life (p≤0.04). No significant differences were found in unadjusted in-hospital mortality and complications between NDD and established or no diabetes.

Conclusions

NDD was common among adults≤55 years admitted with AMI and was more frequent in non-White, obese, financially stressed individuals. Under 20% of patients with NDD received discharge diagnosis or initiated discharge diabetes education or pharmacological treatment within 1 month post-AMI. NDD was not associated with increased risk of worse short-term health status compared with risk noted for established diabetes.

Trial registration number

NCT00597922.

Changes in quality of life, cognition and functional status following catheter ablation of atrial fibrillation

OBJECTIVE

To investigate changes in quality of life (QoL), cognition and functional status according to arrhythmia recurrence after atrial fibrillation (AF) ablation.

METHODS

We compared QoL, cognition and functional status in patients with recurrent atrial tachycardia (AT)/AF versus those without recurrent AT/AF in the AXAFA-AFNET 5 clinical trial. We also sought to identify factors associated with improvement in QoL and functional status following AF ablation by overall change scores with and without analysis of covariance (ANCOVA).

RESULTS

Among 518 patients who underwent AF ablation, 154 (29.7%) experienced recurrent AT/AF at 3 months. Patients with recurrent AT/AF had higher mean CHA₂DS₂-VASc scores (2.8 vs 2.3, p<0.001) and more persistent forms of AF (51 vs 39%, p=0.012). Median changes in the SF-12 physical (3 (25th, 75th: -1, 8) vs 1 (-5, 8), p=0.026) and mental scores (2 (-3, 9) vs 0 (-4, 5), p=0.004), EQ-5D (0 (0,2) vs 0 (-0.1, 0.1), p=0.027) and Karnofsky functional status scores (10 (0, 10) vs 0 (0, 10), p=0.001) were more favourable in patients without recurrent AT/AF. In the overall cohort, the proportion with at least mild cognitive impairment (Montreal Cognitive Assessment <26) declined from 30.3% (n=157) at baseline to 21.8% (n=113) at follow-up. ANCOVA identified greater improvement in Karnofsky functional status (p<0.001) but not SF-12 physical (p=0.238) or mental scores (p=0.065) in those without recurrent AT/AF compared with patients with recurrent AT/AF.

CONCLUSIONS

Patients without recurrent AT/AF appear to experience greater improvement in functional status but similar QoL as those with recurrent AT/AF after AF ablation.

Incidence, predictors, and prognostic impact of recurrent acute myocardial infarction in China

BACKGROUND

Incidence, predictors, and prognostic impact of recurrent acute myocardial infarction (AMI) after initial AMI remain poorly understood. Data on recurrent AMI in China is unknown.

METHODS

Using the China Patient-centred Evaluative Assessment of Cardiac Events (PEACE)-Prospective AMI Study, we studied 3387 patients admitted to 53 hospitals for AMI and discharged alive. The association of recurrent AMI with 1-year mortality was evaluated using time-dependent Cox regression. Recurrent AMI events were classified as early (1-30 days), late (31-180 days), and very late (181-365 days). Their impacts on 1-year mortality were estimated by Kaplan-Meier methodology and compared by the log-rank test. Multivariable modelling was used to identify factors associated with recurrent AMI.

RESULTS

The mean (SD) age was 60.7 (11.9) years and 783 (23.1%) were women. The observed 1-year recurrent AMI rate was 2.5% (95% CI 2.00 to 3.07) with 35.7% events occurring within the first 30 days. Recurrent AMI was associated with 1-year mortality with an adjusted HR of 25.42 (95% CI 15.27 to 42.34). Early recurrent AMI was associated with the highest 1-year mortality rate of 53.3% (log-rank p<0.001). Predictors of recurrent AMI included age 75-84, in-hospital percutaneous coronary intervention, heart rate >90 min/beats at initial admission, renal dysfunction, and not being prescribed any of guideline-based medications at discharge.

CONCLUSIONS

One-third of recurrent AMI events occurred early. Recurrent AMI is strongly associated with 1-year mortality, particularly if early. Heightened surveillance during this early period and improving prescription of recommended discharge medications may reduce recurrent AMI in China.

Characteristics and outcomes of patients with suspected heart failure referred in line with National Institute for Health and Care Excellence guidance

OBJECTIVE

To describe the population, heart failure (HF) diagnosis rate, and 1-year hospitalisation and mortality of patients with suspected HF and elevated N-terminal pro B-type natriuretic peptide (NTproBNP) investigated according to UK National Institute for Health and Care Excellence (NICE) guidelines.

METHODS

NICE recommends patients with suspected HF, based on clinical presentation and elevated NTproBNP, are referred for specialist assessment and echocardiography. Patients should be seen within 2 weeks when NTproBNP is >2000 pg/mL (2-week pathway: 2WP) or within 6 weeks when NTproBNP is 400-2000 pg/mL (6-week pathway: 6WP). This is a retrospective, multicentre, observational study of consecutive patients with suspected HF referred from primary care between 2014 and 2016 to dedicated secondary care HF clinics based on the NICE 2WP and 6WP. Data were obtained from hospital records and episode statistics. Mortality and hospitalisation rates were calculated 1 year from NTproBNP measurement.

RESULTS

1271 patients (median age 80; IQR 73-85) were assessed, 680 (53%) of whom were female. 667 (53%) were referred on the 2WP and 604 (47%) on the 6WP. 698 (55%) were diagnosed with HF (369 HF with reduced ejection fraction) and 566 (45%) as not HF (NHF). 1-year mortality was 10% (n=129) and hospitalisation was 33% (n=413). Patients on the 2WP had higher mortality and hospitalisation rates than those on the 6WP, 14% vs 6% (p<0.001) and 38% vs 27% (p<0.001), respectively. All-cause mortality (11% vs 9%; p=0.306) and hospitalisation rates (35% vs 29%; p=0.128) did not differ between HF and NHF patients, respectively.

