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O'Neill DE, Heckman GA, Graham MM. Malnutrition - a predominant issue in hospitalized older adults, yet an undeveloped research space with huge potential. Can J Cardiol 2024:S0828-282X(24)00341-6. [PMID: 38704145 DOI: 10.1016/j.cjca.2024.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 04/25/2024] [Indexed: 05/06/2024] Open
Affiliation(s)
- Deirdre E O'Neill
- Assistant Professor of Medicine, Division of Cardiology, Department of Medicine, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada, T6G 2R7.
| | - George A Heckman
- Schlegel Research Chair in Geriatric Medicine and Associate Professor, School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada, N2G 3G1.
| | - Michelle M Graham
- Professor of Medicine, Division of Cardiology, University of Alberta and Mazankowski Alberta Heart Institute, 8440-112 St, University of Alberta, Edmonton, Alberta, Canada T6G 2B7.
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2
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O'Neill DE, Heckman GA, Graham MM. The epidemic of immobility in hospitalized patients: How to get your patient up and moving. Can J Cardiol 2024:S0828-282X(24)00271-X. [PMID: 38522622 DOI: 10.1016/j.cjca.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 03/14/2024] [Accepted: 03/16/2024] [Indexed: 03/26/2024] Open
Abstract
The global population is ageing and with cardiovascular disease (CVD) prevalence also increasing, the face of the prototypical cardiology inpatient is changing, from a middle-aged man with cardiovascular risk factors, to an older adult with multimorbidity and frailty. Hospital care is inherently harmful, with immobilization and reliance on others causing functional decline to be the leading complication of hospitalization in older adults. It is imperative to reinvent hospital care, employing age-friendly health systems to maintain health and function in older adults, improving not only CVD outcomes, but patient-centered outcomes such as function and independence and preventing avoidable harms.
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Affiliation(s)
- Deirdre E O'Neill
- Assistant Professor of Medicine, Division of Cardiology, Department of Medicine, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada, T6G 2R7.
| | - George A Heckman
- Schlegel Research Chair in Geriatric Medicine and Associate Professor, School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada, N2G 3G1.
| | - Michelle M Graham
- Professor of Medicine, Division of Cardiology, University of Alberta and Mazankowski Alberta Heart Institute, 8440-112 St, University of Alberta, Edmonton, Alberta, Canada T6G 2B7.
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Lawal OA, Awosoga OA, Santana MJ, Ayilara OF, Wang M, Graham MM, Norris CM, Wilton SB, James MT, Sajobi TT. Response shift in coronary artery disease. Qual Life Res 2024; 33:767-776. [PMID: 38133786 DOI: 10.1007/s11136-023-03564-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2023] [Indexed: 12/23/2023]
Abstract
PURPOSE Patients with coronary artery disease (CAD) experience significant angina symptoms and lifestyle changes. Revascularization procedures can result in better patient-reported outcomes (PROs) than optimal medical therapy (OMT) alone. This study evaluates the impact of response shift (RS) on changes in PROs of patients with CAD across treatment strategies. METHODS Data were from patients with CAD in the Alberta Provincial Project on Outcome Assessment in Coronary Heart Disease (APPROACH) registry who completed the 16-item Canadian version of the Seattle Angina Questionnaire at 2 weeks and 1 year following a coronary angiogram. Multi-group confirmatory factor analysis (MG-CFA) was used to assess measurement invariance across treatment groups at week 2. Longitudinal MG-CFA was used to test for RS according to receipt of coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or optimal medical therapy (OMT) alone. RESULTS Of the 3116 patients included in the analysis, 443 (14.2%) received CABG, 2049(65.8%) PCI, and the remainder OMT alone. The MG-CFA revealed a partial-strong invariance across the treatment groups at 2 weeks (CFI = 0.98, RMSEA [90% CI] = 0.05 [0.03, 0.06]). Recalibration RS was detected on the Angina Symptoms and Burden subscale and its magnitude in the OMT, PCI, and CABG groups were 0.32, 0.28, and 0.53, respectively. After adjusting for RS effects, the estimated target changes were largest in the CABG group and negligible in the OMT group. CONCLUSION Adjusting for RS is recommended in studies that use SAQ-CAN to assess changes in patients with CAD who have received revascularization versus OMT alone.
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Affiliation(s)
- Oluwaseyi A Lawal
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | | | - Maria J Santana
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Olawale F Ayilara
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Meng Wang
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Michelle M Graham
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | | | - Stephen B Wilton
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Matthew T James
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Medicine, Cumming School of Medicine University of Calgary, Calgary, Canada
| | - Tolulope T Sajobi
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada.
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Gamble NKJ, Graham MM. Primum Non Nocere: TAVR, Frailty, and Moral Decision Making. Can J Cardiol 2024; 40:468-469. [PMID: 38042337 DOI: 10.1016/j.cjca.2023.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 11/28/2023] [Indexed: 12/04/2023] Open
Affiliation(s)
- Nathan K J Gamble
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Michelle M Graham
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada.
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5
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Heckman GA, Bhangu J, Graham MM, Keen S, O'Neill DE. Geriatric Cardiology: Moving Beyond Learning by Osmosis. Can J Cardiol 2024:S0828-282X(24)00183-1. [PMID: 38428521 DOI: 10.1016/j.cjca.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/22/2024] [Accepted: 02/23/2024] [Indexed: 03/03/2024] Open
Affiliation(s)
- George A Heckman
- Schlegel Research Institute for Aging and School of Public Health Sciences, University of Waterloo, Ontario, Canada.
| | - Jaspreet Bhangu
- Schulich School of Medicine and Dentistry, Western University, St Joseph's Health Care, Parkwood Institute, London, Ontario, Canada
| | - Michelle M Graham
- Department of Medicine, Division of Cardiology, University of Alberta and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Sabina Keen
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Deirdre E O'Neill
- Division of Cardiology, Department of Medicine, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
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6
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Norris CM, Tegg NL, Ahmed SB, Gingara S, Green BJ, Gresiuk C, Henriquez M, Mulvagh SL, Van Damme A, Myburgh C, Graham MM. Women's Heart Health and the Menopausal Transition: Two Faces of the Same Coin. CJC Open 2024; 6:327-333. [PMID: 38487041 PMCID: PMC10935676 DOI: 10.1016/j.cjco.2023.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 09/23/2023] [Indexed: 03/17/2024] Open
Abstract
The impact of the presence or absence of sex hormones on women's health is woefully underresearched. Fundamentally, women's bodies are now understood to spend considerable time under widely fluctuating hormonal influences, including puberty, pregnancy, peripartum, and menopause, and a woman's vessels are therefore preset for functional and physiological alterations based on levels of sex hormones. However, our understanding of the influences of sex hormones on the regulation of a multitude of biological and physiological processes has not translated into the development and/or collection or analyses of data on therapeutic treatments and/or outcomes in the context of women's disease management.
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Affiliation(s)
- Colleen M. Norris
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
- Cavarzan Chair in Mature Women’s Research, WCHRI, AWHF, Edmonton, Alberta, Canada
- Faculty of Medicine, School of Public Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Nicole L. Tegg
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Sofia B. Ahmed
- Faculty of Medicine, School of Public Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Sharon Gingara
- Member of Canadian Women's Heart Health Alliance with lived experience, Edmonton, Alberta, Canada
| | - Bobbi-Jo Green
- Member of Canadian Women's Heart Health Alliance with lived experience, Edmonton, Alberta, Canada
| | | | - Maya Henriquez
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | | | - Andrea Van Damme
- Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Caitlynd Myburgh
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
- Faculty of Natural Sciences, The Kings University, Edmonton, Alberta, Canada
| | - Michelle M. Graham
- Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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Bainey KR, Marquis-Gravel G, Belley-Côté E, Turgeon RD, Ackman ML, Babadagli HE, Bewick D, Boivin-Proulx LA, Cantor WJ, Fremes SE, Graham MM, Lordkipanidzé M, Madan M, Mansour S, Mehta SR, Potter BJ, Shavadia J, So DF, Tanguay JF, Welsh RC, Yan AT, Bagai A, Bagur R, Bucci C, Elbarouni B, Geller C, Lavoie A, Lawler P, Liu S, Mancini J, Wong GC. Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology 2023 Focused Update of the Guidelines for the Use of Antiplatelet Therapy. Can J Cardiol 2024; 40:160-181. [PMID: 38104631 DOI: 10.1016/j.cjca.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 10/02/2023] [Accepted: 10/03/2023] [Indexed: 12/19/2023] Open
Abstract
Antiplatelet therapy (APT) is the foundation of treatment and prevention of atherothrombotic events in patients with atherosclerotic cardiovascular disease. Selecting the optimal APT strategies to reduce major adverse cardiovascular events, while balancing bleeding risk, requires ongoing review of clinical trials. Appended, the focused update of the Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology guidelines for the use of APT provides recommendations on the following topics: (1) use of acetylsalicylic acid in primary prevention of atherosclerotic cardiovascular disease; (2) dual APT (DAPT) duration after percutaneous coronary intervention (PCI) in patients at high bleeding risk; (3) potent DAPT (P2Y12 inhibitor) choice in patients who present with an acute coronary syndrome (ACS) and possible DAPT de-escalation strategies after PCI; (4) choice and duration of DAPT in ACS patients who are medically treated without revascularization; (5) pretreatment with DAPT (P2Y12 inhibitor) before elective or nonelective coronary angiography; (6) perioperative and longer-term APT management in patients who require coronary artery bypass grafting surgery; and (7) use of APT in patients with atrial fibrillation who require oral anticoagulation after PCI or medically managed ACS. These recommendations are all on the basis of systematic reviews and meta-analyses conducted as part of the development of these guidelines, provided in the Supplementary Material.
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Affiliation(s)
- Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
| | | | - Emilie Belley-Côté
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Ricky D Turgeon
- University of British Columbia, St Paul's Hospital PHARM-HF Clinic, Vancouver, British Columbia, Canada
| | | | - Hazal E Babadagli
- Pharmacy Services, Alberta Health Services, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - David Bewick
- Division of Cardiology, Department of Medicine, Dalhousie University, Saint John Regional Hospital, Saint John, New Brunswick, Canada
| | | | - Warren J Cantor
- Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Michelle M Graham
- Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Marie Lordkipanidzé
- Faculté de pharmacie, Université de Montréal, Research Center, Montréal Heart Institute, Montréal, Québec, Canada
| | - Mina Madan
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Samer Mansour
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Shamir R Mehta
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Brian J Potter
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Jay Shavadia
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Derek F So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jean-François Tanguay
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Robert C Welsh
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew T Yan
- Division of Cardiology, Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
| | - Akshay Bagai
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rodrigo Bagur
- London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Claudia Bucci
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Basem Elbarouni
- Department of Medicine, St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Carol Geller
- University of Ottawa, Centretown Community Health Centre, Ottawa, Ontario, Canada
| | - Andrea Lavoie
- Prairie Vascular Research Inc, Regina, Saskatchewan, Canada
| | - Patrick Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Shuangbo Liu
- Department of Medicine, St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - John Mancini
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Graham C Wong
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Kumar A, Connelly K, Vora K, Bainey KR, Howarth A, Leipsic J, Betteridge-LeBlanc S, Prato FS, Leong-Poi H, Main A, Atoui R, Saw J, Larose E, Graham MM, Ruel M, Dharmakumar R. The Canadian Cardiovascular Society Classification of Acute Atherothrombotic Myocardial Infarction Based on Stages of Tissue Injury Severity: An Expert Consensus Statement. Can J Cardiol 2024; 40:1-14. [PMID: 37906238 DOI: 10.1016/j.cjca.2023.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 09/09/2023] [Accepted: 09/10/2023] [Indexed: 11/02/2023] Open
Abstract
Myocardial infarction (MI) remains a leading cause of morbidity and mortality. In atherothrombotic MI (ST-elevation MI and type 1 non-ST-elevation MI), coronary artery occlusion leads to ischemia. Subsequent cardiomyocyte necrosis evolves over time as a wavefront within the territory at risk. The spectrum of ischemia and reperfusion injury is wide: it can be minimal in aborted MI or myocardial necrosis can be large and complicated by microvascular obstruction and reperfusion hemorrhage. Established risk scores and infarct classifications help with patient management but do not consider tissue injury characteristics. This document outlines the Canadian Cardiovascular Society classification of acute MI. It is an expert consensus formed on the basis of decades of data on atherothrombotic MI with reperfusion therapy. Four stages of progressively worsening myocardial tissue injury are identified: (1) aborted MI (no/minimal myocardial necrosis); (2) MI with significant cardiomyocyte necrosis, but without microvascular injury; (3) cardiomyocyte necrosis and microvascular dysfunction leading to microvascular obstruction (ie, "no-reflow"); and (4) cardiomyocyte and microvascular necrosis leading to reperfusion hemorrhage. Each stage reflects progression of tissue pathology of myocardial ischemia and reperfusion injury from the previous stage. Clinical studies have shown worse remodeling and increase in adverse clinical outcomes with progressive injury. Notably, microvascular injury is of particular importance, with the most severe form (hemorrhagic MI) leading to infarct expansion and risk of mechanical complications. This classification has the potential to stratify risk in MI patients and lay the groundwork for development of new, injury stage-specific and tissue pathology-based therapies for MI.
