Recent Trends in Hospitalizations for Cardiovascular Disease, Stroke, and Vascular Cognitive Impairment in Canada

The Importance of Nontraditional and Sex-Specific Risk Factors in Young Women With Vasomotor Nonobstructive vs Obstructive Coronary Syndromes

Background

Heart disease is the leading cause of premature death for women in Canada. Ischemic heart disease is categorized as myocardial infarction (MI) with no obstructive coronary artery disease (MINOCA), ischemia with no obstructive coronary arteries (INOCA), and atherosclerotic obstructive coronary artery disease (CAD) with MI (MI-CAD) or without MI (non-MI-CAD). This study aims to study the prevalence of traditional and nontraditional ischemic heart disease risk factors and their relationships with (M)INOCA, compared to MI-CAD and non-MI-CAD in young women.

Methods

This study investigated women who presented with premature (at age ≤ 55 years) vasomotor entities of (M)INOCA or obstructive CAD confirmed by coronary angiography, who are currently enrolled in either the Leslie Diamond Women's Heart Health Clinic Registry (WHC) or the Study to Avoid Cardiovascular Events in British Columbia (SAVEBC). Univariable and multivariable regression models were applied to investigate associations of risk factors with odds of (M)INOCA, MI-CAD, and non-MI-CAD.

Results

A total of 254 women enrolled between 2015 and 2022 were analyzed, as follows: 77 with INOCA and 37 with MINOCA from the registry, and 66 with non-MI-CAD and 74 with MI-CAD from the study. Regression analyses demonstrated that migraines and preeclampsia or gestational hypertension were the most significant risk factors, with a higher likelihood of being associated with premature (M)INOCA, relative to obstructive CAD. Conversely, the presence of diabetes and a current or previous smoking history had the highest likelihood of being associated with premature CAD.

Conclusions

The risk factor profiles of patients with premature (M)INOCA, compared to obstructive CAD, have significant differences.

Pre-participation Withdrawal and Noncompletion of Cardiac Rehabilitation in Peripheral Artery Disease: MATCHED COMPARISONS TO CORONARY ARTERY DISEASE

PURPOSE

Despite the mortality benefit of cardiac rehabilitation (CR) participation, as well as its cost-effectiveness for people with peripheral artery disease (PAD), there are limited data on adherence and completion of CR in those with and without concomitant coronary artery disease (CAD). The objective of this study was to compare CR pre-participation withdrawal and noncompletion between patients with PAD and concomitant PAD and CAD (PAD/CAD) versus matched and unmatched patients with CAD (uCAD).

METHODS

Consecutively referred patients between 2006-2017 with PAD (n = 271) and PAD/CAD (n = 610) were matched to CAD by age, sex, diabetes, smoking status, and referral year. The uCAD (n = 14 487) group was included for comparison. Reasons for withdrawal were ascertained by interview.

RESULTS

There were no significant differences in pre-participation withdrawal between PAD and matched CAD (46 vs 43%, P = .49), nor in noncompletion (22 vs 18%, P = .28). Results were similar for PAD/CAD and matched CAD (withdrawal: 36 vs 34%, P = .37) and (noncompletion: 25 vs 23%, P = .46). A smaller proportion of patients with uCAD withdrew (28%) than patients with PAD ( P < .001) and PAD/CAD ( P < .001), with no difference in noncompletion ( P > .40, both). There were no differences between PAD and PAD/CAD and their matched counterparts for medical and nonmedical reasons for withdrawal and noncompletion ( P ≥ .25, all).

CONCLUSION

Pre-participation withdrawal rates were similar between patients with PAD, PAD/CAD, and their matched cohorts but greater than patients with uCAD. Once patients started CR, there were similar completion rates among all groups. Reports that patients with PAD are less likely to start CR may be related to their complex medical profile rather than PAD alone. Strategies to improve participation among patients with PAD should focus on the immediate post-referral period.

Estimating the Number of Hospital or Emergency Department Presentations for Stroke in Canada

BACKGROUND

Although age-standardized stroke occurrence has been decreasing, the absolute number of stroke events globally, and in Canada, is increasing. Stroke surveillance is necessary for health services planning, informing research design, and public health messaging. We used administrative data to estimate the number of stroke events resulting in hospital or emergency department presentation across Canada in the 2017-18 fiscal year.