CONCLUSIONS

Outcomes using the NICE approach of short waiting time targets for specialist assessment of patients with suspected HF and raised NTproBNP are not known. The model identifies an elderly population a high proportion of whom have HF. Irrespective of diagnosis, patients have high rates of adverse outcomes. These contemporary real-world data provide a platform for discussions with patients and shaping HF services.

Cardiovascular disease in homeless versus housed individuals: a systematic review of observational and interventional studies

OBJECTIVES

To identify: (i) risk of cardiovascular disease (CVD) in homeless versus housed individuals and (ii) interventions for CVD in homeless populations.

METHODS

We conducted a systematic literature review in EMBASE until December 2018 using a search strategy for observational and interventional studies without restriction regarding languages or countries. Meta-analyses were conducted, where appropriate and possible. Outcome measures were all-cause and CVD mortality, and morbidity.

RESULTS

Our search identified 17 articles (6 case-control, 11 cohort) concerning risk of CVD and none regarding specific interventions. Nine were included to perform a meta-analysis. The majority (13/17, 76.4%) were high quality and all were based in Europe or North America, including 765 459 individuals, of whom 32 721 were homeless. 12/17 studies were pre-2011. Homeless individuals were more likely to have CVD than non-homeless individuals (pooled OR 2.96; 95% CI 2.80 to 3.13; p<0.0001; heterogeneity p<0.0001; I²=99.1%) and had increased CVD mortality (age-standardised mortality ratio range: 2.6-6.4). Compared with non-homeless individuals, hypertension was more likely in homeless people (pooled OR 1.38-1.75, p=0.0070; heterogeneity p=0.935; I²=0.0%).

CONCLUSIONS

Homeless people have an approximately three times greater risk of CVD and an increased CVD mortality. However, there are no studies of specific pathways/interventions for CVD in this population. Future research should consider design and evaluation of tailored interventions or integrating CVD into existing interventions.

Home monitoring with technology-supported management in chronic heart failure: a randomised trial

OBJECTIVES

We aimed to investigate whether digital home monitoring with centralised specialist support for remote management of heart failure (HF) is more effective in improving medical therapy and patients' quality of life than digital home monitoring alone.

METHODS

In a two-armed partially blinded parallel randomised controlled trial, seven sites in the UK recruited a total of 202 high-risk patients with HF (71.3 years SD 11.1; left ventricular ejection fraction 32.9% SD 15.4). Participants in both study arms were given a tablet computer, Bluetooth-enabled blood pressure monitor and weighing scales for health monitoring. Participants randomised to intervention received additional regular feedback to support self-management and their primary care doctors received instructions on blood investigations and pharmacological treatment. The primary outcome was the use of guideline-recommended medical therapy for chronic HF and major comorbidities, measured as a composite opportunity score (total number of recommended treatment given divided by the total number of opportunities the treatment should have been given, with a score 1 indicating 100% adherence to recommendations). Co-primary outcome was change in physical score of Minnesota Living with Heart Failure questionnaire.

RESULTS

101 patients were randomised to 'enhanced self-management' and 101 to 'supported medical management'. At the end of follow-up, the opportunity score was 0.54 (95% CI 0.46 to 0.62) in the control arm and 0.61 (95% CI 0.52 to 0.70) in the intervention arm (p=0.25). Physical well-being of participants also did not differ significantly between the groups (17.4 (12.4) mean (SD) for control arm vs 16.5 (12.1) in treatment arm; p for change=0.84).

CONCLUSIONS

Central provision of tailored specialist management in a multi-morbid HF population was feasible. However, there was no strong evidence for improvement in use of evidence-based treatment nor health-related quality of life.

TRIAL REGISTRATION NUMBER

ISRCTN86212709.

Limit of detection of troponin discharge strategy versus usual care: randomised controlled trial

Introduction

The clinical effectiveness of a ‘rule-out’ acute coronary syndrome (ACS) strategy for emergency department patients with chest pain, incorporating a single undetectable high-sensitivity cardiac troponin (hs-cTn) taken at presentation, together with a non-ischaemic ECG, remains unknown.

Methods

A randomised controlled trial, across eight hospitals in the UK, aimed to establish the clinical effectiveness of an undetectable hs-cTn and ECG (limit of detection and ECG discharge (LoDED)) discharge strategy. Eligible adult patients presented with chest pain; the treating clinician intended to perform investigations to rule out an ACS; the initial ECG was non-ischaemic; and peak symptoms occurred <6 hours previously. Participants were randomised 1:1 to either the LoDED strategy or the usual rule-out strategy. The primary outcome was discharge from the hospital within 4 hours of arrival, without a major adverse cardiac event (MACE) within 30 days.

Results

Between June 2018 and March 2019, 632 patients were randomised; 3 were later withdrawn. Of 629 patients (age 53.8 (SD 16.1) years, 41% women), 7% had a MACE within 30 days. For the LoDED strategy, 141 of 309 (46%) patients were discharged within 4 hours, without MACE within 30 days, and for usual care, 114 of 311 (37%); pooled adjusted OR 1.58 (95% CI 0.84 to 2.98). No patient with an initial undetectable hs-cTn had a MACE within 30 days.

Conclusion

The LoDED strategy facilitates safe early discharge in >40% of patients with chest pain. Clinical effectiveness is variable when compared with existing rule-out strategies and influenced by wider system factors.

Trial registration number

ISRCTN86184521.

Exercise intervention improves quality of life in older adults after myocardial infarction: randomised clinical trial

OBJECTIVE

To establish the benefits of an early, tailored and low-cost exercise intervention in older patients hospitalised for acute coronary syndrome (ACS).