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Affiliation(s)
- Andreas Kumar
- Northern Ontario School of Medicine University, and Department of Cardiovascular Sciences, Health Sciences North, Sudbury, Ontario, Canada; Health Sciences North, Sudbury, Ontario, Canada.
| | - Kim Connelly
- Keenan Research Centre for Biomedical Science, Unity Health Toronto, St Michael's Hospital, University of Toronto, and Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Keyur Vora
- Krannert Cardiovascular Research Center, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kevin R Bainey
- University of Alberta, Faculty of Medicine and Dentistry, Mazankowski Alberta Heart Institute, Canadian VIGOUR Centre, Edmonton, Alberta, Canada
| | - Andrew Howarth
- Cardiac Sciences, Faculty of Medicine, University of Calgary, and Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Jonathon Leipsic
- Departments of Radiology and Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Suzanne Betteridge-LeBlanc
- Health Sciences North, Sudbury, Ontario, Canada; Northern Ontario School of Medicine University, and Health Sciences North, Sudbury, Ontario, Canada
| | - Frank S Prato
- Lawson Research Institute, University of Western Ontario, London, Ontario, Canada
| | - Howard Leong-Poi
- The Division of Cardiology, St Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Anthony Main
- Northern Ontario School of Medicine University, and Department of Cardiovascular Sciences, Health Sciences North, Sudbury, Ontario, Canada; Health Sciences North, Sudbury, Ontario, Canada
| | - Rony Atoui
- Northern Ontario School of Medicine University, and Department of Surgery, Health Sciences North, Sudbury, Ontario, Canada
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric Larose
- Department of Medicine, University of Laval, Quebec City, Quebec, Canada
| | - Michelle M Graham
- Division of Cardiology, University of Alberta, Faculty of Medicine and Dentistry, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Marc Ruel
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Rohan Dharmakumar
- Krannert Cardiovascular Research Center, Indiana University School of Medicine/IU Health Cardiovascular Institute, Indianapolis, Indiana, USA
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9
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Jacka MJ, Youngson E, Bigam D, Graham MM, Heels-Ansdell D, Jaeyoung Park L, Bendtz Kanstrup CT, Nenshi R, Bagshaw SM, McAlister F, Pannu N, Townsend D, McMurtry MS, Devereaux PJ. Myocardial Injury After Noncardiac Surgery in Major General Surgical Patients a Prospective Observational Cohort Study. Ann Surg 2023; 278:e1192-e1197. [PMID: 37459169 DOI: 10.1097/sla.0000000000005975] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
OBJECTIVE The objective of this study was to determine the prognostic relevance, clinical characteristics, and 30-day outcomes associated with myocardial injury after noncardiac surgery (MINS) in major general surgery patients. BACKGROUND MINS has been independently associated with 30-day mortality after noncardiac surgery. The characteristics and prognostic importance of MINS in major general surgical patients have not been described. METHODS This was an international prospective cohort study of a representative sample of 22,552 noncardiac surgery patients 45 years or older, of whom 4490 underwent major general surgery in 24 centers in 13 countries. All patients had fifth-generation plasma high-sensitivity troponin T (hsTnT) concentrations measured during the first 3 postoperative days. MINS was defined as a hsTnT of 20-65 ng/L and absolute change >5 ng/L or hsTnT ≥65 ng/L secondary to ischemia. The objectives of the present study were to determine (1) whether MINS is prognostically important in major general surgical patients, (2) the clinical characteristics of major general surgical patients with and without MINS, (3) the 30-day outcomes for major general surgical patients with and without MINS, and (4) the proportion of MINS that would have gone undetected without routine postoperative monitoring. RESULTS The incidence of MINS in the major general surgical patients was 16.3% (95% CI, 15.3-17.4%). Thirty-day all-cause mortality in the major general surgical cohort was 6.8% (95% CI, 5.1%-8.9%) in patients with MINS compared with 1.2% (95% CI, 0.9%-1.6%) in patients without MINS ( P <0.01). MINS was independently associated with 30-day mortality in major general surgical patients (adjusted odds ratio 4.7, 95% CI, 3.0-7.4). The 30-day mortality was higher both among MINS patients with no ischemic features (ie, no ischemic symptoms or electrocardiogram findings) (5.4%, 95% CI, 3.7%-7.7%) and among patients with 1 or more clinical ischemic features (10.6%, 95% CI, 6.7%-15.8%). The proportion of major general surgical patients who had MINS without ischemic symptoms was 89.9% (95% CI, 87.5-92.0). CONCLUSIONS Approximately 1 in 6 patients experienced MINS after major general surgery. MINS was independently associated with a nearly 5-fold increase in 30-day mortality. The vast majority of patients with MINS were asymptomatic and would have gone undetected without routine postoperative troponin measurement.
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Affiliation(s)
- Michael J Jacka
- Departments of Anesthesiology and Critical Care, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Erik Youngson
- Provincial Research Data Services (Alberta Health Services), Data and Research Services (Alberta SPOR SUPPORT Unit), Edmonton, AB, Canada
| | - David Bigam
- Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Michelle M Graham
- Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | | | | | - Rahima Nenshi
- Department of Surgery, Division of General Surgery, McMaster University, Hamilton, ON, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Finlay McAlister
- Department of Medicine, Division of General Internal Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Neesh Pannu
- Department of Medicine, Division of Nephrology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Derek Townsend
- Department of Critical Care, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Michael S McMurtry
- Department of Medicine, Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Philip J Devereaux
- Department of Medicine, Division of Cardiology, McMaster University, Hamilton, ON, Canada
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Wu KY, Wang X, Youngson E, Gouda P, Graham MM. Sex differences in post-operative outcomes following non-cardiac surgery. PLoS One 2023; 18:e0293638. [PMID: 37910570 PMCID: PMC10619824 DOI: 10.1371/journal.pone.0293638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 10/17/2023] [Indexed: 11/03/2023] Open
Abstract
It is uncertain whether sex is an independent risk factor for poor outcomes after non-cardiac surgery. We examined sex differences in short- and long-term mortality and morbidity in patients undergoing non-cardiac surgery in Alberta, Canada. Using linked administrative databases, we identified patients undergoing one of 45 different non-cardiac surgeries who were hospitalized between 2008 and 2019. Adjusted odds ratios (95% CI) were reported for mortality at 30-days, 6-months, and 1-year stratified by sex. Secondary outcomes including all-cause hospitalization, hospitalization for heart failure (HF), hospitalization for acute coronary syndrome (ACS), hospitalization for infection, hospitalization for stroke, and hospitalization for bleeding were also analyzed. Multivariate logistic regression was adjusted for age, sex, surgery type, the components of the Charlson Comorbidity Index, and the Revised Cardiac Risk Index. We identified 552,224 unique patients who underwent non-cardiac surgery of which 304,408 (55.1%) were female. Male sex was a predictor of mortality at 30-days (aOR 1.25 (1.14, 1.38), p<0.0001), 6-months (aOR 1.26 (1.20, 1.33), p<0.0001), and 1-year (aOR 1.25 (1.20, 1.31), p<0.0001). Similarly, male sex was a predictor of hospital readmission at 30-days (1.12 (1.09, 1.14), p<0.0001), 6-months (aOR 1.11 (1.10, 1.13), p<0.0001), and 1-year (aOR 1.06 (1.04, 1.07), p<0.0001). When the results were stratified by age, the effect of male sex on clinical outcome diminished for age ≥ 65years compared to younger patients. In conclusion, male patients undergoing non-cardiac surgery have higher risks of all-cause mortality and readmission after adjustment for baseline risk factor differences, particularly in those under 65-years-old. The overall incidence of readmission for stroke, bleeding, HF and ACS after non-cardiac surgery was low. The impact of male sex on clinical outcomes decreases with increasing age, suggesting the importance of considering the effect of both sex and age on clinical outcomes after non-cardiac surgery.
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Affiliation(s)
- Kai Yi Wu
- Mazankowski Alberta Heart Institute, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Xiaoming Wang
- Research Facilitation, Alberta Health Services, Edmonton, Alberta, Canada
| | - Erik Youngson
- Research Facilitation, Alberta Health Services, Edmonton, Alberta, Canada
| | - Pishoy Gouda
- Mazankowski Alberta Heart Institute, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Michelle M. Graham
- Mazankowski Alberta Heart Institute, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
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Ma B, James MT, Javaheri PA, Kruger D, Graham MM, Har BJ, Tyrrell BD, Heavener S, Puzey C, Benterud E. Change Management Accompanying Implementation of Decision Support for Prevention of Acute Kidney Injury in Cardiac Catheterization Units: Program Report. Can J Kidney Health Dis 2023; 10:20543581231206127. [PMID: 37867500 PMCID: PMC10588412 DOI: 10.1177/20543581231206127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 08/26/2023] [Indexed: 10/24/2023] Open
Abstract
Purpose of program Different models exist to guide successful implementation of electronic health tools into clinical practice. The Contrast Reducing Injury Sustained by Kidneys (Contrast RISK) initiative introduced an electronic decision support tool with physician audit and feedback into all of the cardiac catheterization facilities in Alberta, Canada, with the goal of preventing contrast-associated acute kidney injury (CA-AKI) following coronary angiography and intervention. This report describes the change management approaches used by the initiative and end-user's feedback on these processes. Sources of information and methods The Canada Health Infoway Change Management model was used to address 6 activities relevant to project implementation: governance and leadership, stakeholder engagement, communications, workflow analysis and integration, training and education, and monitoring and evaluation. Health care providers and invasive cardiologists from all sites completed preimplementation, usability, and postimplementation surveys to assess integration and change success. Key findings Prior to implementation, 67% of health providers were less than satisfied with processes to determine appropriate contrast dye volumes, 47% were less than satisfied with processes for administering adequate intravenous fluids, and 68% were less than satisfied with processes to ensure follow-up of high-risk patients. 48% of invasive cardiologists were less than satisfied with preprocedural identification of patients at risk of acute kidney injury (AKI). Following implementation, there were significant increases among health providers in the odds of satisfaction with processes for identifying those at high risk of AKI (odds ratio [OR] 3.01, 95% confidence interval [CI] 1.36-6.66, P = .007), quantifying the appropriate level of contrast dye for each patient (OR 6.98, 95% CI 3.06-15.91, P < .001), determining the optimal amount of IV fluid for each patient (OR 1.86, 95% CI 0.88-3.91, P = .102), and following up of kidney function of high risk patients (OR 5.49, 95%CI 2.45-12.30, P < .001). There were also significant increases among physicians in the odds of satisfaction with processes for identifying those at high risk of AKI (OR 19.53, 95% CI 3.21-118.76, P = .001), quantifying the appropriate level of contrast dye for each patient (OR 26.35, 95% CI 4.28-162.27, P < .001), and for following-up kidney function of high-risk patients (OR 7.72, 95% CI 1.62-36.84.30, P = .010). Eighty-nine percent of staff perceived the initiative as being successful in changing clinical practices to reduce the risk of CA-AKI. Physicians uniformly agreed that the system was well-integrated into existing workflows, while 42% of health providers also agreed. Implications The Canada Health Infoway Change Management model was an effective framework for guiding implementation of an electronic decision support tool and audit and feedback intervention to improve processes for AKI prevention within cardiac catheterization units.
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Affiliation(s)
- Bryan Ma
- Department of Medicine, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Matthew T. James
- Department of Medicine, Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, AB, Canada
- Libin Cardiovascular Institute, University of Calgary, AB, Canada
- O’Brien Institute of Public Health, University of Calgary, AB, Canada
| | - Pantea A. Javaheri
- Department of Medicine, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Denise Kruger
- Department of Medicine, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Michelle M. Graham
- Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Bryan J. Har
- Libin Cardiovascular Institute, University of Calgary, AB, Canada
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, AB, Canada
| | - Benjamin D. Tyrrell
- Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | - Shane Heavener
- CK Hui Heart Centre, Royal Alexandra Hospital, Edmonton, AB, Canada
| | - Clare Puzey
- Libin Cardiovascular Institute, University of Calgary, AB, Canada
| | - Eleanor Benterud
- Department of Medicine, Cumming School of Medicine, University of Calgary, AB, Canada
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Burgess SN, Shoaib A, Sharp ASP, Ludman P, Graham MM, Figtree GA, Kontopantelis E, Rashid M, Kinnaird T, Mamas MA. Sex-Specific Differences in Potent P2Y 12 Inhibitor Use in British Cardiovascular Intervention Society Registry STEMI Patients. Circ Cardiovasc Interv 2023; 16:e012447. [PMID: 37725676 DOI: 10.1161/circinterventions.122.012447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 07/25/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Sex-based outcome differences for women with ST-segment-elevation myocardial infarction (STEMI) have not been adequately addressed, and the role played by differences in prescription of potent P2Y12 inhibitors (P-P2Y12) is not well defined. This study explores the hypothesis that disparities in P-P2Y12 (prasugrel or ticagrelor) use may play a role in outcome disparities for women with STEMI. METHODS Data from British Cardiovascular Intervention Society national percutaneous coronary intervention database were analyzed, and 168 818 STEMI patients treated with primary percutaneous coronary intervention from 2010 to 2020 were included. RESULTS Among the included women (43 131; 25.54%) and men (125 687; 74.45%), P-P2Y12 inhibitors were prescribed less often to women (51.71%) than men (55.18%; P<0.001). Women were more likely to die in hospital than men (adjusted odds ratio, 1.213 [95% CI, 1.141-1.290]). Unadjusted mortality was higher among women treated with clopidogrel (7.57%), than P-P2Y12-treated women (5.39%), men treated with clopidogrel (4.60%), and P-P2Y12-treated men (3.61%; P<0.001). The strongest independent predictor of P-P2Y12 prescription was radial access (adjusted odds ratio, 2.368 [95% CI, 2.312-2.425]), used in 67.93% of women and 74.38% of men (P<0.001). Two risk adjustment models were used. Women were less likely to receive a P-P2Y12 (adjusted odds ratio, 0.957 [95% CI, 0.935-0.979]) with risk adjustment for baseline characteristics alone, when procedural factors including radial access were included in the model differences were not significant (adjusted odds ratio, 1.015 [95% CI, 0.991-1.039]). CONCLUSIONS Women were less likely to be prescribed prasugrel or ticagrelor, were less likely to have radial access, and had a higher mortality when being treated for STEMI. Improving rates of P-P2Y12 use and radial access may decrease outcome disparities for women with STEMI.
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Affiliation(s)
- Sonya N Burgess
- Department of Cardiology, Nepean Hospital, Sydney, Australia (S.N.B.)
- University of Sydney, NSW, Australia (S.N.B.)
| | - Ahmad Shoaib
- Victoria Heart Institute Foundation (A.S.), Victoria, BC, Canada
- Royal Jubilee Hospital (A.S.), Victoria, BC, Canada
- Keele Cardiovascular Research Group, Keele University, Stoke on Trent, United Kingdom (A.S., M.R., M.A.M.)
- Birmingham City Hospital, United Kingdom (A.S.)
| | - Andrew S P Sharp
- Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (A.S.P.S., T.K.)
| | - Peter Ludman
- Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom (P.L.)
| | - Michelle M Graham
- Division of Cardiology and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (M.M.G.)
| | - Gemma A Figtree
- Department of Cardiology, Kolling Institute, Royal North Shore Hospital and University of Sydney, Australia (G.A.F.)
| | | | - Muhammad Rashid
- Keele Cardiovascular Research Group, Keele University, Stoke on Trent, United Kingdom (A.S., M.R., M.A.M.)
| | - Tim Kinnaird
- Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (A.S.P.S., T.K.)
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke on Trent, United Kingdom (A.S., M.R., M.A.M.)
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Wilson TA, Hazlewood GS, Sajobi TT, Wilton SB, Pearson WE, Connolly C, Javaheri PA, Finlay JL, Levin A, Graham MM, Tonelli M, James MT. Preferences of Patients With Chronic Kidney Disease for Invasive Versus Conservative Treatment of Acute Coronary Syndrome: A Discrete Choice Experiment. J Am Heart Assoc 2023; 12:e028492. [PMID: 36892063 PMCID: PMC10111540 DOI: 10.1161/jaha.122.028492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
Background Patients with chronic kidney disease (CKD) can experience acute coronary syndromes (ACS) with high morbidity and mortality. Early invasive management of ACS is recommended for most high-risk patients; however, choosing between an early invasive versus conservative management approach may be influenced by the unique risk of kidney failure for patients with CKD. Methods and Results This discrete choice experiment measured the preferences of patients with CKD for future cardiovascular events versus acute kidney injury and kidney failure following invasive heart procedures for ACS. The discrete choice experiment, consisting of 8 choice tasks, was administered to adult patients attending 2 CKD clinics in Calgary, Alberta. The part-worth utilities of each attribute were determined using multinomial logit models, and preference heterogeneity was explored using latent class analysis. A total of 140 patients completed the discrete choice experiment. The mean age of patients was 64 years, 52% were male, and mean estimated glomerular filtration rate was 37 mL/min per 1.73 m2. Across the range of levels, risk of mortality was the most important attribute, followed by risk of end-stage kidney disease and risk of recurrent myocardial infarction. Latent class analysis identified 2 distinct preference groups. The largest group included 115 (83%) patients, who placed the greatest value on treatment benefits and expressed the strongest preference for reducing mortality. A second group of 25 (17%) patients was identified who were procedure averse and had a strong preference toward conservative management of ACS and avoiding acute kidney injury requiring dialysis. Conclusions The preferences of most patients with CKD for management of ACS were most influenced by lowering mortality. However, a distinct subgroup of patients was strongly averse to invasive management. This highlights the importance of clarifying patient preferences to ensure treatment decisions are aligned with patient values.