METHODS

Hospitalization data were obtained from the Canadian Institute for Health Information (CIHI) Discharge Abstract Database and the Ministry of Health and Social Services in Quebec. Emergency department data were obtained from the CIHI National Ambulatory Care Reporting System (Alberta and Ontario). Stroke events were identified using ICD-10 coding. Data were linked into episodes of care to account for readmissions and interfacility transfers. Projections for emergency department visits for provinces/territories outside of Alberta and Ontario were generated based upon age and sex-standardized estimates from Alberta and Ontario.

RESULTS

In the 2017-18 fiscal year, there were 108,707 stroke events resulting in hospital or emergency department presentation across the country. This was made up of 54,357 events resulting in hospital admission and 54,350 events resulting in only emergency department presentation. The events resulting in only emergency department presentation consisted of 25,941 events observed in Alberta and Ontario and a projection of 28,409 events across the rest of the country.

CONCLUSIONS

We estimate a stroke event resulting in hospital or emergency department presentation occurs every 5 minutes in Canada.

Differences in trends in discharge location in a cohort of hospitalized patients with cancer and non-cancer diagnoses receiving specialist palliative care: A retrospective cohort study

BACKGROUND

Patients with and without cancer are frequently hospitalized, and have specialist palliative care needs. In-hospital mortality can serve as a quality indicator of acute care. Trends in acute care outcomes have not previously been evaluated in patients with confirmed specialist palliative care needs or between diagnostic groups.

AIM

To compare trends in discharge location between hospitalized patients with and without cancer who received specialist palliative care.

DESIGN

Retrospective cohort study. Association between diagnosis (cancer, non-cancer) and in-hospital mortality was assessed using multivariable logistic regression, controlling for demographic, clinical, and admission-specific information.

SETTING/PARTICIPANTS

Patients who received specialist palliative care at an academic tertiary hospital in Toronto, Canada from 2013 to 2019.

RESULTS

The cohort comprised 6846 patients, 5024 with and 1822 without cancer. A higher proportion of patients without cancer had a Palliative Performance Scale score <30%, anticipated prognosis of <1 month, and were referred for end-of-life care (all p < 0.001). The adjusted odds of dying in hospital was 1.24-times higher among patients without cancer (95% CI: 1.05-1.46; p = 0.011). Though the proportion of patients without cancer who died in hospital decreased by 8.4% from 2013 to 2019, this proportion (41.2%) remained substantially higher compared to patients with cancer (14.0%) in 2019.

CONCLUSIONS

Hospitalized patients without cancer were referred to specialist palliative care at a lower functional status, a poorer anticipated prognosis, and more likely for end-of-life care; and were more likely to die in hospital. Future studies are required to determine whether a proportion of hospital deaths in patients without cancer represent goal-discordant end-of-life care.

Prevalence of dementia, heart disease and stroke in community-dwelling adults in Canada, 2016-2021: opportunities for joint prevention

INTRODUCTION

This aim of this study is to provide updated estimates on the prevalence of dementia, heart disease, and stroke in Canadian communities. Targeting all three conditions together, at the community level, may be key to disease prevention and health aging in the Canadian population.

METHODS

Using nationwide health survey data, we calculated the age-standardized prevalence of self-reported dementia, heart disease and stroke in adults aged 18 years and over residing in Canadian communities from 2016 to 2021. Poisson regression models were used to detect statistically significant changes in the prevalence of all three conditions from 2016 to 2021.

RESULTS

Less than 1% (~ 175,000 individuals) of adults residing in Canadian communities reported dementia, 5% (~ 1.5 million individuals) reported heart disease, and more than 1% (~ 370,000 individuals) reported stroke annually from 2016 to 2021. Overall, the age-standardized prevalence for stroke decreased minimally from 2016 to 2021 (p = 0.0004). Although the age-standardized prevalence of heart disease and dementia decreased from 2016 to 2018, subsequent increases in prevalence from 2018 to 2021 led to a lack of overall statistically significant changes from 2016 to 2021 (p = 0.10 for heart disease and p = 0.37 for dementia).

CONCLUSION

Recent increases in the prevalence of dementia, heart disease and stroke in Canadian communities threaten to reverse any gains in vascular disease prevention over the past six years. Findings reveal the urgent need for intensified prevention efforts that are community-based with a focus on joint reduction in the shared risk factors contributing to all three diseases.