METHODS

The study was a multicentre, randomised assessment of an exercise intervention in patients with ACS ≥70 years with reduced physical performance (as defined by the short physical performance battery (SPPB), value 4-9). The exercise intervention included four supervised sessions (1, 2, 3, 4 months after discharge) and home-based exercises. The control group attended a health education programme only. The outcomes were the 6-month and 1-year effects on physical performance, daily activities, anxiety/depression and quality of life. Finally, 1-year occurrence of adverse events was recorded.

RESULTS

Overall, 235 patients with ACS (median age 76 (73-81) years) were randomised 1 month after ACS. Exercise and control groups were well balanced. Exercise intervention improved 6-month and 1-year grip strength and gait speed. Exercise intervention was associated with a better quality of life (as measured by EuroQol-visual analogue scale at 6 months 80 (70-90) vs 70 (50-80) points, p<0.001 and at 1 year 75 (70-87) vs 65 (50-80) points, p<0.001) and with a reduced perception of anxiety and/or depression (6 months: 21% vs 42%, p=0.001; 1 year 32% vs 47%, p=0.03). The occurrence of cardiac death and hospitalisation for cardiac cause was lower in the intervention group (7.5% vs 17%, p=0.04).

CONCLUSIONS

The proposed early, tailored, low-cost exercise intervention improves mobility, daily activities, quality of life and outcomes in older patients with ACS. Larger studies are needed to confirm the clinical benefit.

TRIAL REGISTRATION NUMBER

NCT03021044.

Association of household income and adverse outcomes in patients with atrial fibrillation

Background

Social determinants of health are relevant to cardiovascular outcomes but have had limited examination in atrial fibrillation (AF).

Objectives

The purpose of this study was to examine the association of annual household income and cardiovascular outcomes in individuals with AF.

Methods

We analysed administrative claims for individuals with AF from 2009 to 2015 captured by a health claims database. We categorised estimates of annual household income as <$40 000; $40–$59 999; $60–$74 999; $75–$99 999; and ≥$100 000. Covariates included demographics, education, cardiovascular disease risk factors, comorbid conditions and anticoagulation. We examined event rates by income category and in multivariable-adjusted models in reference to the highest income category (≥$100 000).

Results

Our analysis included 336 736 individuals (age 72.7±11.9 years; 44.5% women; 82.6% white, 8.4% black, 7.0% Hispanic and 2.1% Asian) with AF followed for median (25th and 75th percentile) of 1.5 (95% CI 0.6 to 3.0) years. We observed an inverse association between income and heart failure and myocardial infarction (MI) with evidence of progressive risk across decreased income categories. Individuals with household income <$40 000 had the greatest risk for heart failure (HR 1.17; 95% CI 1.05 to 1.30) and MI (HR 1.18; 95% CI 0.98 to 1.41) compared with those with income ≥$100 000.

Conclusions

We identified an association between lower household income and adverse outcomes in a large cohort of individuals with AF. Our findings support consideration of income in the evaluation of cardiovascular risk in individuals with AF.

Shared decision making in older patients with symptomatic severe aortic stenosis: a systematic review

This review provides an overview of the status of shared decision making (SDM) in older patients regarding treatment of symptomatic severe aortic stenosis (SSAS). The databases Embase, Medline Ovid, Cinahl and Cochrane Dare were searched for relevant studies from January 2002 to May 2018 regarding perspectives of professionals, patients and caregivers; aspects of decision making; type of decision making; application of the six domains of SDM; barriers to and facilitators of SDM. The systematic search yielded 1842 articles, 15 studies were included. Experiences of professionals and informal caregivers with SDM were scarcely found. Patient refusal was a frequently reported result of decision making, but often no insight was given into the decision process. Most studies investigated the 'decision' and 'option' domains of SDM, yet no study took all six domains into account. Problem analysis, personalised treatment aims, use of decision aids and integrating patient goals in decisions lacked in all studies. Barriers to and facilitators of SDM were 'individualised formal and informal information support' and 'patients' opportunity to use their own knowledge about their health condition and preferences for SDM'. In conclusion, SDM is not yet common practice in the decision making process of older patients with SSAS. Moreover, the six domains of SDM are not often applied in this process. More knowledge is needed about the implementation of SDM in the context of SSAS treatment and how to involve patients, professionals and informal caregivers.

Association between procedure appropriateness and patient-reported outcomes after percutaneous coronary intervention

OBJECTIVE

The Appropriate Use Criteria (AUC) has been used to identify individuals who are likely to benefit from percutaneous coronary intervention (PCI) for stable ischaemic heart disease. However, whether physicians reliably grade PCI appropriateness and whether AUC categories stratify symptomatic improvement in real-world practice are unclear.

METHODS

Patient-reported outcomes measures (PROMs) for angina (Seattle Angina Questionnaire (SAQ-7)), dyspnoea (Rose Dyspnea Scale (RDS)) and depression (Patient Health Questionnaire-2 (PHQ-2)) were collected on patients undergoing elective coronary angiography at an academic medical centre. Retrospectively, two physicians independently determined PCI appropriateness by the AUC criteria.

RESULTS

Inter-rater agreement on appropriateness was moderate (κ=0.48, 95% CI 0.32 to 0.63). Of PCI procedures evaluated, 57 (47.1%) were appropriate (A-PCI), 62 (51.2%) were maybe appropriate (MA-PCI) and 2 (1.6%) were rarely appropriate. At baseline, A-PCI compared with MA-PCI patients had worse RDS scores (2.0 vs 1.2, p=0.01). At 30 days, the change in SAQ-7 summary score was similar between groups (A-PCI vs MA-PCI, +27.1 vs +20.7, p=0.11). The mean change in RDS score was greater in A-PCI than MA-PCI (-1.0 vs -0.5, p for group by time interaction=0.03). PHQ-2 scores were similar and did not improve at 30 days.

CONCLUSION

In patients undergoing PCI with PROMs collected before and 30 days after PCI, similar improvements in angina were observed regardless of appropriateness. Inter-rater agreement on PCI appropriateness was only moderate. Use of PROMs may improve reliability of physician assessments of PCI appropriateness.