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Affiliation(s)
- Todd A Wilson
- Department of Medicine University of Calgary Calgary Alberta Canada
| | - Glen S Hazlewood
- Department of Medicine University of Calgary Calgary Alberta Canada
| | - Tolulope T Sajobi
- Department of Community Health Sciences University of Calgary Calgary Alberta Canada
| | - Stephen B Wilton
- Department of Community Health Sciences University of Calgary Calgary Alberta Canada
- Department of Cardiac Sciences University of Calgary Calgary Alberta Canada
| | - Winnie E Pearson
- Patient and Community Engagement Research Program, O'Brien Institute of Public Health University of Calgary Calgary Alberta Canada
| | - Carol Connolly
- Patient and Community Engagement Research Program, O'Brien Institute of Public Health University of Calgary Calgary Alberta Canada
| | | | - Juli L Finlay
- Department of Medicine University of Calgary Calgary Alberta Canada
| | - Adeera Levin
- Division of Nephrology University of British Columbia Vancouver British Columbia Canada
| | - Michelle M Graham
- Department of Medicine, Division of Cardiology University of Alberta Edmonton Alberta Canada
| | - Marcello Tonelli
- Department of Medicine University of Calgary Calgary Alberta Canada
| | - Matthew T James
- Department of Medicine University of Calgary Calgary Alberta Canada
- Department of Community Health Sciences University of Calgary Calgary Alberta Canada
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Gouda P, Graham MM. Detection of Myocardial Injury After Noncardiac Surgery: Levelling the Troponin Playing Field. Can J Cardiol 2023; 39:319-320. [PMID: 36641048 DOI: 10.1016/j.cjca.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 01/13/2023] Open
Affiliation(s)
- Pishoy Gouda
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Insitute, Edmonton, Alberta, Canada
| | - Michelle M Graham
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Insitute, Edmonton, Alberta, Canada.
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Opgenorth D, Bagshaw SM, Lau V, Graham MM, Fraser N, Klarenbach S, Morrin L, Norris C, Pannu N, Sinnadurai S, Valaire S, Wang X, Rewa OG. A study protocol for improving the delivery of acute kidney replacement therapy (KRT) to critically ill patients in Alberta – DIALYZING WISELY. BMC Nephrol 2022; 23:369. [DOI: 10.1186/s12882-022-02990-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 10/24/2022] [Indexed: 11/17/2022] Open
Abstract
Abstract
Background
Acute kidney replacement therapy (KRT) is delivered to acutely ill patients to support organ function and life in the Intensive Care Unit (ICU). Implementing standardized acute KRT pathways can ensure its safe and effective management. At present, there is no standardized approach to the management of acute KRT in Alberta ICUs.
Methods
Dialyzing Wisely is a registry embedded, stepped-wedge, interrupted time-series evaluation of the implementation of a standardized, stakeholder-informed, and evidence-based acute KRT pathway into Alberta ICUs. The acute KRT pathway will consist of two distinct phases. First, we will implement routine monitoring of evidence-informed key performance indicators (KPIs) of acute KRT. Second, we will provide prescriber and program reports for acute KRT initiation patterns. After the implementation of both phases of the pathway, we will evaluate acute KRT performance quarterly and implement a customized suite of interventions aimed at improving performance. We will compare this with baseline and evaluate iterative post implementation effects of the care pathway.
Discussion
Dialyzing Wisely will implement, monitor, and report a suite of KPIs of acute KRT, coupled with a care pathway that will transform the quality of acute KRT across ICUs in Alberta. This program will provide a framework for scaling evidence-informed approaches to monitoring and management of acute KRT in other jurisdictions. We anticipate improvements in acute KRT performance, decreased healthcare system costs and improved patient quality of life by decreasing patient dependence on maintenance dialysis.
Trial registration
Clinicaltrials.gov, NCT05186636. Registered 11, January, 2022.
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James MT, Har BJ, Tyrrell BD, Faris PD, Tan Z, Spertus JA, Wilton SB, Ghali WA, Knudtson ML, Sajobi TT, Pannu NI, Klarenbach SW, Graham MM. Effect of Clinical Decision Support With Audit and Feedback on Prevention of Acute Kidney Injury in Patients Undergoing Coronary Angiography: A Randomized Clinical Trial. JAMA 2022; 328:839-849. [PMID: 36066520 PMCID: PMC9449791 DOI: 10.1001/jama.2022.13382] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Contrast-associated acute kidney injury (AKI) is a common complication of coronary angiography and percutaneous coronary intervention (PCI) that has been associated with high costs and adverse long-term outcomes. OBJECTIVE To determine whether a multifaceted intervention is effective for the prevention of AKI after coronary angiography or PCI. DESIGN, SETTING, AND PARTICIPANTS A stepped-wedge, cluster randomized clinical trial was conducted in Alberta, Canada, that included all invasive cardiologists at 3 cardiac catheterization laboratories who were randomized to various start dates for the intervention between January 2018 and September 2019. Eligible patients were aged 18 years or older who underwent nonemergency coronary angiography, PCI, or both; who were not undergoing dialysis; and who had a predicted AKI risk of greater than 5%. Thirty-four physicians performed 7820 procedures among 7106 patients who met the inclusion criteria. Participant follow-up ended in November 2020. INTERVENTIONS During the intervention period, cardiologists received educational outreach, computerized clinical decision support on contrast volume and hemodynamic-guided intravenous fluid targets, and audit and feedback. During the control (preintervention) period, cardiologists provided usual care and did not receive the intervention. MAIN OUTCOMES AND MEASURES The primary outcome was AKI. There were 12 secondary outcomes, including contrast volume, intravenous fluid administration, and major adverse cardiovascular and kidney events. The analyses were conducted using time-adjusted models. RESULTS Of the 34 participating cardiologists who were divided into 8 clusters by practice group and center, the intervention group included 31 who performed 4327 procedures among 4032 patients (mean age, 70.3 [SD, 10.7] years; 1384 were women [32.0%]) and the control group included 34 who performed 3493 procedures among 3251 patients (mean age, 70.2 [SD, 10.8] years; 1151 were women [33.0%]). The incidence of AKI was 7.2% (310 events after 4327 procedures) during the intervention period and 8.6% (299 events after 3493 procedures) during the control period (between-group difference, -2.3% [95% CI, -0.6% to -4.1%]; odds ratio [OR], 0.72 [95% CI, 0.56 to 0.93]; P = .01). Of 12 prespecified secondary outcomes, 8 showed no significant difference. The proportion of procedures in which excessive contrast volumes were used was reduced to 38.1% during the intervention period from 51.7% during the control period (between-group difference, -12.0% [95% CI, -14.4% to -9.4%]; OR, 0.77 [95% CI, 0.65 to 0.90]; P = .002). The proportion of procedures in eligible patients in whom insufficient intravenous fluid was given was reduced to 60.8% during the intervention period from 75.1% during the control period (between-group difference, -15.8% [95% CI, -19.7% to -12.0%]; OR, 0.68 [95% CI, 0.53 to 0.87]; P = .002). There were no significant between-group differences in major adverse cardiovascular events or major adverse kidney events. CONCLUSIONS AND RELEVANCE Among cardiologists randomized to an intervention including clinical decision support with audit and feedback, patients undergoing coronary procedures during the intervention period were less likely to develop AKI compared with those treated during the control period, with a time-adjusted absolute risk reduction of 2.3%. Whether this intervention would show efficacy outside this study setting requires further investigation. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03453996.
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Affiliation(s)
- Matthew T. James
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Bryan J. Har
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Benjamin D. Tyrrell
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
- CK Hui Heart Centre, University of Alberta, Edmonton, Canada
| | | | - Zhi Tan
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - John A. Spertus
- Departments of Biomedical and Health Informatics, University of Missouri, Kansas City
- Saint Luke’s Mid America Heart Institute, Kansas City, Missouri
| | - Stephen B. Wilton
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - William A. Ghali
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Merril L. Knudtson
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tolulope T. Sajobi
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
- O’Brien Institute of Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Neesh I. Pannu
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Scott W. Klarenbach
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Michelle M. Graham
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
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Moledina SM, Shoaib A, Graham MM, Biondi-Zoccai G, Van Spall HGC, Kontopantelis E, Rashid M, Aktaa S, Gale CP, Weston C, Mamas MA. Association of admitting physician specialty and care quality and outcomes in non-ST-segment elevation myocardial infarction (NSTEMI): insights from a national registry. Eur Heart J Qual Care Clin Outcomes 2022; 8:557-567. [PMID: 33982094 DOI: 10.1093/ehjqcco/qcab038] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/04/2021] [Accepted: 05/11/2021] [Indexed: 02/07/2023]
Abstract
AIM Little is known about the association between admitting physician specialty and care quality and outcomes for non-ST-segment elevation myocardial infarction (NSTEMI). METHODS AND RESULTS We identified 288 420 patients hospitalized with NSTEMI between 2010 and 2017 in the UK Myocardial Infarction National Audit Project database. The cohort was dichotomized according to care under a non-cardiologist (n = 146 722) and care under a cardiologist (n = 141 698) within the first 24 h of admission to hospital. Patients admitted under a cardiologist were significantly younger (70 vs. 75 years, P < 0.001), and less likely to be female (32% vs. 39%, P < 0.001). Independent factors associated with admission under a cardiologist included prior history of percutaneous coronary intervention (PCI) [odds ratio (OR) 1.04, 95% confidence interval (CI) 1.01-1.07; P = 0.04], hypercholesterolaemia (OR 1.17, 95% CI 1.15-1.20; P < 0.001), hypertension (OR 1.03, 95% CI 1.01-1.04; P = 0.01), and admission to an interventional centre (OR 3.90, 95% CI 3.79-4.00; P < 0.001). Patients admitted under cardiology were more likely to receive optimal pharmacotherapy, undergo invasive coronary angiography (79% vs. 60%, P < 0.001), and receive revascularization in the form of PCI (52% vs. 36%, P < 0.001). Following propensity score matching, odds of in-hospital all-cause mortality (OR 0.81, 95% CI 0.79-0.85; P < 0.001), re-infarction (OR 0.78, 95% CI 0.66-0.91; P = 0.001), and major adverse cardiovascular events (OR 0.81, 95% CI 0.78-0.84; P < 0.001) were lower in patients admitted under a cardiologist. CONCLUSION Patients with NSTEMI admitted under a cardiologist within 24 h of hospital admission were more likely to receive guideline-directed management and had better clinical outcomes.
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Affiliation(s)
- Saadiq M Moledina
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Ahmad Shoaib
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Michelle M Graham
- Division of Cardiology, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.,Mediterranea Cardiocentro, Napoli, Italy
| | - Harriette G C Van Spall
- Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Evangelos Kontopantelis
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Suleman Aktaa
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK.,Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.,Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Chris P Gale
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK.,Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.,Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Clive Weston
- Glangwili General Hospital, Carmarthen, Wales, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, Keele, UK
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Bainey KR, Bastiany A, Cohen E, Eckstein J, Elbarouni B, Graham MM, Kidwai B, Liu S, Mansour S, Matteau A, O'Neill B, Sathananthan J, Sibbald M, Welsh RC, Madan M. 2022 CCS/CAIC Guidelines for Training and Retraining in Adult Interventional Cardiology. Can J Cardiol 2022; 38:1307-1311. [PMID: 35257823 DOI: 10.1016/j.cjca.2022.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 02/26/2022] [Accepted: 02/22/2022] [Indexed: 12/14/2022] Open
Affiliation(s)
- Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
| | - Alexandra Bastiany
- Thunder Bay Regional Health Sciences Centre, Thunder Bay, Ontario, Canada
| | - Eric Cohen
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Janine Eckstein
- Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Basem Elbarouni
- Cardiac Sciences Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Michelle M Graham
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | | | - Shuangbo Liu
- Cardiac Sciences Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Samer Mansour
- Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Alexis Matteau
- Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Blair O'Neill
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Janarthanan Sathananthan
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Robert C Welsh
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Mina Madan
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Verma S, Graham MM, Lecamwasam A, Romanovsky A, Duggan S, Bagshaw S, Senaratne JM. Cardiorenal Interactions: A Review. CJC Open 2022; 4:873-885. [PMID: 36254331 PMCID: PMC9568715 DOI: 10.1016/j.cjco.2022.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 06/24/2022] [Indexed: 10/29/2022] Open
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Wu KY, Gouda P, Wang X, Graham MM. Association of Frailty, Age, Socioeconomic Status, and Type of Surgery With Perioperative Outcomes in Patients Undergoing Noncardiac Surgery. JAMA Netw Open 2022; 5:e2224625. [PMID: 35904785 PMCID: PMC9338404 DOI: 10.1001/jamanetworkopen.2022.24625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This cohort study examines the association of Hospital Frailty Risk Score classification, demographic characteristics, and type of surgery with risk of mortality among patients undergoing noncardiac surgery.
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Affiliation(s)
- Kai Yi Wu
- Mazankowski Alberta Heart Institute, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Pishoy Gouda
- Mazankowski Alberta Heart Institute, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Xiaoming Wang
- Research Facilitation, Alberta Health Services, Edmonton, Alberta, Canada
| | - Michelle M. Graham
- Mazankowski Alberta Heart Institute, Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
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21
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Bastiany A, Pacheco C, Sedlak T, Saw J, Miner SE, Liu S, Lavoie A, Kim DH, Gulati M, Graham MM. A Practical Approach to Invasive Testing in Ischemia with No Obstructive Coronary Arteries (INOCA). CJC Open 2022; 4:709-720. [PMID: 36035733 PMCID: PMC9402961 DOI: 10.1016/j.cjco.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 04/26/2022] [Indexed: 11/18/2022] Open
Abstract
Up to 65% of women and approximately 30% of men have ischemia with no obstructive coronary artery disease (CAD; commonly known as INOCA) on invasive coronary angiography performed for stable angina. INOCA can be due to coronary microvascular dysfunction or coronary vasospasm. Despite the absence of obstructive CAD, those with INOCA have an increased risk of all-cause mortality and adverse outcomes, including recurrent angina and cardiovascular events. These patients often undergo repeat testing, including cardiac catheterization, resulting in lifetime healthcare costs that rival those for obstructive CAD. Patients with INOCA often remain undiagnosed and untreated. This review discusses the symptoms and prognosis of INOCA, offers a systematic approach to the diagnostic evaluation of these patients, and summarizes therapeutic management, including tailored therapy according to underlying pathophysiological mechanisms.