Regional variation in lower extremity revascularization and amputation for peripheral artery disease

OBJECTIVE

The aim of this study was to quantify the recent and historical extent of regional variation in revascularization and amputation for peripheral artery disease (PAD).

METHODS

This was a repeated cross-sectional analysis of all Ontarians aged 40 years or greater between 2002 and 2019. The co-primary outcomes were revascularization (endovascular or open) and major (above-ankle) amputation for PAD. For each of 14 health care administrative regions, rates per 100,000 person-years (PY) were calculated for 6-year time periods from the fiscal years 2002 to 2019. Rates were directly standardized for regional demographics (age, sex, income) and comorbidities (congestive heart failure, diabetes, chronic obstructive pulmonary disease, chronic kidney disease). The extent of regional variation in revascularization and major amputation rates for each time period was quantified by the ratio of 90th over the 10th percentile (PRR).

RESULTS

In 2014 to 2019, there were large differences across regions in demographics (rural living [range, 0%-39.4%], lowest neighborhood income quintile [range, 10.1%-25.5%]) and comorbidities (diabetes [range, 14.2%-22.0%], chronic obstructive pulmonary disease [range, 7.8%-17.9%]), and chronic kidney disease [range, 2.1%-4.0%]. Standardized revascularization rates ranged across regions from 52.6 to 132.6/100,000 PY and standardized major amputation rates ranged from 10.0 to 37.7/100,000 PY. The extent of regional variation was large (PRR ≥2.0) for both revascularization and major amputation. From 2002-2004 to 2017-2019, the extent of regional variation increased from moderate to large for revascularization (standardized PRR, 1.87 to 2.04) and major amputation (standardized PRR, 1.94 to 3.07).

CONCLUSIONS

Significant regional differences in revascularization and major amputation rates related to PAD remain after standardizing for regional differences in demographics and comorbidities. These differences have not improved over time.

Experimental optimization of single-exposure dual-energy angiography with photon-counting x-ray detectors

BACKGROUND

Photon-counting x-ray detectors may enable single-exposure dual-energy (DE) x-ray angiography.

PURPOSE

The purpose of this paper is to experimentally optimize the energy thresholds and tube voltage for single-exposure DE x-ray angiography.

METHODS

We optimized single-exposure DE x-ray angiography using the iodine signal-difference-to-noise ratio (SDNR) per root patient air kerma (κ) as a figure of merit. We measured the iodine SDNR by imaging an iodine stepwedge immersed in a water tank with a depth of 30 cm in the direction of x-ray propagation. The stepwedge was imaged using tube voltages ranging from 90 to 150 kV and a cadmium telluride (CdTe) x-ray detector with two energy bins and analog charge summing for charge sharing suppression. The energy threshold that separates the two energy bins was varied from approximately 35 keV to approximately 75% of the maximum energy of the x-ray beam. Curve fitting was used to determine the threshold that maximized SDNR / κ $\mathrm{SDNR}/\sqrt {\kappa }$ . The effect of scatter was determined from measurements of the scatter-to-primary ratios (SPRs) of the low-energy and high-energy images and a semi-empirical model of the relationship between SDNR and SPR. Using the optimal parameters, we imaged a phantom with vessel-simulating structures and background clutter.

RESULTS

The optimal energy thresholds increased monotonically from ∼50 to ∼85 keV over the range of tube voltages considered. For tube voltages greater than 90 kV, the optimal energy thresholds consistently allocated approximately two thirds of all detected primary photons to the low energy bin; this ratio was preserved without scatter. Consistent with prior modeling studies, SDNR / κ $\mathrm{SDNR}/\sqrt {\kappa }$ increased monotonically with tube voltage from 90 to 150 kV; SDNR / κ $\mathrm{SDNR}/\sqrt {\kappa }$ at 150 kV was approximately 38% higher than that at 90 kV for an iodine area density of ∼50 mg/cm² . Scatter reduced SDNR by approximately 25% for SPRs of ∼1 and 0.4 in low-energy and high-energy images, respectively.