A nationwide causal mediation analysis of survival following ST-elevation myocardial infarction

Objective

International studies report a decline in mortality following ST-elevation myocardial infarction (STEMI). The extent to which the observed improvements in STEMI survival are explained by temporal changes in patient characteristics and utilisation of treatments is unknown.

Methods

Cohort study using national registry data from the Myocardial Ischaemia National Audit Project between first January 2004 and 30th June 2013. 232 353 survivors of hospitalisation with STEMI as recorded in 247 hospitals in England and Wales. Flexible parametric survival modelling and causal mediation analysis were used to estimate the relative contribution of temporal changes in treatments and patient characteristics on improved STEMI survival.

Results

Over the study period, unadjusted survival at 6 months and 1 year improved by 0.9% and 1.0% on average per year (HR: 0.991, 95% CI: 0.988 to 0.994 and HR: 0.990, 95% CI: 0.987 to 0.993, respectively). The uptake of primary percutaneous coronary intervention (PCI) (HR: 1.025, 95% CI: 1.021 to 1.028) and increased prescription of P2Y₁₂ inhibitors (HR: 1.035, 95% CI: 1.031 to 1.039) were significantly associated with improvements in 1-year survival. Primary PCI explained 16.8% (95% CI: 10.8% to 31.6%) and 13.2% (9.2% to 21.9%) of the temporal survival improvements at 6 months and 1 year, respectively, whereas P2Y₁₂ inhibitor prescription explained 5.3% (3.6% to 8.8%) of the temporal improvements at 6 months but not at 1 year.

Conclusions

For STEMI in England and Wales, improvements in survival between 2004 and 2013 were significantly explained by the uptake of primary PCI and increased use of P2Y₁₂ inhibitors at 6 months and primary PCI only at 1 year.

Trial registration number

NCT03749694

Marital status, telomere length and cardiovascular disease risk in a Swedish prospective cohort

OBJECTIVE

To investigate if marital status is associated with risk of cardiovascular disease (CVD) and to explore the potential influence of leucocyte telomere length (LTL), a marker of biological ageing, on such association.

DESIGN

Population-based prospective cohort study SETTINGS: Swedish Twin Registry.

PARTICIPANTS

Based on the Screening Across the Lifespan Twin Study from the Swedish Twin Registry, we included 10 058 twins born between 1900 and 1958 who underwent an interview between 1998 and 2002 during which information about marital status was collected. Blood samples from these participants were subsequently collected between 2004 and 2008 and used for LTL assessment using quantitative PCR technique.

MAIN OUTCOME MEASURES

Incident cases of CVD were identified through the Swedish Patient Register and Causes of Death Register through December 31, 2016. Multivariable linear regression and Cox proportional hazards regression models were used to estimate the regression coefficients (βs) and HRs with 95% CIs respectively. Potential confounders included age, sex, educational attainment and body mass index.

RESULTS

A total of 2010 participants were diagnosed with CVD during a median follow-up of 9.8 years. LTL was shorter among individuals living singly, including those who were divorced or separated (β:-0.014, 95% CI: -0.035, 0.007), widowed (β:-0.035, 95% CI: -0.061, -0.010), or living alone (β:-0.033, 95% CI: -0.052, -0.014), than individuals who were married or cohabitating. One SD increase of LTL was associated with a lower risk of CVD (HR: 0.79, 95% CI: 0.66, 0.93). Individuals who were divorced or separated, widowed, or living alone had a higher risk of CVD than individuals who were married or cohabitating. The summary HR of CVD was 1.21 (95% CI: 1.08, 1.35) when comparing individuals who were living singly, regardless of reason, with the individuals who were married or cohabitating. LTL appeared to mediate little of the association between marital status and CVD (HR additionally adjusted for LTL: 1.20; 95% CI: 1.08, 1.34).

CONCLUSIONS

Living singly, regardless of reason, was associated with a shorter LTL and a higher risk of CVD. The association between marital status and CVD was however not greatly attributable to telomere shortening.

Identifying patients likely to be readmitted after transcatheter aortic valve replacement

Hospital readmission following transcatheter aortic valve replacement (TAVR) contributes considerably to the costs of care. Readmission rates following TAVR have been reported to be as high as 17.4% at 30 days and 53.2% at 1 year. Patient and procedural factors predict an increased likelihood of readmission including non-transfemoral access, acute and chronic kidney impairment, chronic lung disease, left ventricular systolic dysfunction, atrial fibrillation, major bleeding and prolonged index hospitalisation. Recent studies have also found the requirement for new pacemaker implantation and the severity of paravalvular aortic regurgitation and tricuspid regurgitation to be novel predictors of readmission. Post-TAVR readmission within 30 days of discharge is more likely to occur for non-cardiac than cardiac pathology, although readmission for cardiac causes, especially heart failure, predicts higher mortality than readmission for non-cardiac causes. To combat the risk of readmission and associated mortality, the routine practice of calculating and considering readmission risk should be adopted by the heart team. Furthermore, because most readmissions following TAVR occur for non-cardiac reasons, more holistic approaches to readmission prevention are necessary. Familiarity with the most common predictors and causes of readmission should guide the development of initiatives to address these conditions proactively.