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Affiliation(s)
- Alexandra Bastiany
- Thunder Bay Regional Health Sciences Centre, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
- Corresponding author: Dr Alexandra Bastiany, Thunder Bay Regional Health Sciences Centre, Catheterization Laboratory, 980 Oliver Rd, Thunder Bay, Ontario P7B 6V4, Canada. Tel.: +1-807-622-3091; fax: +1-807-333-0903.
| | - Christine Pacheco
- Hôpital Pierre-Boucher, Université de Montréal, Montreal, Quebec, Canada
- Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada
| | - Tara Sedlak
- Department of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jaqueline Saw
- Department of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Shuangbo Liu
- Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Andrea Lavoie
- Saskatchewan Health Authority and Regina Mosaic Heart Centre, Regina, Saskatchewan, Canada
| | - Daniel H. Kim
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Martha Gulati
- Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Michelle M. Graham
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
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22
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Wu P, Sharma GV, Mehta LS, Chew-Graham CA, Lundberg GP, Nerenberg KA, Graham MM, Chappell LC, Kadam UT, Jordan KP, Mamas MA. In-Hospital Complications in Pregnancies Conceived by Assisted Reproductive Technology. J Am Heart Assoc 2022; 11:e022658. [PMID: 35191320 PMCID: PMC9075081 DOI: 10.1161/jaha.121.022658] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Assisted reproductive technology (ART) has emerged as a common treatment option for infertility, a problem that affects an estimated 48 million couples worldwide. Advancing maternal age with increasing prepregnancy cardiovascular risk factors, such as chronic hypertension, obesity, and diabetes, has raised concerns about pregnancy complications associated with ART. However, in-hospital complications following pregnancies conceived by ART are poorly described. Methods and Results To assess the patient characteristics, obstetric outcomes, vascular complications and temporal trends of pregnancies conceived by ART, we analyzed hospital deliveries conceived with or without ART between January 1, 2008, and December 31, 2016, from the United States National Inpatient Sample database. We included 106 248 deliveries conceived with ART and 34 167 246 deliveries conceived without ART. Women who conceived with ART were older (35 versus 28 years; P<0.0001) and had more comorbidities. ART-conceived pregnancies were independently associated with vascular complications (acute kidney injury: adjusted odds ratio [aOR], 2.52; 95% CI 1.99-3.19; and arrhythmia: aOR, 1.65; 95% CI, 1.46-1.86), and adverse obstetric outcomes (placental abruption: aOR, 1.57; 95% CI, 1.41-1.74; cesarean delivery: aOR, 1.38; 95% CI, 1.33-1.43; and preterm birth: aOR, 1.26; 95% CI, 1.20-1.32), including in subgroups without cardiovascular disease risk factors or without multifetal pregnancies. Higher hospital charges ($18 705 versus $11 983; P<0.0001) were incurred compared with women who conceived without ART. Conclusions Pregnancies conceived by ART have higher risks of adverse obstetric outcomes and vascular complications compared with spontaneous conception. Clinicians should have detailed discussions on the associated complications of ART in women during prepregnancy counseling.
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Affiliation(s)
- Pensée Wu
- Keele Cardiovascular Research Group School of Medicine Keele University Staffordshire United Kingdom.,Academic Unit of Obstetrics and Gynaecology University Hospital of North Midlands Stoke-on-Trent United Kingdom.,Department of Obstetrics and Gynecology National Cheng Kung University Hospital, College of MedicineNational Cheng Kung University Tainan Taiwan
| | - Garima V Sharma
- Division of Cardiology Department of Medicine Ciccarone Center for the Prevention of Cardiovascular Disease Johns Hopkins University School of Medicine Baltimore MD
| | - Laxmi S Mehta
- Division of Cardiology Department of Medicine The Ohio State University Columbus OH
| | - Carolyn A Chew-Graham
- School of Medicine Keele University Staffordshire United Kingdom.,National Institute for Health ResearchApplied Research CollaborationWest Midlands, Keele University Staffordshire United Kingdom
| | - Gina P Lundberg
- Division of Cardiology MedStar Heart and Vascular InstituteMedStar Washington Hospital CenterGeorgetown University Washington DC.,Division of Cardiology Emory University School of Medicine Atlanta GA
| | - Kara A Nerenberg
- Departments of Medicine, Obstetrics and Gynecology and Community Health Sciences University of Calgary Calgary Alberta Canada
| | - Michelle M Graham
- Division of Cardiology University of Alberta and Mazankowski Alberta Heart Institute Edmonton Alberta Canada
| | - Lucy C Chappell
- School of Life Course Sciences King's College London London United Kingdom
| | - Umesh T Kadam
- Diabetes Research Centre University of Leicester Leicester United Kingdom
| | - Kelvin P Jordan
- School of Medicine Keele University Staffordshire United Kingdom
| | - Mamas A Mamas
- Keele Cardiovascular Research Group School of Medicine Keele University Staffordshire United Kingdom.,The Heart Centre University Hospital of North Midlands Stoke-on-Trent United Kingdom
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23
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Kontopantelis E, Mamas MA, Webb RT, Castro A, Rutter MK, Gale CP, Ashcroft DM, Pierce M, Abel KM, Price G, Faivre-Finn C, Van Spall HGC, Graham MM, Morciano M, Martin GP, Sutton M, Doran T. Excess years of life lost to COVID-19 and other causes of death by sex, neighbourhood deprivation, and region in England and Wales during 2020: A registry-based study. PLoS Med 2022; 19:e1003904. [PMID: 35167587 PMCID: PMC8846534 DOI: 10.1371/journal.pmed.1003904] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 01/05/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Deaths in the first year of the Coronavirus Disease 2019 (COVID-19) pandemic in England and Wales were unevenly distributed socioeconomically and geographically. However, the full scale of inequalities may have been underestimated to date, as most measures of excess mortality do not adequately account for varying age profiles of deaths between social groups. We measured years of life lost (YLL) attributable to the pandemic, directly or indirectly, comparing mortality across geographic and socioeconomic groups. METHODS AND FINDINGS We used national mortality registers in England and Wales, from 27 December 2014 until 25 December 2020, covering 3,265,937 deaths. YLLs (main outcome) were calculated using 2019 single year sex-specific life tables for England and Wales. Interrupted time-series analyses, with panel time-series models, were used to estimate expected YLL by sex, geographical region, and deprivation quintile between 7 March 2020 and 25 December 2020 by cause: direct deaths (COVID-19 and other respiratory diseases), cardiovascular disease and diabetes, cancer, and other indirect deaths (all other causes). Excess YLL during the pandemic period were calculated by subtracting observed from expected values. Additional analyses focused on excess deaths for region and deprivation strata, by age-group. Between 7 March 2020 and 25 December 2020, there were an estimated 763,550 (95% CI: 696,826 to 830,273) excess YLL in England and Wales, equivalent to a 15% (95% CI: 14 to 16) increase in YLL compared to the equivalent time period in 2019. There was a strong deprivation gradient in all-cause excess YLL, with rates per 100,000 population ranging from 916 (95% CI: 820 to 1,012) for the least deprived quintile to 1,645 (95% CI: 1,472 to 1,819) for the most deprived. The differences in excess YLL between deprivation quintiles were greatest in younger age groups; for all-cause deaths, a mean of 9.1 years per death (95% CI: 8.2 to 10.0) were lost in the least deprived quintile, compared to 10.8 (95% CI: 10.0 to 11.6) in the most deprived; for COVID-19 and other respiratory deaths, a mean of 8.9 years per death (95% CI: 8.7 to 9.1) were lost in the least deprived quintile, compared to 11.2 (95% CI: 11.0 to 11.5) in the most deprived. For all-cause mortality, estimated deaths in the most deprived compared to the most affluent areas were much higher in younger age groups, but similar for those aged 85 or over. There was marked variability in both all-cause and direct excess YLL by region, with the highest rates in the North West. Limitations include the quasi-experimental nature of the research design and the requirement for accurate and timely recording. CONCLUSIONS In this study, we observed strong socioeconomic and geographical health inequalities in YLL, during the first calendar year of the COVID-19 pandemic. These were in line with long-standing existing inequalities in England and Wales, with the most deprived areas reporting the largest numbers in potential YLL.
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Affiliation(s)
- Evangelos Kontopantelis
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, England
- NIHR School for Primary Care Research, University of Oxford, Oxford, England
- Health Organisation, Policy and Economics (HOPE) Research Group, University of Manchester, Manchester, England
- * E-mail:
| | - Mamas A. Mamas
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, England
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele, England
- Department of Cardiology, Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Roger T. Webb
- Centre for Mental Health & Safety, Division of Psychology & Mental Health, University of Manchester and Manchester Academic Health Sciences Centre (MAHSC), England
- NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester, England
| | - Ana Castro
- Department of Health Sciences, University of York, England
| | - Martin K. Rutter
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, University of Manchester, Manchester, England
- Diabetes, Endocrinology and Metabolism Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, England
| | - Chris P. Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, England
- Leeds Institute for Data Analytics, University of Leeds, Leeds, England
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, England
| | - Darren M. Ashcroft
- NIHR School for Primary Care Research, University of Oxford, Oxford, England
- NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester, England
- Division of Pharmacy & Optometry, University of Manchester, Manchester, England
| | - Matthias Pierce
- Centre for Women’s Mental Health, Division of Psychology and Mental Health, University of Manchester, Manchester, England
| | - Kathryn M. Abel
- Centre for Women’s Mental Health, Division of Psychology and Mental Health, University of Manchester, Manchester, England
| | - Gareth Price
- Manchester Cancer Research Centre, The Christie NHS Foundation Trust, University of Manchester, Manchester, England
| | - Corinne Faivre-Finn
- Manchester Cancer Research Centre, The Christie NHS Foundation Trust, University of Manchester, Manchester, England
| | - Harriette G. C. Van Spall
- Department of Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Michelle M. Graham
- Division of Cardiology, University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Marcello Morciano
- NIHR School for Primary Care Research, University of Oxford, Oxford, England
- Health Organisation, Policy and Economics (HOPE) Research Group, University of Manchester, Manchester, England
| | - Glen P. Martin
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, England
| | - Matt Sutton
- NIHR School for Primary Care Research, University of Oxford, Oxford, England
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, England
| | - Tim Doran
- Department of Health Sciences, University of York, England
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24
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Dafaalla M, Rashid M, Bond RM, Smith T, Parwani P, Thamman R, Moledina SM, Graham MM, Mamas MA. Racial Disparities in Management and Outcomes of Out-of-Hospital Cardiac Arrest Complicating Myocardial Infarction: A National Study From England and Wales. CJC Open 2022; 3:S81-S88. [PMID: 34993437 PMCID: PMC8712673 DOI: 10.1016/j.cjco.2021.09.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 09/26/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Studies of racial disparities in care of patients admitted with an out-of-hospital cardiac arrest (OHCA) in the setting of acute myocardial infarction (AMI) have shown inconsistent results. Whether these differences in care exist in the universal healthcare system in United Kingdom is unknown. METHODS Patients admitted with a diagnosis of AMI and OHCA between 2010 and 2017 from the Myocardial Ischaemia National Audit Project (MINAP) were studied. All patients were stratified based on ethnicity into a Black, Asian, or minority ethnicity (BAME) group vs a White group. We used multivariable logistic regression models to evaluate the predictors of clinical outcomes and treatment strategy. RESULTS From 14,287 patients admitted with AMI complicated by OHCA, BAME patients constituted a minority of patients (1185 [8.3%]), compared with a White group (13,102 [91.7%]). BAME patients were younger (median age [interquartile range]) for BAME group, 58 [50-70] years; for White group, 65 [55-74] years). Cardiogenic shock (BAME group, 33%; White group, 20.7%; P < 0.001) and severe left ventricular impairment (BAME group, 21%; White group, 16.5%; P < 0.003) were more frequent among BAME patients. BAME patients were more likely to be seen by a cardiologist (BAME group, 95.9%; White group, 92.5%; P < 0.001) and were more likely to receive coronary angiography than the White group (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.2-1.88). The BAME group had significantly higher in-hospital mortality (OR 1.26, 95% CI 1.04-1.52) and re-infarction (OR 1.52, 95% CI 1.06-2.18) than the White group. CONCLUSIONS BAME patients were more likely to be seen by a cardiologist and receive coronary angiography than White patients. Despite this difference, the in-hospital mortality of BAME patients, particularly in the Asian population, was significantly higher.
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Affiliation(s)
- Mohamed Dafaalla
- Keele Cardiovascular Research Group, School of Medicine, Keele University, Stoke-on-Trent, United Kingdom.,Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, School of Medicine, Keele University, Stoke-on-Trent, United Kingdom.,Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Rachel M Bond
- Women's Heart Health, Dignity Health, Gilbert, Arizona, USA.,Internal Medicine, Creighton University School of Medicine, Chandler, Arizona, USA
| | - Triston Smith
- Department of Cardiology, Trinity Health System, Steubenville, Ohio, USA
| | - Purvi Parwani
- Division of Cardiology, Department of Medicine, Loma Linda University Health, Loma Linda, California, USA
| | - Ritu Thamman
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Saadiq M Moledina
- Keele Cardiovascular Research Group, School of Medicine, Keele University, Stoke-on-Trent, United Kingdom.,Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Michelle M Graham
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, School of Medicine, Keele University, Stoke-on-Trent, United Kingdom.,Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom.,Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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25
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McKay B, Tseng NWH, Sheikh HI, Syed MK, Pakosh M, Caterini JE, Sharma A, Colella TJF, Konieczny KM, Connelly KA, Graham MM, McDonald M, Banks L, Randhawa VK. Sex, Race, and Age Differences of Cardiovascular Outcomes in Cardiac Resynchronization Therapy RCTs: A Systematic Review and Meta-analysis. CJC Open 2022; 3:S192-S201. [PMID: 34993449 PMCID: PMC8712541 DOI: 10.1016/j.cjco.2021.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/07/2021] [Indexed: 11/05/2022] Open
Abstract
Background Cardiac resynchronization therapy (CRT) is beneficial in patients who have heart failure with reduced ejection fraction or arrhythmic events. However, most randomized controlled trials (RCTs) showing survival benefits primarily enrolled older white men. This study aims to evaluate CRT efficacy by sex, race, and age in RCTs. Methods Five electronic databases (CINAHL, Embase, Emcare, Medline, and PubMed) were searched from inception to July 12, 2021 for RCTs with CRT in adult patients. Data were analyzed for clinical outcomes including all-cause or cardiovascular (CV) death, worsening heart failure (HF), and HF hospitalization (HFH) according to sex, race, and age. Results Among six RCTs with up to moderate risk of bias, 54% (n = 3,630 of 6,682; mean age 64 years, 22% female, 8% black patients) had CRT device implantation. All-cause death (odds ratio [OR], 0.51; P = 0.053) was reduced in female versus male CRT patients, whereas CV death, HFH, or all-cause death with worsening HF or HFH did not differ significantly. No difference was seen in CRT patients for all-cause death and worsening HF (OR, 1.32; P = 0.46) among white vs black patients or for all-cause death and HFH (OR, 1.19; P = 0.55) among ≥ 65 versus < 65 years. Conclusions Whereas all-cause death was lower in female CRT patients, other reported outcomes did not significantly differ by sex, race, or age. Only 6 studies partially reported outcomes. Thus, enhanced reporting and analyses are required to overcome such paucity of data to evaluate the impact of these factors on clinical outcomes in distinct patient cohorts with CRT indication.
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Affiliation(s)
- Bradley McKay
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
| | | | - Hassan I Sheikh
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
| | - Mohammad K Syed
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
| | - Maureen Pakosh
- Library & Information Services, University Health Network, Toronto, Ontario, Canada
| | | | - Abhinav Sharma
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Tracey J F Colella
- KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada.,Lawrence S. Bloomberg Faculty of Nursing, Faculty of Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Kaja M Konieczny
- Department of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Kim A Connelly
- Department of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Michelle M Graham
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Michael McDonald
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Laura Banks
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada.,KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Varinder Kaur Randhawa
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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26
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Gouda P, Wang X, Youngson E, McGillion M, Mamas MA, Graham MM. Beyond the revised cardiac risk index: Validation of the hospital frailty risk score in non-cardiac surgery. PLoS One 2022; 17:e0262322. [PMID: 35045122 PMCID: PMC8769314 DOI: 10.1371/journal.pone.0262322] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 12/22/2021] [Indexed: 12/12/2022] Open
Abstract
Frailty is an established risk factor for adverse outcomes following non-cardiac surgery. The Hospital Frailty Risk Score (HFRS) is a recently described frailty assessment tool that harnesses administrative data and is composed of 109 International Classification of Disease variables. We aimed to examine the incremental prognostic utility of the HFRS in a generalizable surgical population. Using linked administrative databases, a retrospective cohort of patients admitted for non-cardiac surgery between October 1st, 2008 and September 30th, 2019 in Alberta, Canada was created. Our primary outcome was a composite of death, myocardial infarction or cardiac arrest at 30-days. Multivariable logistic regression was undertaken to assess the impact of HFRS on outcomes after adjusting for age, sex, components of the Charlson Comorbidity Index (CCI), Revised Cardiac Risk Index (RCRI) and peri-operative biomarkers. The final cohort consisted of 712,808 non-cardiac surgeries, of which 55·1% were female and the average age was 53·4 +/- 22·4 years. Using the HFRS, 86.3% were considered low risk, 10·7% were considered intermediate risk and 3·1% were considered high risk for frailty. Intermediate and high HFRS scores were associated with increased risk of the primary outcome with an adjusted odds ratio of 1·61 (95% CI 1·50-1.74) and 1·55 (95% CI 1·38-1·73). Intermediate and high HFRS were also associated with increased adjusted odds of prolonged hospital stay, in-hospital mortality, and 1-year mortality. The HFRS is a minimally onerous frailty assessment tool that can complement perioperative risk stratification in identifying patients at high risk of short- and long-term adverse events.