CONCLUSIONS

Achieving optimal image quality in single-exposure DE angiography with photon-counting x-ray detectors will require high tube voltages (i.e., >130 kV) and, for thick patients, energy thresholds that allocate approximately two thirds of all primary photons to the low-energy image. Future work will compare the image quality of singe-exposure photon-counting and kV-switching approaches to DE x-ray angiography.

Comparing Virtual and Center-Based Cardiac Rehabilitation on Changes in Frailty

Many patients with cardiovascular disease (CVD) are frail. Center-based cardiac rehabilitation (CR) can improve frailty; however, whether virtual CR provides similar frailty improvements has not been examined. To answer this question, we (1) compared the effect of virtual and accelerated center-based CR on frailty and (2) determined if admission frailty affected frailty change and CVD biomarkers. The virtual and accelerated center-based CR programs provided exercise and education on nutrition, medication, exercise safety, and CVD. Frailty was measured with a 65-item frailty index. The primary outcome, frailty change, was analyzed with a two-way mixed ANOVA. Simple slopes analysis determined whether admission frailty affected frailty and CVD biomarker change by CR model type. Our results showed that admission frailty was higher in center-based versus virtual participants. However, we observed no main effect of CR model on frailty change. Results also revealed that participants who were frailer at CR admission observed greater frailty improvements and reductions in triglyceride and cholesterol levels when completing virtual versus accelerated center-based CR. Even though both program models did not change frailty, higher admission frailty was associated with greater frailty reductions and change to some CVD biomarkers in virtual CR.

Theoretical comparison of energy-resolved and digital-subtraction angiography

BACKGROUND

X-ray coronary angiography is a sub-optimal vascular imaging technique because it cannot suppress un-enhanced anatomy that may obscure the visualization of coronary artery disease.

PURPOSE

The purpose of this paper is to evaluate the theoretical image quality of energy-resolved x-ray angiography (ERA) implemented with spectroscopic x-ray detectors (SXDs), which may overcome limitations of x-ray coronary angiography.

METHODS

We modeled the large-area signal-difference-to-noise (SDNR) of contrast-enhanced vasculature in ERA images and compared with that of digital-subtraction angiography (DSA), which served as a gold standard vascular imaging technique. To this end, we used calibrated numerical models of the response of cadmium telluride SXDs including the effects of charge sharing, electronic noise, and energy thresholding. Our models assumed zero scatter, no pulse pile up and small signals such that image contrast is approximately linear in the area density of contrast agents. For DSA, we similarly modeled x-ray detection by cesium iodide energy-integrating detectors using validated numerical models. For ERA, we investigated iodine and gadolinium (Gd) contrast agents, two-material and three-material decompositions, analog charge summing for charge sharing correction, and optimized image quality with respect to the tube voltage and energy thresholds assuming cadmium telluride SXDs with three energy bins.

RESULTS

Our analysis reveals that a three-material decomposition using iodine contrast agents will require x-ray exposures that are approximately 400 times those of DSA to achieve the same SDNR as DSA in coronary applications, and is therefore not feasible in a clinical setting. However, three-material decompositions with Gd contrast agents have the potential to provide SDNR that is ∼45% of that of DSA for matched patient air kerma. For two-material decompositions that suppress soft-tissue, ERA has the potential to produce images with SDNR that is 50%-75% of that of DSA for matched patient air kermas but lower levels of tube loading. Achieving these SDNR levels will require the use of analog charge summing for charge sharing correction, which increased SDNR by up to a factor of 1.7 depending on the contrast agent and whether or not a two-material or three-material decomposition was assumed.

CONCLUSIONS

We conclude that three-material ERA implemented with Gd contrast agents and two-material ERA implemented with either iodine or Gd contrast agents, should be investigated as alternatives to DSA in situations where motion artifacts preclude the use of DSA, such as in coronary imaging.

Trends in prevalence of self-reports of Alzheimer’s disease/dementia among non-institutionalized individuals 45+ in Canada, 1994–2014

Background:

Alzheimer’s disease/dementia (AD) prevalence is of concern globally and in Canada owing to the rapidly aging population and increase in life expectancy. This study explored: (1) trends in the overall prevalence of self-reported AD/dementia by sex, age groups, educational levels, and geographic areas in Canada from 1994 to 2014, and (2) assessed what the observed trends mean in the context of the aging Canadian population and the health care system.