Diagnosis of patients with angina and non-obstructive coronary disease in the catheter laboratory

Around 40% of all patients undergoing angiography are found to have normal coronary arteries or non-obstructive coronary artery disease (NOCAD). Despite the high prevalence, this is a group who rarely receive a definitive diagnosis, are frequently labelled and managed inappropriately and by and large, continue to remain symptomatic. Half of this group will have coronary microvascular dysfunction (CMD), associated with a higher rate of major adverse cardiovascular events; identifying CMD represents a therapeutic target of unmet need. As the pressure wire has revolutionised our ability to interrogate epicardial coronary disease during the time of angiography, measuring flow can similarly classify NOCAD during a single procedure. Assessment of flow is a function that is already integral to some pressure wires and furthermore, the familiarity and usage of the combined Doppler and pressure wire is rapidly increasing-these are techniques that readily lend themselves to the skillset of a practising interventional cardiologist. We present a structured algorithm designed for cardiologists who frequently encounter NOCAD in the catheter laboratory, identifying specific disease phenotypes within this heterogeneous population with linked therapy. This review paper clearly explains the rationale for this algorithm and outlines its applicability to routine clinical practice and also, the importance of phenotyping for future research. Ultimately, personalised therapy could improve outcomes for both patients and healthcare providers; while these approaches in turn will need robust evaluation to ensure that they improve both clinical outcomes and health economic benefits, this proposal will provide a framework for future trials and evaluations.

Characteristics of subjects with alcoholic cardiomyopathy and sudden cardiac death

OBJECTIVE

To study social and clinical characteristics of victims of sudden cardiac death (SCD) due to alcoholic cardiomyopathy (ACM).

METHODS

The study population comprised a subset of Fingesture cohort. All subjects were verified SCD victims determined to have ACM as cause of death in medico-legal autopsy between 1998 and 2017 in Northern Finland. The Finnish Population Register Centre provided SCD victims' last place of residence. Population data of residential area were obtained from Statistics Finland.

RESULTS

From a total of 5869 SCD victims in Fingesture cohort, in 290 victims the cause of SCD was ACM (4.9%; median age 56 (50-62) years; 83% males). In 64 (22.1%) victims, the diagnosis of cardiac disease was made prior to death and in 226 (77.9%) at autopsy. There were no significant differences in autopsy findings between victims with or without known cardiac diagnosis, but steatohepatitis (94.5%) and liver cirrhosis (64,5%) were common in both groups. Alcoholism was more often recorded in the known cardiac disease group (64.1% vs 47.3%, p=0.023). Majority were included in the working age population (ie, under 65 years) (54.8% and 53.1%, p=0.810). In high-income communities, 28.8% of ACM SCD victims had previously diagnosed cardiac disease, the proportion in the middle-income and low-income communities was 18.6% (p=0.05).

CONCLUSIONS

Majority of SCD victims due to ACM did not have previously diagnosed cardiac disease, but documented risk consumption of alcohol was common. This emphasises the importance of routine screening of alcohol consumption and signs of cardiomyopathy in heavy alcohol users in primary healthcare.

Impact of a community-based cardiovascular disease service intervention in a highly deprived area

Objective

To examine the effects on emergency hospital admissions, length of stay and emergency re-admissions of providing a consultant-led, community-based cardiovascular diagnostic, treatment and rehabilitation service, based in a highly deprived area in the North West of England.

Methods

A longitudinal matched controlled study using difference-in-differences analysis compared the change in outcomes in the intervention population, to the change in outcomes in a matched comparison population that had not received the intervention, 5 years before and after implementation. The outcomes were emergency hospitalisations, length of inpatient stay and re-admission rates for cardiovascular disease (CVD).

Results

Findings show that the intervention was associated with 66 fewer emergency CVD admissions per 100 000 population per year (95% CI 22.13 to 108.98) in the post-intervention period, relative to the control group. No significant measurable effects on length of stay or emergency re-admission rates were observed.

Conclusion

This consultant-led, community-based cardiovascular diagnostic, treatment and rehabilitation service was associated with a lower rate of emergency hospital admissions in a highly disadvantaged population. Similar approaches could be an effective component of strategies to reduce unplanned hospital admissions.

Underuse of ECG monitoring in oncology patients receiving QT-interval prolonging drugs

OBJECTIVE

We examined use of ECG monitoring in oncology patients prescribed QT-prolonging drugs.

METHODS

Patients ≥66 years diagnosed with cancer between 2005 and 2011 were identified through the Ontario Cancer Registry and linked to multiple population-based administrative databases to ascertain demographics, comorbidities, prescription drug use, systemic therapy and ECG. QT-prolonging drugs were identified as per drug lists developed by the Arizona Center for Education and Research on Therapeutics. Univariable and multivariable analyses were used to examine factors associated with ECG use in patients on first-line systemic therapy.

RESULTS

A total of 48 236 patients (median age 74; 49% women) received one or more drugs associated with a risk of QT-interval prolongation but only 27% of patients had an ECG performed. Factors associated with more ECG use on multivariable analysis included recent cancer diagnosis (p for trend <0.001 between 2005 and 2011), use of concurrent QT-prolonging drugs (OR=1.15 per each additional QT-prolonging drug, 95% CI 1.12 to 1.17) and the presence of coronary artery disease (OR 1.31; 95% CI 1.25 to 1.38) and heart failure (OR 1.25; 95% CI 1.17 to 1.35). Use of anticancer (OR 0.74; 95% CI 0.70 to 0.79) and antiemetic (OR 0.93; 95% CI 0.88 to 0.99) QT-prolonging drugs was paradoxically associated with less ECG use.

CONCLUSIONS

Our study highlights common use of QT-prolonging drugs and underuse of ECG in oncology patients. Since ECG is an inexpensive, non-invasive and widely available test, it may be readily incorporated in the monitoring of patients for toxicities in routine clinical practice.

Association of sex and atrial fibrillation therapies with patient-reported outcomes

OBJECTIVES

Women report higher atrial fibrillation (AF) symptom severity and receive less AF therapies than their male counterparts. It is understudied if differences in AF therapies received explains sex differences in AF symptom severity. We investigate the impact of sex and AF therapies on patient-reported outcomes.

METHODS

Participants were recruited (n=953) across four academic medical centres with an AF diagnosis and age ≥18 years. Patient-reported outcomes (AF symptom severity, AF-related quality of life, functional status and emotional status) were determined by biannual surveys. We performed multiple linear regressions on propensity-matched cohorts to determine the association of AF therapies and sex on patient-reported outcomes.