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Affiliation(s)
- Pishoy Gouda
- University of Alberta, Division of Cardiology and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Xiaoming Wang
- Research Facilitation, Alberta Health Services, Edmonton, Alberta, Canada
| | - Erik Youngson
- Research Facilitation, Alberta Health Services, Edmonton, Alberta, Canada
| | - Michael McGillion
- School of Nursing, Faculty of Health Sciences and Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele, Newcastle, United Kingdom
| | - Michelle M. Graham
- University of Alberta, Division of Cardiology and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
- * E-mail:
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27
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Eberhardt TE, Bungard TJ, Graham MM, Picard M, Wang GT, Ackman ML. Effect of New Evidence on Antithrombotic Therapies in Atrial Fibrillation Patients Who Undergo Percutaneous Coronary Intervention in Alberta, Canada. CJC Open 2021; 4:378-382. [PMID: 35495861 PMCID: PMC9039572 DOI: 10.1016/j.cjco.2021.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 12/20/2021] [Indexed: 10/26/2022] Open
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28
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Syed MK, Sheikh HI, McKay B, Tseng N, Pakosh M, Caterini JE, Sharma A, Colella TJ, Konieczny KM, Connelly KA, Graham MM, McDonald M, Banks L, Randhawa VK. Sex, Race, and Age Differences in Cardiovascular Outcomes in Implantable Cardioverter–Defibrillator Randomized Controlled Trials: A Systematic Review and Meta-analysis. CJC Open 2021; 3:S209-S217. [PMID: 34993451 PMCID: PMC8712708 DOI: 10.1016/j.cjco.2021.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 09/16/2021] [Indexed: 11/27/2022] Open
Affiliation(s)
- Mohammad K. Syed
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
| | - Hassan I. Sheikh
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
| | - Bradley McKay
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
| | - Nicholas Tseng
- Faculty of Biomedical Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Maureen Pakosh
- Library & Information Services, University Health Network, Toronto, Ontario, Canada
| | | | - Abhinav Sharma
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Tracey J.F. Colella
- KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Lawrence S. Bloomberg Faculty of Nursing, Faculty of Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Kaja M. Konieczny
- Department of Cardiology, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Kim A. Connelly
- Department of Cardiology, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Michelle M. Graham
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Michael McDonald
- Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Laura Banks
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
- KITE, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Corresponding author: Dr Laura Banks, Affiliate Scientist, University Health Network, Assistant Teaching Professor, Faculty of Health Sciences, Ontario Tech University, KITE, Toronto Rehabilitation Institute, Cardiovascular Prevention & Rehabilitation Program, 347 Rumsey Rd, Toronto, Ontario M4G 1R7, Canada. Tel.: +1-416-597-3422; fax: +1-416-425-0301.
| | - Varinder Kaur Randhawa
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Graham MM, Simpson CS. The Indirect Impact of COVID-19 on Cardiac Care and Outcomes: Lessons From a Stretched System. Can J Cardiol 2021; 37:1502-1503. [PMID: 34600794 PMCID: PMC8481083 DOI: 10.1016/j.cjca.2021.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 06/02/2021] [Accepted: 06/03/2021] [Indexed: 12/04/2022] Open
Affiliation(s)
- Michelle M Graham
- Division of Cardiology, Department of Medicine, University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada.
| | - Christopher S Simpson
- Division of Cardiology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
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30
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Ko DT, Ahmed T, Austin PC, Cantor WJ, Dorian P, Goldfarb M, Gong Y, Graham MM, Gu J, Hawkins NM, Huynh T, Humphries KH, Koh M, Lamarche Y, Lambert LJ, Lawler PR, Légaré JF, Ly HQ, Qiu F, Quraishi AUR, So DY, Welsh RC, Wijeysundera HC, Wong G, Yan AT, Gurevich Y. Development of Acute Myocardial Infarction Mortality and Readmission Models for Public Reporting on Hospital Performance in Canada. CJC Open 2021; 3:1051-1059. [PMID: 34505045 PMCID: PMC8413230 DOI: 10.1016/j.cjco.2021.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Given changes in the care and outcomes of acute myocardial infarction (AMI) patients over the past several decades, we sought to develop prediction models that could be used to generate accurate risk-adjusted mortality and readmission outcomes for hospitals in current practice across Canada. Methods A Canadian national expert panel was convened to define appropriate AMI patients for reporting and develop prediction models. Preliminary candidate variable evaluation was conducted using Ontario patients hospitalized with a most responsible diagnosis of AMI from April 1, 2015 to March 31, 2018. National data from the Canadian Institute for Health Information was used to develop AMI prediction models. The main outcomes were 30-day all-cause in-hospital mortality and 30-day urgent all-cause readmission. Discrimination of these models (measured by c-statistics) was compared with that of existing Canadian Institute for Health Information models in the same study cohort. Results The AMI mortality model was assessed in 54,240 Ontario AMI patients and 153,523 AMI patients across Canada. We observed a 30-day in-hospital mortality rate of 6.3%, and a 30-day all-cause urgent readmission rate of 10.7% in Canada. The final Canadian AMI mortality model included 12 variables and had a c-statistic of 0.834. For readmission, the model had 13 variables and a c-statistic of 0.679. Discrimination of the new AMI models had higher c-statistics compared with existing models (c-statistic 0.814 for mortality; 0.673 for readmission). Conclusions In this national collaboration, we developed mortality and readmission models that are suitable for profiling performance of hospitals treating AMI patients in Canada.
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Affiliation(s)
- Dennis T Ko
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Tareq Ahmed
- Canadian Institute for Health Information, Toronto, Ontario, Canada
| | - Peter C Austin
- ICES, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Warren J Cantor
- University of Toronto, Toronto, Ontario, Canada.,Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Paul Dorian
- University of Toronto, Toronto, Ontario, Canada.,Unity Health Toronto, Toronto, Ontario, Canada
| | - Michael Goldfarb
- Azrieli Heart Centre, Jewish General Hospital, Montreal, Quebec, Canada
| | - Yanyan Gong
- Canadian Institute for Health Information, Toronto, Ontario, Canada
| | - Michelle M Graham
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Jing Gu
- Canadian Institute for Health Information, Toronto, Ontario, Canada
| | - Nathaniel M Hawkins
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Thao Huynh
- Department of Medicine, Division of Cardiology, McGill University, Montreal, Quebec, Canada
| | - Karin H Humphries
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Health Evaluation and Outcome Sciences (CHEOS), Vancouver, British Columbia, Canada
| | | | - Yoan Lamarche
- Department of Surgery, Montreal Heart Institute, Montreal Quebec, Canada
| | - Laurie J Lambert
- INESSS, Quebec City, Quebec, Canada.,CADTH, Ottawa, Ontario, Canada
| | - Patrick R Lawler
- University of Toronto, Toronto, Ontario, Canada.,Peter Munk Cardiac Centre, University Healthy Network, Toronto, Ontario, Canada
| | - Jean-Francois Légaré
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,Saint John Regional Hospital, Saint John, New Brunswick, Canada
| | - Hung Q Ly
- Department of Surgery, Montreal Heart Institute, Montreal Quebec, Canada
| | | | - Ata Ur Rehman Quraishi
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.,QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Derek Y So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada.,Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Robert C Welsh
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Harindra C Wijeysundera
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Graham Wong
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Cardiovascular Innovation, University of British Columbia, British Columbia, Canada
| | - Andrew T Yan
- University of Toronto, Toronto, Ontario, Canada.,Unity Health Toronto, Toronto, Ontario, Canada
| | - Yana Gurevich
- Canadian Institute for Health Information, Toronto, Ontario, Canada
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31
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Kontopantelis E, Mamas MA, Webb RT, Castro A, Rutter MK, Gale CP, Ashcroft DM, Pierce M, Abel KM, Price G, Faivre-Finn C, Van Spall HG, Graham MM, Morciano M, Martin GP, Doran T. Excess deaths from COVID-19 and other causes by region, neighbourhood deprivation level and place of death during the first 30 weeks of the pandemic in England and Wales: A retrospective registry study. Lancet Reg Health Eur 2021; 7:100144. [PMID: 34557845 PMCID: PMC8454637 DOI: 10.1016/j.lanepe.2021.100144] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Excess deaths during the COVID-19 pandemic compared with those expected from historical trends have been unequally distributed, both geographically and socioeconomically. Not all excess deaths have been directly related to COVID-19 infection. We investigated geographical and socioeconomic patterns in excess deaths for major groups of underlying causes during the pandemic. METHODS Weekly mortality data from 27/12/2014 to 2/10/2020 for England and Wales were obtained from the Office of National Statistics. Negative binomial regressions were used to model death counts based on pre-pandemic trends for deaths caused directly by COVID-19 (and other respiratory causes) and those caused indirectly by it (cardiovascular disease or diabetes, cancers, and all other indirect causes) over the first 30 weeks of the pandemic (7/3/2020-2/10/2020). FINDINGS There were 62,321 (95% CI: 58,849 to 65,793) excess deaths in England and Wales in the first 30 weeks of the pandemic. Of these, 46,221 (95% CI: 45,439 to 47,003) were attributable to respiratory causes, including COVID-19, and 16,100 (95% CI: 13,410 to 18,790) to other causes. Rates of all-cause excess mortality ranged from 78 per 100,000 in the South West of England and in Wales to 130 per 100,000 in the West Midlands; and from 93 per 100,000 in the most affluent fifth of areas to 124 per 100,000 in the most deprived. The most deprived areas had the highest rates of death attributable to COVID-19 and other indirect deaths, but there was no socioeconomic gradient for excess deaths from cardiovascular disease/diabetes and cancer. INTERPRETATION During the first 30 weeks of the COVID-19 pandemic there was significant geographic and socioeconomic variation in excess deaths for respiratory causes, but not for cardiovascular disease, diabetes and cancer. Pandemic recovery plans, including vaccination programmes, should take account of individual characteristics including health, socioeconomic status and place of residence. FUNDING None.
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Affiliation(s)
- Evangelos Kontopantelis
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Oxford Road, M13 9PL Manchester, England, United Kingdom
- NIHR School for Primary Care Research, University of Oxford, Oxford, England, United Kingdom
- Health Organisation, Policy and Economics (HOPE) research group, University of Manchester, Manchester, England, United Kingdom
| | - Mamas A. Mamas
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Oxford Road, M13 9PL Manchester, England, United Kingdom
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele, England, United Kingdom
- Department of Cardiology, Jefferson University, Philadelphia, United States
| | - Roger T. Webb
- Centre for Mental Health & Safety, Division of Psychology & Mental Health, University of Manchester and Manchester Academic Health Sciences Centre (MAHSC), England, United Kingdom
- NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester, England, United Kingdom
| | - Ana Castro
- Department of Health Sciences, University of York, England, United Kingdom
| | - Martin K. Rutter
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, University of Manchester, Manchester, England, United Kingdom
- Diabetes, Endocrinology and Metabolism Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, England, United Kingdom
| | - Chris P. Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, England, United Kingdom
- Leeds Institute for Data Analytics, University of Leeds, Leeds, England, United Kingdom
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, England, United Kingdom
| | - Darren M. Ashcroft
- NIHR School for Primary Care Research, University of Oxford, Oxford, England, United Kingdom
- NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester, England, United Kingdom
- Division of Pharmacy & Optometry, University of Manchester, Manchester, England, United Kingdom
| | - Matthias Pierce
- Centre for Women's Mental Health, Division of Psychology and Mental Health, University of Manchester, Manchester, England, United Kingdom
| | - Kathryn M. Abel
- Centre for Women's Mental Health, Division of Psychology and Mental Health, University of Manchester, Manchester, England, United Kingdom
| | - Gareth Price
- Manchester Cancer Research Centre, The Christie NHS Foundation Trust, University of Manchester, Manchester, England, United Kingdom
| | - Corinne Faivre-Finn
- Manchester Cancer Research Centre, The Christie NHS Foundation Trust, University of Manchester, Manchester, England, United Kingdom
| | - Harriette G.C. Van Spall
- Department of Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Michelle M. Graham
- Division of Cardiology, University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Marcello Morciano
- NIHR School for Primary Care Research, University of Oxford, Oxford, England, United Kingdom
- Health Organisation, Policy and Economics (HOPE) research group, University of Manchester, Manchester, England, United Kingdom
| | - Glen P. Martin
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Oxford Road, M13 9PL Manchester, England, United Kingdom
| | - Tim Doran
- Department of Health Sciences, University of York, England, United Kingdom
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32
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Blumer V, Gayowsky A, Xie F, Greene SJ, Graham MM, Ezekowitz JA, Perez R, Ko DT, Thabane L, Zannad F, Van Spall HGC. Effect of patient-centered transitional care services on patient-reported outcomes in heart failure: sex-specific analysis of the PACT-HF randomized controlled trial. Eur J Heart Fail 2021; 23:1488-1498. [PMID: 34302417 DOI: 10.1002/ejhf.2312] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/10/2021] [Accepted: 07/20/2021] [Indexed: 12/28/2022] Open
Abstract
AIMS We assessed the effect of transitional care on patient-reported outcomes (PROs) in women and men hospitalized for heart failure. METHODS AND RESULTS In this sex-specific analysis of a stepped wedge cluster randomized trial in Canada, the effect of a patient-centered transitional care model was tested on pre-specified PROs of discharge preparedness (B-PREPARED score, range 0-22), quality of transition [Care Transitions Measure-3 (CTM-3) score, range 0-100], and health-related quality of life (HRQOL) (EQ-5D-5L, range 0-1). Among 986 patients (47.4% women), B-PREPARED at 6 weeks was greater with the intervention than usual care [mean difference (MD) 4.01 (95% confidence interval-CI 2.90-5.12); P < 0.001], with no sex differences (P sex-interaction = 0.24). CTM-3 at 6 weeks was greater with the intervention than usual care [MD 10.52 (95% CI 6.00-15.04); P < 0.001], with no sex differences (P sex-interaction = 0.69). EQ-5D-5L was greater with intervention than usual care at discharge [MD 0.17 (95% CI 0.12-0.22); P < 0.001], 6 weeks [MD 0.06 (95% CI 0.01-0.12); P = 0.02], and 6 months [MD 0.05 (95% CI -0.01 to 0.12); P = 0.09], although the 6-month difference was not statistically significant. At discharge, women reported lower EQ-5D-5L but experienced significantly greater treatment benefit than men (P sex-interaction = 0.02). Treatment effect on EQ-5D-5L was numerically greater in women than men at 6 weeks and 6 months, but there were no significant sex differences (P sex-interaction 0.18 and 0.19, respectively). CONCLUSION A patient-centered transitional care model improved discharge preparedness, transition quality, and HRQOL in the weeks following heart failure hospitalization, with effects largely consistent in women and men. However, women reported lower HRQOL and experienced greater treatment benefit in this endpoint than men at hospital discharge. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT02112227.