Design and methods:

This cross-sectional study used Canadian national survey data. Data for this study were from two Canadian national health surveys (National Population Health Survey and the Canadian Community Health Survey), between 1994 and 2014. After age-sex standardization, trends in the prevalence of self-reported Alzheimer’s disease/dementia were tracked over time. The two cross-sectional surveys used similar diagnostic criteria over the years.

Results:

The overall prevalence of Alzheimer’s disease/dementia increased from 0.14 in 1994 to 0.80 in 2014 representing a 0.66-point increase over the 20 years. Alzheimer’s disease/dementia prevalence increased with age across all years but was more pronounced after age 80. Men 65+ years, those with lower education, and Canadians living in Central Canada had an increased prevalence.

Conclusions:

The overall prevalence of Alzheimer’s disease/dementia in the community increased over time. This study highlights the importance of establishing effective community-based prevention strategies that focus on minimizing risk and optimizing protection as well as health system capacity strengthening and preparation for long-term care including increased demand for neurologists’ services, increased associated disability, psychosocial difficulties, rising costs, and caregiver burden.

Mortality and morbidity of surgical and transcatheter mitral valve repair in octogenarians: A systematic review

BACKGROUND

Valvular heart disease (VHD) is a prominent problem in healthcare today with mitral regurgitation (MR) being the leading cause of VHD in the elderly population. While mitral valve repair (MVr) surgery is one of the only options for the end-stage disease, octogenarians are often denied MVr due to concerns with operative mortality and postoperative morbidity. To provide information on this underrepresented group of surgical patients, a systematic approach was taken to review the mortality and morbidity rates of octogenarians who received MVr.

METHODS

Pubmed and Medline were searched for articles containing outcomes of octogenarians receiving surgical mitral valve repair (SMVr) or transcatheter mitral valve repair (TMVr) published after 2000. Ten articles met the inclusion criteria for a total of 7968 patients included in the analysis using Microsoft Excel, Version 2105.

RESULTS

Short-term mortality rates for SMVr and TMVr were 2.6% and 1.4% for in-hospital, and 7.8% and 3.3% for 30 days, respectively. The average incidence of stroke, acute kidney injury, infection, and major bleeding for SMVr were 3.2%, 11.2%, 7.7%, and 24%, respectively, and 0.3%, 6.7%, 2.7%, and 7.9% for TMVr, respectively.

CONCLUSION

Octogenarians receiving SMVr or TMVr experienced similar rates of short-term mortality and morbidity as younger populations, and when considering life expectancy, midterm mortality was also similar. With these results, denying octogenarians MVr operations based on age alone should be reconsidered. Depending on risk factors and comorbidities, either SMVr or TMVr is a viable and relatively safe option for octogenarians with severe MR.

Temporal Trends in Hospitalization for Lower Extremity Peripheral Artery Disease in Ontario: The Importance of Diabetes

We sought to assess temporal trends in peripheral artery disease (PAD)-related hospitalization rates in Ontario. Trends in quarterly rates of PAD hospitalization per 100,000 Ontarians between 2006 and 2019 were assessed using autocorrelated linear regression. Stratified analyses according to age, sex, and most responsible diagnosis code type (with vs without diabetes-specific PAD codes) were performed. From 2006 to 2019, overall PAD hospitalizations did not decrease significantly when diabetes-specific codes were included. A significant decrease was observed among women and those older than 65 years old. Future studies of PAD epidemiology and outcomes using administrative data should include diabetic angiopathy.

Hospitalizations in Sarcoidosis: A Cohort Study of a Universal Health Care Population

RATIONALE

Population-based analyses of hospitalization rates from countries with universal health care systems are lacking for patients with sarcoidosis.

OBJECTIVES

We aimed to evaluate the long-term trends in hospitalization rates and risk factors for hospitalization in patients with sarcoidosis in Ontario, Canada.

METHODS

We performed a cohort study using health administrative data from Ontario, Canada between 1996 and 2015. Sarcoidosis patients were identified by ≥ 2 physician visits using International Classification of Diseases codes. All-cause and sarcoidosis-related hospitalization rates were age- and sex-standardized. Hospitalization rates between groups were analyzed using Cochran-Armitage and Breslow-Day tests. Associations between patient characteristics and hospitalization rates were evaluated using multivariable Poisson regression.