RESULTS

Our study population (n=953) was 65% male (n=616), 93% white (n=890) and 72 (±10) years old. Individuals receiving rate control therapy reported comparatively lower AF-related quality of life (-7.22, 95% CI -11.51 to -2.92) and poorer functional status (-3.69, 95% CI -5.27 to -2.12). Individuals receiving rhythm control strategies did not report significantly different patient-reported outcomes. Women were more likely to report poorer functional status (-2.63, 95% CI -3.86 to -1.40) and poorer AF-related quality of life, higher anxiety (2.33, 95% CI 1.07 to 3.59), higher symptoms of depression (1.48, 95% CI 0.31 to 2.65) and AF symptom severity (0.29, 95% CI 0.07 to 0.52).

CONCLUSIONS

Female sex was associated with comparatively poorer AF symptom severity and quality of life, and this association remained after accounting for AF therapies received. Receiving rate control medication alone was associated with comparatively poorer AF-related quality of life and functional status.

Hospital-based quality improvement interventions for patients with heart failure: a systematic review

OBJECTIVE

To estimate the direction and magnitude of effect and quality of evidence for hospital-based heart failure (HF) quality improvement interventions on process of care measures and clinical outcomes among patients with acute HF.

REVIEW METHODS

We performed a structured search to identify relevant randomised trials evaluating the effect of in-hospital quality improvement interventions for patients hospitalised with HF through February 2017. Studies were independently reviewed in duplicate for key characteristics, outcomes were summarised and a qualitative synthesis was performed due to substantial heterogeneity.

RESULTS

From 3615 records, 14 randomised controlled trials were identified for inclusion with multifaceted interventions. There was a trend towards higher in-hospital use of ACE inhibitors (ACE-I; 57.9%vs40.0%) and beta-blockers (BBs; 46.7%vs10.2%) in the intervention than the comparator in one trial (n=429 participants). Five trials (n=78 727 participants) demonstrated no effect of the intervention on use of ACE-I or angiotensin receptor blocker at discharge. Three trials (n=89 660 participants) reported no effect on use of BB at discharge. Two trials (n=419 participants) demonstrated a trend towards lower hospital readmission up to 90 days after discharge. There was no consistent effect of the quality improvement intervention on 30-day all-cause mortality, hospital length of stay and patient-level health-related quality of life.

CONCLUSIONS

Randomised trials of hospital-based HF quality improvement interventions do not show a consistent effect on most process of care measures and clinical outcomes. The overall quality of evidence for the prespecified primary and key secondary outcomes was very low to moderate, suggesting that future research will likely influence these estimates.

TRIAL REGISTRATION NUMBER

CRD42016049545.

Education level and outcomes after acute myocardial infarction in China

Objective

To assess the association between educational attainment and acute myocardial infarction (AMI) outcomes in China to inform future healthcare interventions.

Methods

We used data from the China Patient-centred Evaluative Assessment of Cardiac Events-Prospective AMI study of 3369 consecutive patients hospitalised with AMI from 53 hospitals. Educational attainment was categorised as: high (senior high school, college or postgraduate degree), intermediate (junior high school) or low (primary school or illiterate). We used survival models to assess the relationship between education and 1-year major adverse cardiovascular events (MACE), all-cause mortality, both unadjusted and after adjustment for demographic characteristics and cardiovascular risk factors.

Results

The median participant age was 61 (52, 69) years, 23.2% were women, and 33.3% had high, 32.4% intermediate and 34.3% low educational attainment. In unadjusted analysis, compared with high educational attainment, low educational attainment was associated with a higher 1-year risk of MACE (HR 2.41, 95% CI 1.72 to 3.37) and death (HR for low vs high education 3.09, 95% CI 1.69 to 5.65). In risk-adjusted analyses, the association between education and death was attenuated and no longer statistically significant (adjusted HR 1.41, 95% CI 0.74 to 2.69, p=0.30). However, the risk of 1-year MACE (adjusted HR 1.68, 95% CI 1.18 to 2.41, p=0.004) remained significantly greaterin low educational attainment group.

Conclusions

In a national Chinese cohort of patients hospitalised with AMI, low educational attainment was associated with a higher risk of adverse events in the year following discharge. This association highlights the need to consider interventions to improve AMI outcomes in adults with low levels of education.

Clinical trial registration

NCT01624909; Results.

Assessing aeromedical risk: a three-dimensional risk matrix approach

Early aeromedical risk i was based on aeromedical standards designed to eliminate individuals ii from air operations with any identifiable medical risk, and led to frequent medical disqualification. The concept of considering aeromedical risk as part of the spectrum of risks that could lead to aircraft accidents (including mechanical risks and human factors) was first proposed in the 1980s and led to the development of the 1% rule which defines the maximum acceptable risk for an incapacitating medical event as 1% per year (or 1 in 100 person-years) to align with acceptable overall risk in aviation operations. Risk management has subsequently evolved as a formal discipline, incorporating risk assessment as an integral part of the process. Risk assessment is often visualised as a risk matrix, with the level of risk, urgency or action required defined for each cell, and colour-coded as red, amber or green depending on the overall combination of risk and consequence. This manuscript describes an approach to aeromedical risk management which incorporates risk matrices and how they can be used in aeromedical decision-making, while highlighting some of their shortcomings.

Propensity-matched analysis of minimally invasive approach versus sternotomy for mitral valve surgery

OBJECTIVE

The objective of this multicentre study was to compare short-term and midterm outcomes between sternotomy and minimally invasive approaches for mitral valve surgery.

METHODS

Data for all mitral valve procedures with or without concomitant tricuspid atrial fibrillation surgery were analysed from three UK hospitals between January 2008 and December 2016. To account for selection bias between minimally invasive approach and sternotomy, one-to-one propensity score calliper matching without replacement was performed. The main outcome measure was midterm reintervention free survival that was summarised by the Kaplan-Meier estimator and compared between treatment arms using the stratified log-rank test.