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Affiliation(s)
- Vanessa Blumer
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Anastasia Gayowsky
- ICES (formerly the Institute for Clinical Evaluative Sciences), Hamiltion, Canada
| | - Feng Xie
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Canada
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Michelle M Graham
- Division of Cardiology, University of Alberta, Edmonton, Canada.,Mazankowski Heart Centre, University of Alberta, Edmonton, Canada
| | | | - Richard Perez
- ICES (formerly the Institute for Clinical Evaluative Sciences), Hamiltion, Canada
| | - Dennis T Ko
- ICES (formerly the Institute for Clinical Evaluative Sciences), Hamiltion, Canada.,Sunnybrook Heart Centre, Toronto, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,Population Health Research Institute, Hamilton, Canada
| | - Faiez Zannad
- Université de Lorraine, INSERM CIC-P 1433, and INSERM U1116 CHRU Nancy Brabois F-CRIN INI-CRCT, Nancy, France
| | - Harriette G C Van Spall
- ICES (formerly the Institute for Clinical Evaluative Sciences), Hamiltion, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.,Population Health Research Institute, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
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33
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Harrison TG, Ronksley PE, James MT, Brindle ME, Ruzycki SM, Graham MM, McRae AD, Zarnke KB, McCaughey D, Ball CG, Dixon E, Hemmelgarn BR. The Perioperative Surgical Home, Enhanced Recovery After Surgery and how integration of these models may improve care for medically complex patients. Can J Surg 2021; 64:E381-E390. [PMID: 34296705 PMCID: PMC8410465 DOI: 10.1503/cjs.002020] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2020] [Indexed: 12/11/2022] Open
Abstract
Perioperative medicine is changing rapidly, and with this change comes the opportunity to improve upon current models of care delivery and integration within the health care system. Perioperative models of care are structured or conceptual arrangements for surgical patients before, during and after their surgery. Models of care such as the Perioperative Surgical Home and Enhanced Recovery After Surgery pathways are increasingly used to guide the structure of perioperative care delivery with an aim to improve patient outcomes and experience in Canadian settings. In this narrative review, we summarize the origins of these perioperative models of care. They are fundamentally different in scope and level of evidence. Both models have potential benefits and limitations to their broad implementation in our health care system. As currently developed, both models are limited in their application to patients with chronic disease. We discuss how these models of care can be used to develop integrated horizontal and vertical perioperative pathways in a Canadian setting. Such integration is a potential solution that will improve their applicability to patients with medically complex conditions and in times when health care systems are under pressure. We describe this approach using the example of patients with kidney failure receiving dialysis.
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Affiliation(s)
- Tyrone G Harrison
- From the Department of Medicine, University of Calgary, Calgary, Alta. (Harrison, James, Ruzycki, Zarnke, Hemmelgarn); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Harrison, James, Ronksley, Ruzycki, McRae, McCaughey, Dixon); the O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ronksley, Zarnke, McCaughey, James); the Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alta. (James); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle, Ball, Dixon); the Department of Emergency Medicine, University of Calgary, Calgary, Alta. (McRae); the Mazankowski Alberta Heart Institute, Edmonton, Alta. (Graham); and the Department of Medicine, University of Alberta, Edmonton, Alta. (Graham, Hemmelgarn)
| | - Paul E Ronksley
- From the Department of Medicine, University of Calgary, Calgary, Alta. (Harrison, James, Ruzycki, Zarnke, Hemmelgarn); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Harrison, James, Ronksley, Ruzycki, McRae, McCaughey, Dixon); the O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ronksley, Zarnke, McCaughey, James); the Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alta. (James); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle, Ball, Dixon); the Department of Emergency Medicine, University of Calgary, Calgary, Alta. (McRae); the Mazankowski Alberta Heart Institute, Edmonton, Alta. (Graham); and the Department of Medicine, University of Alberta, Edmonton, Alta. (Graham, Hemmelgarn)
| | - Matthew T James
- From the Department of Medicine, University of Calgary, Calgary, Alta. (Harrison, James, Ruzycki, Zarnke, Hemmelgarn); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Harrison, James, Ronksley, Ruzycki, McRae, McCaughey, Dixon); the O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ronksley, Zarnke, McCaughey, James); the Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alta. (James); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle, Ball, Dixon); the Department of Emergency Medicine, University of Calgary, Calgary, Alta. (McRae); the Mazankowski Alberta Heart Institute, Edmonton, Alta. (Graham); and the Department of Medicine, University of Alberta, Edmonton, Alta. (Graham, Hemmelgarn)
| | - Mary E Brindle
- From the Department of Medicine, University of Calgary, Calgary, Alta. (Harrison, James, Ruzycki, Zarnke, Hemmelgarn); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Harrison, James, Ronksley, Ruzycki, McRae, McCaughey, Dixon); the O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ronksley, Zarnke, McCaughey, James); the Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alta. (James); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle, Ball, Dixon); the Department of Emergency Medicine, University of Calgary, Calgary, Alta. (McRae); the Mazankowski Alberta Heart Institute, Edmonton, Alta. (Graham); and the Department of Medicine, University of Alberta, Edmonton, Alta. (Graham, Hemmelgarn)
| | - Shannon M Ruzycki
- From the Department of Medicine, University of Calgary, Calgary, Alta. (Harrison, James, Ruzycki, Zarnke, Hemmelgarn); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Harrison, James, Ronksley, Ruzycki, McRae, McCaughey, Dixon); the O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ronksley, Zarnke, McCaughey, James); the Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alta. (James); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle, Ball, Dixon); the Department of Emergency Medicine, University of Calgary, Calgary, Alta. (McRae); the Mazankowski Alberta Heart Institute, Edmonton, Alta. (Graham); and the Department of Medicine, University of Alberta, Edmonton, Alta. (Graham, Hemmelgarn)
| | - Michelle M Graham
- From the Department of Medicine, University of Calgary, Calgary, Alta. (Harrison, James, Ruzycki, Zarnke, Hemmelgarn); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Harrison, James, Ronksley, Ruzycki, McRae, McCaughey, Dixon); the O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ronksley, Zarnke, McCaughey, James); the Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alta. (James); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle, Ball, Dixon); the Department of Emergency Medicine, University of Calgary, Calgary, Alta. (McRae); the Mazankowski Alberta Heart Institute, Edmonton, Alta. (Graham); and the Department of Medicine, University of Alberta, Edmonton, Alta. (Graham, Hemmelgarn)
| | - Andrew D McRae
- From the Department of Medicine, University of Calgary, Calgary, Alta. (Harrison, James, Ruzycki, Zarnke, Hemmelgarn); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Harrison, James, Ronksley, Ruzycki, McRae, McCaughey, Dixon); the O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ronksley, Zarnke, McCaughey, James); the Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alta. (James); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle, Ball, Dixon); the Department of Emergency Medicine, University of Calgary, Calgary, Alta. (McRae); the Mazankowski Alberta Heart Institute, Edmonton, Alta. (Graham); and the Department of Medicine, University of Alberta, Edmonton, Alta. (Graham, Hemmelgarn)
| | - Kelly B Zarnke
- From the Department of Medicine, University of Calgary, Calgary, Alta. (Harrison, James, Ruzycki, Zarnke, Hemmelgarn); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Harrison, James, Ronksley, Ruzycki, McRae, McCaughey, Dixon); the O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ronksley, Zarnke, McCaughey, James); the Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alta. (James); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle, Ball, Dixon); the Department of Emergency Medicine, University of Calgary, Calgary, Alta. (McRae); the Mazankowski Alberta Heart Institute, Edmonton, Alta. (Graham); and the Department of Medicine, University of Alberta, Edmonton, Alta. (Graham, Hemmelgarn)
| | - Deirdre McCaughey
- From the Department of Medicine, University of Calgary, Calgary, Alta. (Harrison, James, Ruzycki, Zarnke, Hemmelgarn); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Harrison, James, Ronksley, Ruzycki, McRae, McCaughey, Dixon); the O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ronksley, Zarnke, McCaughey, James); the Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alta. (James); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle, Ball, Dixon); the Department of Emergency Medicine, University of Calgary, Calgary, Alta. (McRae); the Mazankowski Alberta Heart Institute, Edmonton, Alta. (Graham); and the Department of Medicine, University of Alberta, Edmonton, Alta. (Graham, Hemmelgarn)
| | - Chad G Ball
- From the Department of Medicine, University of Calgary, Calgary, Alta. (Harrison, James, Ruzycki, Zarnke, Hemmelgarn); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Harrison, James, Ronksley, Ruzycki, McRae, McCaughey, Dixon); the O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ronksley, Zarnke, McCaughey, James); the Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alta. (James); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle, Ball, Dixon); the Department of Emergency Medicine, University of Calgary, Calgary, Alta. (McRae); the Mazankowski Alberta Heart Institute, Edmonton, Alta. (Graham); and the Department of Medicine, University of Alberta, Edmonton, Alta. (Graham, Hemmelgarn)
| | - Elijah Dixon
- From the Department of Medicine, University of Calgary, Calgary, Alta. (Harrison, James, Ruzycki, Zarnke, Hemmelgarn); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Harrison, James, Ronksley, Ruzycki, McRae, McCaughey, Dixon); the O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ronksley, Zarnke, McCaughey, James); the Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alta. (James); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle, Ball, Dixon); the Department of Emergency Medicine, University of Calgary, Calgary, Alta. (McRae); the Mazankowski Alberta Heart Institute, Edmonton, Alta. (Graham); and the Department of Medicine, University of Alberta, Edmonton, Alta. (Graham, Hemmelgarn)
| | - Brenda R Hemmelgarn
- From the Department of Medicine, University of Calgary, Calgary, Alta. (Harrison, James, Ruzycki, Zarnke, Hemmelgarn); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Harrison, James, Ronksley, Ruzycki, McRae, McCaughey, Dixon); the O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ronksley, Zarnke, McCaughey, James); the Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alta. (James); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle, Ball, Dixon); the Department of Emergency Medicine, University of Calgary, Calgary, Alta. (McRae); the Mazankowski Alberta Heart Institute, Edmonton, Alta. (Graham); and the Department of Medicine, University of Alberta, Edmonton, Alta. (Graham, Hemmelgarn)
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34
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Zhang PY, Becher H, Jeerakathil T, Graham MM, Shanks M. The incidence of stroke in patients with early echocardiography after acute myocardial infarction. Int J Cardiovasc Imaging 2021; 37:3423-3429. [PMID: 34251550 DOI: 10.1007/s10554-021-02333-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 06/25/2021] [Indexed: 01/03/2023]
Abstract
Left ventricular (LV) thrombus formation after ST-elevation myocardial infarction (STEMI) increases the risk of stroke. In our center, most echocardiograms are performed within 2 days post-STEMI. However, LV thrombi often become visible later. We assessed the 1-year incidence of stroke in patients without LV thrombus on echocardiography performed early (1-2 days) vs. later (day ≥ 3) post-STEMI. This retrospective observational study included 416 patients with acute STEMI. Patients with atrial fibrillation were excluded. All patients underwent echocardiography during admission. Patients with stroke within 12 months post-STEMI were identified from the hospital charts and administrative databases. Most echocardiograms (75%) were performed ≤ 2 days post-STEMI. LV thrombus was identified in 12 patients. One (8.3%) patient with LV thrombus and 10 (2.5%) patients without LV thrombus suffered stroke within 12 months post-STEMI. Most patients with stroke had apical akinesis. Most strokes occurred during the index admission or within 67 days of STEMI. There was no significant difference in the incidence of stroke between the patients with early vs. later echocardiography post-STEMI. The incidence of stroke after STEMI is low and similar between patients with echocardiography performed early vs. later post-STEMI which supports our current clinical practice. Importantly, most strokes occur in patients without LV thrombus on early echocardiography. High reported mortality rate associated with stroke following STEMI justifies the need for further validation in prospective studies to identify patients who may benefit from repeat imaging to detect later LV thrombus formation, and how this will impact patient outcomes and healthcare costs.
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Affiliation(s)
- Peter Yuan Zhang
- Division of Cardiology, Department of Medicine, 2C2 Walter Mackenzie Health Sciences Center, Mazankowski Alberta Heart Institute, University of Alberta, 8440-112 Street, Edmonton, AB, T6G 2B7, Canada
| | - Harald Becher
- Division of Cardiology, Department of Medicine, 2C2 Walter Mackenzie Health Sciences Center, Mazankowski Alberta Heart Institute, University of Alberta, 8440-112 Street, Edmonton, AB, T6G 2B7, Canada
| | - Thomas Jeerakathil
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Michelle M Graham
- Division of Cardiology, Department of Medicine, 2C2 Walter Mackenzie Health Sciences Center, Mazankowski Alberta Heart Institute, University of Alberta, 8440-112 Street, Edmonton, AB, T6G 2B7, Canada
| | - Miriam Shanks
- Division of Cardiology, Department of Medicine, 2C2 Walter Mackenzie Health Sciences Center, Mazankowski Alberta Heart Institute, University of Alberta, 8440-112 Street, Edmonton, AB, T6G 2B7, Canada.
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35
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Turgeon RD, Youngson E, Graham MM. Risk of Pneumonia with Ticagrelor Versus Clopidogrel: a Population-Based Cohort Study. J Gen Intern Med 2021; 36:2158-2160. [PMID: 32820419 PMCID: PMC8298709 DOI: 10.1007/s11606-020-06131-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 08/11/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Ricky D Turgeon
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Erik Youngson
- Alberta SPOR Support Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Michelle M Graham
- Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
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36
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Thompson S, Wiebe N, Arena R, Rouleau C, Aggarwal S, Wilton SB, Graham MM, Hemmelgarn B, James MT. Effectiveness and Utilization of Cardiac Rehabilitation Among People With CKD. Kidney Int Rep 2021; 6:1537-1547. [PMID: 34169194 PMCID: PMC8207316 DOI: 10.1016/j.ekir.2021.03.889] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 03/02/2021] [Accepted: 03/15/2021] [Indexed: 01/23/2023] Open
Abstract
Introduction Cardiac rehabilitation (CR) is a proven therapy for reducing cardiovascular death and hospitalization. Whether CR participation is associated with improved outcomes in patients with chronic kidney disease (CKD) is unknown. Methods We obtained data on all adult patients in Calgary, Alberta, Canada with angiographically proven coronary artery disease from 1996 to 2016 referred to CR from The Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease and TotalCardiology Rehabilitation. An estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2 or kidney replacement therapy defined CKD. Predictors of CR use were estimated with multinomial logistic regression. The association between starting versus not starting and completion versus noncompletion of CR and clinical outcomes were estimated using multivariable Cox proportional hazards models. Results Of 23,215 patients referred to CR, 12,084 were eligible for inclusion. Participants with CKD (N = 1322) were older, had more comorbidity, lower exercise capacity on graded treadmill testing, and took longer to be referred and to start CR than those without CKD. CKD predicted not starting CR: odds ratio 0.73 (95% confidence interval [CI] 0.64-0.83). Over a median 1 year follow-up, there were 146 deaths, 40 (0.3%) from CKD and 106 (1.0%) not from CKD. Similar to those without CKD, the risk of death was lower in CR completers (hazard ratio [HR] 0.24 [95% CI 0.06-0.91) and starters (HR 0.56 [95% CI 0.29- 1.10]) with CKD. Conclusion CR participation was associated with comparable benefits in people with moderate CKD as those without who survived to CR. Lower rates of CR attendance in this high-risk population suggest that strategies to increase CR utilization are needed.