RESULTS

In total, 18,550 individuals with sarcoidosis experienced 33,516 all-cause and 1,725 sarcoidosis-related hospitalizations. Adjusted all-cause hospitalization rates decreased from 206.4 to 152.1 per 1000 cases between 1996 and 2015 (26% decrease, p<0.001). The largest decrease in all-cause hospitalization occurred in patients 18-25 years old (67% decrease, p<0.001). Adjusted sarcoidosis-related hospitalization rates decreased from 21.8 to 4.2 per 1000 cases between 1996 and 2015 (80% decrease, p<0.001). The decrease in sarcoidosis-related hospitalizations was largest in women compared with men (87% vs. 72%, p=0.004) and in those 26-35 years old (91% reduction, p<0.001). Lower income [RR 1.16 (1.10-1.23), p<0.001)] and rural residence [RR 1.16 (1.08-1.24), p<0.001] were associated with increased all-cause hospitalizations.

CONCLUSIONS

Hospitalization rates in sarcoidosis patients have decreased over the past 20 years, most substantially in patients of younger age. Important differences in the risk of hospitalization exists based on gender, socioeconomic and geographic factors in patients with sarcoidosis.

The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women-Chapter 2: Scope of the Problem

Background

This Atlas chapter summarizes the epidemiology of cardiovascular disease (CVD) in women in Canada, discusses sex and gender disparities, and examines the intersectionality between sex and other factors that play a prominent role in CVD outcomes in women, including gender, indigenous identity, ethnic variation, disability, and socioeconomic status.

Methods

CVD is the leading cause of premature death in Canadian women. Coronary artery disease, including myocardial infarction, and followed by stroke, accounts for the majority of CVD-related deaths in Canadian women. The majority of emergency department visits and hospitalizations by women are due to coronary artery disease, heart failure, and stroke. The effect of traditional cardiovascular risk factors and their association with increasing cardiovascular morbidity is unique in this group.

Results

Indigenous women in Canada experience increased CVD, linked to colonization and subsequent social, economic, and political challenges. Women from particular racial and ethnic backgrounds (ie, South Asian, Afro-Caribbean, Hispanic, and Chinese North American women) have greater CVD risk factors, and CVD risk in East Asian women increases with duration of stay in Canada.

Conclusions

Canadians living in northern, rural, remote, and on-reserve residences experience greater CVD morbidity, mortality, and risk factors. An increase in CVD risk among Canadian women has been linked with a background of lower socioeconomic status, and women with disabilities have an increased risk of adverse cardiac events.

Temporal and Age-Specific Trends in Acute Stroke Incidence: A 15-Year Population-Based Study of Administrative Data in Ontario, Canada

BACKGROUND

Contemporary data on temporal trends in acute stroke incidence, specific to stroke type and age, are lacking. We sought to evaluate temporal trends in incidence of ischemic stroke and intracerebral hemorrhage over 15 years in a large population.

METHODS

We used linked administrative data to identify all emergency department visits and hospital admissions for first-ever ischemic stroke or intracerebral hemorrhage in Ontario, Canada from 2003-2017. We evaluated annual age-/sex-standardized incidence per 100,000 person-years for ischemic stroke and intracerebral hemorrhage across the study period. We used negative binomial regression to determine incidence rate ratios for each year compared to 2003, with assessment of modification by age, sex, or stroke type.

RESULTS

Our cohort had 163,574 people with stroke (88% ischemic stroke). For ischemic stroke and intracerebral hemorrhage combined, age-/sex-standardized incidence decreased between 2003 and 2011 (standardized rate 109.4 to 85.8 per 100,000; 22%), then increased until 2017 (standardized rate 96.8 per 100,000; 13%). The pattern of change was similar for ischemic stroke and intracerebral hemorrhage, and for men and women, but was modified by age. For those aged 60 and above, adjusted incidence rate ratios decreased from 2003 to 2011 then subsequently increased, whereas for those aged <60 years incidence rate ratios increased throughout the entire study time period, particularly after 2011.

CONCLUSIONS

Acute stroke incidence decreased from 2003 to 2011 but subsequently increased until 2017. Among those aged <60, incidence increased continuously from 2003 to 2017 but especially after 2011. The underlying reasons for these changes should be determined.