RESULTS

A total of 2404 procedures (1757 sternotomy and 647 minimally invasive) were performed during the study period. Propensity score matching resulted in 639 matched pairs with improved balance postmatching in all 31 covariates (absolute standardised mean differences <10%). Despite longer procedural times patients who underwent minimally invasive surgery had a lower need for transfusion (20.5%vs14.4%, p=0.005) and reduced median postoperative length of stay (7 vs 6 days, p<0.001). There were no statistically significant differences in the rates of in-hospital mortality or postoperative stroke. Reintervention-free survival at 8 years was estimated as 86.1% in the minimally invasive group and 84.1% in the sternotomy group (p=0.40).

CONCLUSIONS

Minimally invasive surgery is associated with excellent short-term outcomes and comparable midterm outcomes for patients undergoing mitral valve surgery. A minimally invasive approach should be considered for all patients who require mitral valve intervention and should be the standard against which transcatheter mitral techniques are compared.

Sex differences in quality indicator attainment for myocardial infarction: a nationwide cohort study

Aim

To investigate sex differences in acute myocardial infarction (AMI) guideline-indicated care as defined by the European Society of Cardiology (ESC) Acute Cardiovascular Care Association (ACCA) quality indicators.

Methods

Nationwide cohort study comprising 691 290 AMI hospitalisations in England and Wales (n=233 hospitals) from the Myocardial Ischaemia National Audit Project between 1 January 2003 and 30 June 2013.

Results

There were 34.5% (n=238 489) women (median age 76.7 (IQR 66.3–84.0) years; 33.9% (n=80 884) ST-elevation myocardial infarction (STEMI)) and 65.5% (n=452 801) men (median age 67.1 (IQR 56.9–77.2) years; 42.5% (n=192 229) STEMI). Women less frequently received 13 of the 16 quality indicators compared with men, including timely reperfusion therapy for STEMI (76.8% vs 78.9%; p<0.001), timely coronary angiography for non-STEMI (24.2% vs 36.7%; p<0.001), dual antiplatelet therapy (75.4% vs 78.7%) and secondary prevention therapies (87.2% vs 89.6% for statins, 82.5% vs 85.6% for ACE inhibitor/angiotensin receptor blockers and 62.6% vs 67.6% for beta-blockers; all p<0.001). Median 30-day Global Registry of Acute Coronary Events risk score adjusted mortality was higher for women than men (median: 5.2% (IQR 1.8%–13.1%) vs 2.3% (IQR 0.8%–7.1%), p<0.001). An estimated 8243 (95% CI 8111 to 8375) deaths among women could have been prevented over the study period if their quality indicator attainment had been equal to that attained by men.

Conclusion

According to the ESC ACCA AMI quality indicators, women in England and Wales less frequently received guideline-indicated care and had significantly higher mortality than men. Greater attention to the delivery of recommended AMI treatments for women has the potential to reduce the sex-AMI mortality gap.

Challenges in outlier surgeon assessment in the era of public reporting

OBJECTIVE

To assess the effect of various evaluation and reporting strategies in determining outlier surgeons, defined by having worse-than-expected mortality after cardiac surgery.

METHODS

Our study included 33 394 isolated coronary artery bypass graft (CABG) procedures performed by 136 surgeons and 12 172 surgical aortic valve replacement (SAVR) procedures performed by 113 surgeons between 2010 and 2014. Three current methodologies based on the framework of comparing observed and expected (O/E ratio) mortality, with different distributional assumptions, were examined. We further assessed the consistency of outliers detected by these three methods and the impact of using different time windows and aggregating data of CABG and SAVR procedures.

RESULTS

The three methods were consistent and detected same outliers, with the least conservative method detecting additional outliers (outliers detected for methods 1, 2 and 3: CABG 3 (2.2%), 2 (1.5%) and 8 (5.9%); SAVR 1 (0.9%), 0 (0.0%) and 11 (9.7%)). When numbers of cases recorded were low and events were rare, the two more conservative methods were unlikely to detect outliers unless the O/E ratios were extremely high. However, these two methods were more consistent in detecting the same surgeons as outliers across different time windows for assessment. Of the surgeons who performed both CABG and SAVR, none was an outlier for both procedures when assessed separately. Aggregating data from CABG and SAVR may lead to results to be dominated by the procedure that had a higher caseload.

CONCLUSIONS

The choices of outlier assessment method, time window for assessment and data aggregation have an intertwined impact on detecting outlier surgeons, often representing different value assumptions toward patient protection and provider penalty. It is desirable to use different methods as sensitivity analyses, avoid aggregating procedures and avoid rare-event endpoints if possible.

Male-female differences in aortic valve and combined aortic valve/coronary surgery: a national cohort study in the Netherlands

Objective

The outcome of female patients after adult cardiac surgery has been reported to be less favourable compared with the outcome of male patients. This study compares men with women with respect to patient and procedural characteristics and early mortality in a contemporary national cohort of patients who underwent aortic valve (AV) and combined aortic valve/coronary (CABG/AV) surgery.

Methods

All patients who underwent AV (n=8717, 56% male) or a combined CABG/AV surgery (n=5867, 67% male) in the Netherlands between January 2007 and December 2011 were included.

Results

In both groups, women were generally older than men (p<0.001) and presented with higher logistic EuroSCORES. In isolated AV surgery, men and women had comparable in-hospital mortality (OR 1.20, 95% CI 0.90 to 1.61; p=0.220). In concomitant CABG/AV surgery, in-hospital mortality was higher in women compared with men (OR 2.00, 95% CI 1.44 to 2.79; p<0.001). The area under the curve for logistic EuroSCORE 1 was systematically higher for men versus women in isolated AV surgery 0.82 (95% CI 0.78 to 0.86) vs 0.75 (95% CI 0.69 to 0.80) and in concomitant CABG/AV surgery 0.78 (95% CI 0.73 to 0.82) vs 0.69 (95% CI 0.63 to 0.74). Finally, (the weight of) risk factors associated with in-hospital mortality differed between men and women.