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Affiliation(s)
- Stephanie Thompson
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Correspondence: Stephanie Thompson, Division of Nephrology and Immunology, University of Alberta, 11-112R CSB, 152 University Campus NW, University of Alberta, Edmonton, AB, T6G 2G3 Canada.
| | - Natasha Wiebe
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ross Arena
- Department of Physical Therapy, University of Illinois at Chicago, Chicago, Illinois, USA
- TotalCardiology Research Network, Calgary, Alberta, Canada
| | - Codie Rouleau
- TotalCardiology Research Network, Calgary, Alberta, Canada
- Department of Psychology, University of Calgary, Calgary, Alberta, Canada
| | - Sandeep Aggarwal
- TotalCardiology Research Network, Calgary, Alberta, Canada
- Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Stephen B. Wilton
- Libin Cardiovascular Institute of Alberta and O'Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michelle M. Graham
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
- Mazankowksi Alberta Heart Institute, Calgary, Alberta, Canada
| | - Brenda Hemmelgarn
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Matthew T. James
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
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Banks L, Randhawa VK, Colella TJF, Dhanvantari S, Connelly KA, Robinson L, Mak S, Ouzounian M, Mulvagh SL, Straus S, Allan K, Yin Yip CY, Graham MM. Cardiovascular Physicians, Scientists, and Trainees Balancing Work and Caregiving Responsibilities in the COVID-19 Era: Sex and Race-Based Inequities. CJC Open 2021; 3:627-630. [PMID: 34027367 PMCID: PMC8134915 DOI: 10.1016/j.cjco.2020.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/30/2020] [Indexed: 11/14/2022] Open
Abstract
Background The ongoing COVID-19 pandemic has exposed a work-life (im)balance that has been present but not openly discussed in medicine, surgery, and science for decades. The pandemic has exposed inequities in existing institutional structure and policies concerning clinical workload, research productivity, and/or teaching excellence inadvertently privileging those who do not have significant caregiving responsibilities or those who have the resources to pay for their management. Methods We sought to identify the challenges facing multidisciplinary faculty and trainees with dependents, and highlight a number of possible strategies to address challenges in work-life (im)balance. Results To date, there are no Canadian-based data to quantify the physical and mental effect of COVID-19 on health care workers, multidisciplinary faculty, and trainees. As the pandemic evolves, formal strategies should be discussed with an intersectional lens to promote equity in the workforce, including (but not limited to): (1) the inclusion of broad representation (including equal representation of women and other marginalized persons) in institutional-based pandemic response and recovery planning and decision-making; (2) an evaluation (eg, institutional-led survey) of the effect of the pandemic on work-life balance; (3) the establishment of formal dialogue (eg, workshops, training, and media campaigns) to normalize coexistence of work and caregiving responsibilities and to remove stigma of gender roles; (4) a reevaluation of workload and promotion reviews; and (5) the development of formal mentorship programs to support faculty and trainees. Conclusions We believe that a multistrategy approach needs to be considered by stakeholders (including policy-makers, institutions, and individuals) to create sustainable working conditions during and beyond this pandemic.
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Affiliation(s)
- Laura Banks
- Cardiovascular Prevention and Rehabilitation Program, University Health Network, Toronto, Ontario, Canada.,Faculty of Health Sciences, Ontario Tech University, Ontario, Canada
| | - Varinder K Randhawa
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tracey J F Colella
- Cardiovascular Prevention and Rehabilitation Program, University Health Network, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | | | - Kim A Connelly
- Department of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Lisa Robinson
- University of Toronto, Toronto, Ontario, Canada.,Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Susanna Mak
- University of Toronto, Toronto, Ontario, Canada.,Department of Cardiology, University Health Network, Toronto, Ontario, Canada
| | - Maral Ouzounian
- University of Toronto, Toronto, Ontario, Canada.,Department of Cardiothoracic Surgery, University Health Network, Toronto, Ontario, Canada
| | - Sharon L Mulvagh
- Division of Cardiology, Dalhousie University, Halifax, Ontario, Canada
| | - Sharon Straus
- University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, St Michael's Hospital, Toronto, Ontario, Canada
| | - Katherine Allan
- Department of Cardiology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Cindy Ying Yin Yip
- Project Management Institute, Toronto, Ontario, Canada.,HeartLife Foundation, British Columbia, Canada
| | - Michelle M Graham
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
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Rowe BH, McAlister FA, Graham MM, Holroyd BR, Rosychuk RJ. Despite Having Worse Risk Profiles, Northern Albertans Wait Longer for Specialist Follow-up After Emergency Department Visits for Atrial Fibrillation. CJC Open 2020; 2:610-618. [PMID: 33305221 PMCID: PMC7710999 DOI: 10.1016/j.cjco.2020.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/23/2020] [Indexed: 11/12/2022] Open
Abstract
Background Atrial fibrillation and flutter (AFF) are common arrhythmias diagnosed in the emergency department (ED), and prompt follow-up with specialists may yield better outcomes. This study examines time to first specialist outpatient visit following ED discharge for AFF. Methods Alberta residents aged ≥ 35 years with ED presentations for AFF ending in discharge during 2017-2018 were extracted and linked with hospitalizations and physician claims. A spatial scan and multinomial logistic regression were performed. Regression model predictors included demographics, prior diagnoses, and prior health service use. Results ED presentations for 4387 patients (54% male; mean age 68 years) were analyzed. Two geographic areas were identified as clusters that had longer times than would be expected by chance: a north cluster of northern areas with an estimated median time of 98 days (95% confidence interval [CI] 82,139), and an east cluster of eastern areas with a median of 57 days (95% CI 47, 68). Patients in the north cluster were more likely to be younger (adjusted odds ratio [aOR] = 0.76 per 5 years, 95% CI 0.62, 0.93) and have prior histories of AFF (aOR = 1.45, 95% CI 1.11, 1.90), congestive heart failure (aOR=1.51, 95% CI 1.15, 1.98), chronic obstructive pulmonary disease (aOR = 2.03, 95% CI 1.55, 2.65), and diabetes (aOR = 1.30, 95% CI 1.00, 1.67). They were less likely to have prior general practitioner outpatient visits (aOR = 0.65 per 5 visits, 95% CI 0.53, 0.81) and specialist outpatient visits (aOR = 0.39, 95% CI 0.30, 0.50) than other patients. Conclusions Despite being at higher risk, patients in northern areas took longer to see a specialist after an ED presentation for AFF than those from other regions. Innovative strategies for promoting specialist follow-up should be explored.
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Affiliation(s)
- Brian H Rowe
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada.,School of Public Health, University of Alberta, Edmonton, Alberta, Canada.,Institute of Circulatory and Respiratory Health, Canadian Institutes of Health Research, Ottawa, Ontario, Canada.,Alberta Health Services, Edmonton, Alberta, Canada
| | - Finlay A McAlister
- Alberta Health Services, Edmonton, Alberta, Canada.,Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Michelle M Graham
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Brian R Holroyd
- Department of Emergency Medicine, University of Alberta, Edmonton, Alberta, Canada.,Alberta Health Services, Edmonton, Alberta, Canada
| | - Rhonda J Rosychuk
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.,Women & Children's Health Research Institute, Edmonton, Alberta, Canada
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39
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Gouda P, Wang X, McGillion M, Graham MM. Underutilization of Perioperative Screening for Cardiovascular Events After Noncardiac Surgery in Alberta. Can J Cardiol 2020; 37:57-65. [PMID: 33309208 DOI: 10.1016/j.cjca.2020.06.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 06/02/2020] [Accepted: 06/02/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Perioperative myocardial injury after noncardiac surgery affects more than 10% of individuals, with increased morbidity and mortality. Perioperative cardiac risk assessment targets the identification of this high-risk population using preoperative natriuretic peptides and postoperative troponin measurements. Our objective was to assess the use of these biomarkers in the province of Alberta. METHODS A retrospective cohort of all patients who underwent noncardiac surgery in Alberta from January 2013 to December 2017 was created using linked provincial administrative databases. Inclusion criteria were modified from recommendations for perioperative cardiac screening including: patients with a Revised Cardiac Risk Index score ≥ 1 and age 65 years or older, or 45 years of age or older with history of cardiovascular disease, with planned overnight hospital stay. RESULTS In our cohort of 59,506 patients, only 6.8% underwent preoperative natriuretic peptide screening. Rates of appropriate preoperative natriuretic peptide testing increased marginally from 5.7% to 8.8% over the study period. Postoperative troponin was measured at least once in 19.5% of patients. Patients with elevated perioperative screening biomarkers showed increased 6-month mortality, and increased hospitalizations for heart failure and acute coronary syndromes. CONCLUSIONS The use of biomarkers to assist in cardiac risk stratification and postoperative monitoring remains low. Addressing access to these tests and improving physician education regarding the asymptomatic nature of postoperative cardiac events might improve compliance with national guidelines.
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Affiliation(s)
- Pishoy Gouda
- University of Alberta, Division of Cardiology and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Xiaoming Wang
- Research Facilitation, Alberta Health Services, Edmonton, Alberta, Canada
| | - Michael McGillion
- School of Nursing, Faculty of Health Sciences and Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Michelle M Graham
- University of Alberta, Division of Cardiology and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada.
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40
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Lawal OA, Awosoga O, Santana MJ, James MT, Southern DA, Wilton SB, Graham MM, Knudtson M, Lu M, Quan H, Ghali WA, Norris CM, Sajobi T. Psychometric evaluation of a Canadian version of the Seattle Angina Questionnaire (SAQ-CAN). Health Qual Life Outcomes 2020; 18:377. [PMID: 33261627 PMCID: PMC7706021 DOI: 10.1186/s12955-020-01627-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 11/16/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The Seattle Angina Questionnaire (SAQ) is a widely-used patient-reported outcomes measure in patients with heart disease. This study assesses the validity and reliability of the SAQ in a Canadian cohort of individuals with stable angina. METHODS AND RESULTS Data are from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) registry, a population-based registry of patients who received cardiac catheterization in Alberta, Canada. The cohort consists of 4052 patients undergoing cardiac catheterization for stable angina and completed the SAQ within 2 weeks. Exploratory factor analysis and confirmatory factor analysis (CFA) were used to assess the factorial structure of the SAQ. Internal and test-retest reliabilities of a new measure (i.e., SAQ-CAN) was measured using Cronbach α and intraclass correlation coefficient, respectively. CFA model fit was assessed using the root mean square error of approximation (RMSEA) and comparative fit index (CFI). Construct validity of the SAQ-CAN was assessed in relation to Hospital Anxiety and Depression Scales (HADS), Euro Quality of life 5 dimension (EQ5D), and original SAQ. Of the 4052 patients included in this analysis, 3281 (80.97%) were younger than 75 years old, while 3239 (79.94%) were male. Both exploratory and confirmatory factor analyses revealed a four-factorial structure consisting of 16 items that provided a better fit to the data (RMSEA = 0.049 [90% CI = (0.047, 0.052)]; CFI = 0.975). The 16-item SAQ demonstrated good to excellent internal reliability (Cronbach's α range from 0.77 to 0.90), moderate to strong correlation with the Original SAQ and EQ5D but negligible correlations with HADS. CONCLUSION The SAQ-CAN has acceptable psychometric properties that are comparable to the original SAQ. We recommend its use for assessing coronary health outcomes in Canadian patients with Coronary Artery Disease.
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Affiliation(s)
- Oluwaseyi A Lawal
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, Canada
| | | | - Maria J Santana
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, Canada
| | - Matthew T James
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, Canada
| | - Danielle A Southern
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, Canada
| | - Stephen B Wilton
- Department of Cardiac Sciences, University of Calgary, Calgary, Canada
| | - Michelle M Graham
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Merrill Knudtson
- Department of Cardiac Sciences, University of Calgary, Calgary, Canada
| | - Mingshan Lu
- Department of Economics, University of Calgary, Calgary, Canada
| | - Hude Quan
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, Canada
| | - William A Ghali
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, Canada
| | | | - Tolulope Sajobi
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, Canada.
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Natha J, Javaheri PA, Kruger D, Benterud E, Pearson W, Tan Z, Ma B, Tyrrell BD, Har BJ, Graham MM, James MT. Patient Experience After Risk Stratification and Follow-up for Acute Kidney Injury After Cardiac Catheterization: Patient Survey. CJC Open 2020; 3:337-344. [PMID: 33778450 PMCID: PMC7985009 DOI: 10.1016/j.cjco.2020.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 10/28/2020] [Indexed: 11/26/2022] Open
Abstract
Background Acute kidney injury (AKI) after cardiac catheterization procedures is associated with poor health outcomes. We sought to characterize the experiences of patients after receiving standardized information on their risk of AKI accompanied by instructions for follow-up care after cardiac catheterization. Methods We implemented an initiative across 3 cardiac catheterization units in Alberta, Canada to provide standardized assessment, followed by guidance for patients at risk of AKI. This was accompanied by communication to primary care providers to improve continuity of care when patients transition from the hospital to the community. A structured survey from a sample of 100 participants at increased risk of AKI determined their perceptions of information provided and experiences with follow-up steps after the initiative was implemented in each cardiac catheterization unit in Alberta. Results The mean age of participants was 72.4 (SD 10.4) years, 37% were female, and the mean risk of AKI was 8.8%. Most (63%) participants were able to recall the information provided to them about their risk of kidney injury, 68% recalled the education provided on strategies to reduce risk, and 65% believed their primary care practitioner had received enough information to conduct appropriate follow-up care. Eighty-six percent of patients were satisfied with their transition to the community, and 53% were reassured by the information and follow-up care they received. Conclusions These findings suggest that communicating risk information to patients, in combination with education and collaboration for follow-up with primary care providers, is associated with positive patient experiences and satisfaction with care.
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Affiliation(s)
- Jennifer Natha
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Pantea Amin Javaheri
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Denise Kruger
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Eleanor Benterud
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Winnie Pearson
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Zhi Tan
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Bryan Ma
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ben D Tyrrell
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,CK Hui Heart Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Bryan J Har
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michelle M Graham
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Heart Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Matthew T James
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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42
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Finlay J, Wilson T, Javaheri PA, Pearson W, Connolly C, Elliott MJ, Graham MM, Norris CM, Wilton SB, James MT. Patient and physician perspectives on shared decision-making for coronary procedures in people with chronic kidney disease: a patient-oriented qualitative study. CMAJ Open 2020; 8:E860-E868. [PMID: 33303572 PMCID: PMC7867031 DOI: 10.9778/cmajo.20200039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) and heart disease face challenging treatment decisions. We sought to explore the perceptions of patients and physicians about shared decision-making for coronary procedures for people with CKD, as well as opinions about strategies and tools to improve these decisions. METHODS We partnered with 4 patients with CKD and 1 caregiver to design and conduct a qualitative descriptive study using semi-structured interviews and content analysis. Patient participants with CKD and either acute coronary syndrome or cardiac catheterization in the preceding year were recruited from a provincial cardiac registry, cardiology wards and clinics in Calgary between March and September 2018. Cardiologists from the region also participated in the study. Data analysis emphasized identifying, organizing and describing themes found within the data. RESULTS Twenty patients with CKD and 10 cardiologists identified several complexities related to bidirectional information exchange needed for shared decision-making. Themes identified by both patients and physicians included challenges synthesizing best evidence, variable patient knowledge seeking, timeliness in the acute care setting and influence of roles on decision-making. Themes identified by physicians related to processes and tools to help support shared decision-making in this setting included personalization to reflect the variability of risks and heterogeneity of patient preferences as well as allowing for physicians to share their clinical judgment. INTERPRETATION There are complexities related to bidirectional information exchange between patients with CKD and their physicians for shared decision-making about coronary procedures. Processes and tools to facilitate shared decision-making in this setting require personalization and need to be time sensitive.