Conclusions

There are substantial male-female differences in patient presentation and procedural aspects in isolated AV and concomitant CABG/AV surgery in the Netherlands. Further studies are necessary to explore the mechanisms underlying the observed differences. In addition, the observation that standard risk scores perform worse in women warrants exploration of male-female specific risk models for patients undergoing cardiac surgery.Brief title:

Fixed-dose combination antihypertensives and risk of medication errors

OBJECTIVE

While fixed-dose combinations (FDC) can improve adherence, they may add complexity to the prescribing/dispensing process, potentially increasing risk of medication errors. This study aimed to determine if prescriptions for antihypertensive FDCs increase the risk of therapeutic duplication and drug-drug interactions (DDI).

METHODS

This retrospective observational study used administrative pharmacy claims data from the Irish Primary Care Reimbursement Service. Prescriptions dispensed to adults in 2015 were included if they contained an antihypertensive FDC, or the same drugs prescribed separately. The outcomes were therapeutic duplication and potentially serious DDI involving FDC drugs. Relative risk (RR) of these outcomes, adjusted for prescription and patient factors, was determined using generalised linear models with Poisson distributions and propensity score matching.

RESULTS

This study included 307 833 FDC prescriptions (67.0%) and 151 632 separate component prescriptions. Half of patients prescribed FDCs were female with a mean age of 67.1 (SD 12.5) years and, compared with separate component prescriptions, FDCs were less often coprescribed with other cardiovascular medications. Therapeutic duplication occurred in 0.8% of prescriptions, most often involving calcium channel blockers, and 10.6% contained a DDI (most often amlodipine and simvastatin). The RR of therapeutic duplication on FDC prescriptions compared with separate component prescriptions was 1.46 (95% CI 1.17 to 1.83) and the adjusted RR was 2.06 (95% CI 1.64 to 2.60). For DDIs, there was no significant difference between FDC and separate component prescriptions after confounder adjustment.

CONCLUSIONS

This study found FDCs were associated with increased risk of duplication. When considering prescribing FDCs, this safety consideration should be weighed against potential benefits.

Characteristics and outcomes of adults with chronic obstructive pulmonary disease and atrial fibrillation

OBJECTIVE

Chronic obstructive pulmonary disease (COPD) is associated with the development of atrial fibrillation (AF), and may complicate treatment of AF. We examined the association between COPD and symptoms, quality of life (QoL), treatment and outcomes among patients with AF.

METHODS

We compared patients with and without a diagnosis of COPD in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation, a prospective registry that enrolled outpatients with AF not secondary to reversible causes, from both academic and community settings.

RESULTS

Among 9749 patients with AF, 1605 (16%) had COPD. Relative to patients without COPD, those with COPD were more likely to be older, current/former smokers (73% vs 43%), have heart failure (54% vs 29%) and coronary artery disease (49% vs 34%). Oral anticoagulant and beta blocker use were similar, whereas digoxin use was more common among patients with COPD. Symptom burden was generally higher, and QoL worse, among patients with COPD (median Atrial Fibrillation Effect on QualiTy-of-Life score 76 vs 83). Patients with COPD had higher risk of all-cause mortality (adjusted HR 1.52 (95% CI 1.32 to 1.74)), cardiovascular mortality (adjusted HR 1.51 (95% CI 1.24 to 1.84)) and cardiovascular hospitalisation (adjusted HR 1.15 (95% CI 1.05 to 1.26)). Patients with COPD also had higher risk of major bleeding events (adjusted HR 1.25 (95% CI 1.05 to 1.50)). There did not appear to be associations between COPD and AF progression, ischaemic events or new-onset heart failure.

CONCLUSIONS

Among patients with AF, COPD is associated with higher symptom burden, worse QoL, and worse cardiovascular and bleeding outcomes. These associations were not fully explained by cardiovascular risk factors, AF treatment or smoking history.

CLINICAL REGISTRATION NUMBER

NCT01165710.

Increasing trends in hospital care burden of atrial fibrillation in Korea, 2006 through 2015

OBJECTIVE

Temporal changes in the healthcare burden of atrial fibrillation (AF) are less well known in rapidly ageing Asian countries. We examined trends in hospitalisations, costs, treatment patterns and outcomes related to AF in Korea.

METHODS

Using the National Health Insurance Service (NHIS) database involving the entire adult Korean population (n=41 701 269 in 2015), we analysed a nationwide AF cohort representing 931 138 patients with AF. We studied all hospitalisations due to AF from 2006 to 2015.

RESULTS

Overall, hospitalisations for AF increased by 420% from 767 to 3986 per 1 million Korean population from 2006 to 2015. Most admissions occurred in patients aged ≥70 years, and the most frequent coexisting conditions were hypertension, heart failure and chronic obstructive pulmonary disease. Hospitalisations mainly due to major bleeding and AF control increased, whereas hospitalisations mainly due to ischaemic stroke and myocardial infarction decreased. The total cost of care increased even after adjustment for inflation from €68.4 million in 2006 to €388.4 million in 2015, equivalent to 0.78% of the Korean NHIS total expenditure. Overall in-hospital mortality decreased from 7.5% in 2006 to 4.3% in 2015. The in-hospital mortality was highest in patients ≥80 years of age (7.7%) and in patients with chronic kidney disease (7.4%).

CONCLUSIONS

AF hospitalisations have increased exponentially over the past 10 years in Korea, in association with an increase in comorbid chronic diseases. Mortality associated with AF hospitalisations decreased during the last decade, but hospitalisation costs have markedly increased.