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Affiliation(s)
- Juli Finlay
- Departments of Medicine (Finlay, Javaheri, Pearson, Elliott, James), Community Health Sciences (Wilson, Wilton, James) and Cardiac Sciences (Connolly, Wilton), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Medicine (Graham), Faculty of Medicine & Dentistry, and Faculty of Nursing (Norris), University of Alberta, Edmonton, Alta
| | - Todd Wilson
- Departments of Medicine (Finlay, Javaheri, Pearson, Elliott, James), Community Health Sciences (Wilson, Wilton, James) and Cardiac Sciences (Connolly, Wilton), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Medicine (Graham), Faculty of Medicine & Dentistry, and Faculty of Nursing (Norris), University of Alberta, Edmonton, Alta
| | - Pantea Amin Javaheri
- Departments of Medicine (Finlay, Javaheri, Pearson, Elliott, James), Community Health Sciences (Wilson, Wilton, James) and Cardiac Sciences (Connolly, Wilton), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Medicine (Graham), Faculty of Medicine & Dentistry, and Faculty of Nursing (Norris), University of Alberta, Edmonton, Alta
| | - Winnie Pearson
- Departments of Medicine (Finlay, Javaheri, Pearson, Elliott, James), Community Health Sciences (Wilson, Wilton, James) and Cardiac Sciences (Connolly, Wilton), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Medicine (Graham), Faculty of Medicine & Dentistry, and Faculty of Nursing (Norris), University of Alberta, Edmonton, Alta
| | - Carol Connolly
- Departments of Medicine (Finlay, Javaheri, Pearson, Elliott, James), Community Health Sciences (Wilson, Wilton, James) and Cardiac Sciences (Connolly, Wilton), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Medicine (Graham), Faculty of Medicine & Dentistry, and Faculty of Nursing (Norris), University of Alberta, Edmonton, Alta
| | - Meghan J Elliott
- Departments of Medicine (Finlay, Javaheri, Pearson, Elliott, James), Community Health Sciences (Wilson, Wilton, James) and Cardiac Sciences (Connolly, Wilton), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Medicine (Graham), Faculty of Medicine & Dentistry, and Faculty of Nursing (Norris), University of Alberta, Edmonton, Alta
| | - Michelle M Graham
- Departments of Medicine (Finlay, Javaheri, Pearson, Elliott, James), Community Health Sciences (Wilson, Wilton, James) and Cardiac Sciences (Connolly, Wilton), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Medicine (Graham), Faculty of Medicine & Dentistry, and Faculty of Nursing (Norris), University of Alberta, Edmonton, Alta
| | - Colleen M Norris
- Departments of Medicine (Finlay, Javaheri, Pearson, Elliott, James), Community Health Sciences (Wilson, Wilton, James) and Cardiac Sciences (Connolly, Wilton), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Medicine (Graham), Faculty of Medicine & Dentistry, and Faculty of Nursing (Norris), University of Alberta, Edmonton, Alta
| | - Stephen B Wilton
- Departments of Medicine (Finlay, Javaheri, Pearson, Elliott, James), Community Health Sciences (Wilson, Wilton, James) and Cardiac Sciences (Connolly, Wilton), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Medicine (Graham), Faculty of Medicine & Dentistry, and Faculty of Nursing (Norris), University of Alberta, Edmonton, Alta
| | - Matthew T James
- Departments of Medicine (Finlay, Javaheri, Pearson, Elliott, James), Community Health Sciences (Wilson, Wilton, James) and Cardiac Sciences (Connolly, Wilton), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Medicine (Graham), Faculty of Medicine & Dentistry, and Faculty of Nursing (Norris), University of Alberta, Edmonton, Alta.
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O'Brien B, Graham MM. BSc nursing & midwifery students experiences of guided group reflection in fostering personal and professional development. Part 2. Nurse Educ Pract 2020; 48:102884. [PMID: 32971375 DOI: 10.1016/j.nepr.2020.102884] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 08/21/2020] [Accepted: 09/08/2020] [Indexed: 10/23/2022]
Abstract
Reflective practice is a learning strategy supporting preregistration nursing and midwifery students in meeting everyday clinical practice challenges. This paper reports on a development and innovation evaluation using a qualitative approach exploring students' experiences of guided group reflection organised during fourth year undergraduate internship. Data were collected through student feedback and interviews using a descriptive approach. Three categories emerged from the findings; beginnings for reflective learning, engaging in reflective learning and being a reflective practitioner. Students reported that guided group reflection provided positive opportunities for enhancing confidence. Students demonstrated understanding of reflection and valued reflective time within the closed group structure, which fostered personal and professional development. Findings support the benefits of the established collaborative guided group reflection structures. Guided group reflection is described as a valuable learning strategy on the journey of becoming a nurse in an ever-demanding health care practice world.
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Affiliation(s)
- B O'Brien
- Department of Nursing & Midwifery, University of Limerick, Ireland
| | - M M Graham
- Department of Nursing & Midwifery, University of Limerick, Ireland.
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Banks L, Randhawa VK, Caterini J, Colella TJF, Dhanvantari S, McMurtry S, Connelly KA, Robinson L, Anand SS, Ouzounian M, Zieroth S, Mak S, Straus S, Graham MM. Sex, Gender, and Equity in Cardiovascular Medicine, Surgery, and Science in Canada : Challenges, Successes, and Opportunities for Change. CJC Open 2020; 2:522-529. [PMID: 33305212 PMCID: PMC7711008 DOI: 10.1016/j.cjco.2020.06.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/29/2020] [Indexed: 01/01/2023] Open
Abstract
Background A previous review of sex, gender, and equity within cardiovascular (CV) medicine, surgery, and science in Canada has revealed parity during medical and graduate school training. The purpose of this study was to explore sex and gendered experiences within the Canadian CV landscape, and their impact on career training and progression. Methods An environmental scan was conducted of the Canadian CV landscape, which included an equity survey using Qualtrics software. Results The environmental scan revealed that women remain underrepresented within CV training programs as trainees (12%–30%), program directors (33%), in leadership roles at the divisional level (21%), and in other professional or career-related activities (< 30%). Our analysis also showed improvements of career engagement at these levels of women at over time. The thematic analysis of the equity survey responses (n = 71 respondents; 83% female; 9.7% response rate among female Canadian Cardiovascular Society members) identified the following themes reported within the socio-ecological framework: desire to report inequities vs staying the course (individual level); desire for social support and mentorship and challenges of dual responsibilities (interpersonal level); concerns over exclusionary cliques and desire for respect and opportunity (organizational level); and increasing awareness and actions to overcome institutional barriers and accountability (societal level). Conclusions Although women face challenges and remain underrepresented in CV medicine, surgery, and science, this study highlights potential opportunities for improving access of female medical, surgical, and research trainees and professionals to specialized cardiovascular training, career advancement, leadership, and research.
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Affiliation(s)
- Laura Banks
- Cardiovascular Prevention and Rehabilitation Program, University Health Network, Toronto, Ontario, Canada.,Faculty of Health Sciences, Ontario Tech University, Ontario, Canada
| | - Varinder K Randhawa
- Department of Cardiovascular Medicine, Kaufman Center for Heart Failure and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Tracey J F Colella
- Cardiovascular Prevention and Rehabilitation Program, University Health Network, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Savita Dhanvantari
- Imaging Program, Lawson Health Research Institute, London, Ontario, Canada
| | - Sean McMurtry
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Kim A Connelly
- Department of Cardiology, St Michaels Hospital, Toronto, Ontario, Canada
| | - Lisa Robinson
- University of Toronto, Toronto, Ontario, Canada.,Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sonia S Anand
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Maral Ouzounian
- University of Toronto, Toronto, Ontario, Canada.,Department of Cardiothoracic Surgery, University Health Network, Toronto, Ontario, Canada
| | - Shelley Zieroth
- Section of Cardiology, St Boniface Hospital, and University of Manitoba, Winnipeg, Canada
| | - Susanna Mak
- University of Toronto, Toronto, Ontario, Canada.,Department of Cardiology, University Health Network, Toronto, Ontario, Canada
| | - Sharon Straus
- Department of Medicine, St Michaels Hospital, Toronto, Ontario, Canada
| | - Michelle M Graham
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
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Harrison TG, Shukalek CB, Hemmelgarn BR, Zarnke KB, Ronksley PE, Iragorri N, Graham MM, James MT. Association of NT-proBNP and BNP With Future Clinical Outcomes in Patients With ESKD: A Systematic Review and Meta-analysis. Am J Kidney Dis 2020; 76:233-247. [PMID: 32387090 DOI: 10.1053/j.ajkd.2019.12.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 12/30/2019] [Indexed: 12/18/2022]
Abstract
RATIONALE & OBJECTIVE Use of brain natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) for cardiovascular (CV) risk assessment in patients with end-stage kidney disease (ESKD) remains unclear. We examined the associations between different threshold elevations of these peptide levels and clinical outcomes in patients with ESKD. STUDY DESIGN Systematic review and meta-analysis. SETTING & STUDY POPULATIONS We searched MEDLINE and EMBASE (through September 2019) for observational studies of adults with ESKD (estimated glomerular filtration rate≤15mL/min/1.73m2 or receiving maintenance dialysis). SELECTION CRITERIA FOR STUDIES Studies that reported NT-proBNP or BNP levels and future CV events, CV mortality, or all-cause mortality. DATA EXTRACTION Cohort characteristics and measures of risk associated with study-specified peptide thresholds. ANALYTICAL APPROACH Hazard ratios (HRs) for clinical outcomes associated with different NT-proBNP and BNP ranges were categorized into common thresholds and pooled using random-effects meta-analysis. RESULTS We identified 61 studies for inclusion in our review (19,688 people). 49 provided sufficient detail for inclusion in meta-analysis. Pooled unadjusted HRs for CV mortality were progressively greater for greater thresholds of NT-proBNP, from 1.45 (95% CI, 0.91-2.32) for levels>2,000pg/mL to 5.95 (95% CI, 4.23-8.37) for levels>15,000pg/mL. Risk for all-cause mortality was significantly higher at all NT-proBNP thresholds ranging from> 1,000 to> 20,000pg/mL (HR range, 1.53-4.00). BNP levels>550pg/mL were associated with increased risk for CV mortality (HR, 2.54; 95% CI, 1.49-4.33), while the risks for all-cause mortality were 2.04 (95% CI, 0.82-5.12) at BNP levels>100pg/mL and 2.97 (95% CI, 2.21-3.98) at BNP levels>550pg/mL. Adjusted analyses demonstrated similarly greater risks for CV and all-cause mortality with greater NT-proBNP concentrations. LIMITATIONS Incomplete outcome reporting and risk for outcome reporting bias. Estimation of risk for CV events for specific thresholds of both peptides were limited by poor precision. CONCLUSIONS ESKD-specific NT-proBNP and BNP level thresholds of elevation are associated with increased risk for CV and all-cause mortality. This information may help guide interpretation of NT-proBNP and BNP levels in patients with ESKD.
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Affiliation(s)
- Tyrone G Harrison
- Departments of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Caley B Shukalek
- Departments of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brenda R Hemmelgarn
- Departments of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kelly B Zarnke
- Departments of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul E Ronksley
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nicolas Iragorri
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michelle M Graham
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Matthew T James
- Departments of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Graham MM, Higginson L, Brindley PG, Jetly R. Feel Better, Work Better: The COVID-19 Perspective. Can J Cardiol 2020; 36:789-791. [PMID: 32360173 PMCID: PMC7161513 DOI: 10.1016/j.cjca.2020.04.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 04/13/2020] [Accepted: 04/13/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Michelle M Graham
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
| | - Lyall Higginson
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter G Brindley
- Department of Critical Care, University of Alberta, Edmonton, Alberta, Canada
| | - Rakesh Jetly
- Canadian Forces Health Services Group, Department of National Defence, Government of Canada, Edmonton, Alberta, and Ottawa, Ontario, Canada
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Turgeon RD, Koshman SL, Youngson E, Har B, Wilton SB, James MT, Graham MM. Association of Ticagrelor vs Clopidogrel With Major Adverse Coronary Events in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention. JAMA Intern Med 2020; 180:420-428. [PMID: 31930361 PMCID: PMC6990835 DOI: 10.1001/jamainternmed.2019.6447] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
IMPORTANCE Guidelines currently recommend ticagrelor over clopidogrel for patients with acute coronary syndrome (ACS) based on randomized clinical trial data in which ticagrelor reduced major adverse coronary events (MACE) vs clopidogrel but increased bleeding and dyspnea. OBJECTIVE To compare the risk of MACE with ticagrelor vs clopidogrel in patients with ACS treated with percutaneous coronary intervention (PCI), to compare major bleeding and dyspnea, and to evaluate the association between P2Y12 inhibitor adherence and MACE. DESIGN, SETTING, AND PARTICIPANTS Population-based cohort study using data of patients discharged alive after PCI for ACS from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry from April 1, 2012, to March 31, 2016, with follow-up to 1 year. Analysis began April 2018. EXPOSURES Outpatient prescription for ticagrelor or clopidogrel within 31 days after PCI. Adherence was defined as a medication refill adherence value of 80% or higher. MAIN OUTCOMES AND MEASURES Major adverse coronary events, a composite of all-cause death, hospitalization for ACS, unplanned coronary revascularization, or stent thrombosis within 365 days after index PCI. Secondary outcomes included hospitalization for major bleeding and emergency department visit for dyspnea. RESULTS Of 11 185 individuals who underwent PCI, the median (interquartile range) age was 61 (54-71) years, and 2760 (24.7%) were women. Ticagrelor users (4076 [36.4%]) were generally younger and had fewer cardiac and noncardiac comorbidities than clopidogrel users. Ticagrelor was not associated with lower risk of MACE (adjusted hazard ratio [aHR], 0.97; 95% CI, 0.85-1.10); however, it was associated with an increased risk of major bleeding (aHR, 1.51; 95% CI, 1.29-1.78) and dyspnea (aHR, 1.98; 95% CI, 1.47-2.65). A total of 3328 ticagrelor users (81.6%) were adherent during the study vs 5256 of clopidogrel users (73.9%) (P < .001; χ2 = 86.4). In the full cohort, adherence was associated with a lower MACE risk (aHR, 0.79; 95% CI, 0.69-0.90 for adherence of ≥80% vs <80%). Differences in other secondary outcomes were not statistically significant. Sensitivity and subgroup analyses were consistent with primary analyses. CONCLUSIONS AND RELEVANCE In this population-based cohort study of patients with ACS who underwent PCI, outpatient use of ticagrelor was not associated with a statistically significant reduction in MACE vs clopidogrel; however, it was associated with more major bleeding and dyspnea.
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Affiliation(s)
- Ricky D Turgeon
- Department of Pharmacy, Vancouver General Hospital, Vancouver, British Columbia, Canada.,Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sheri L Koshman
- Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Erik Youngson
- Alberta SPOR Support Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Bryan Har
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Stephen B Wilton
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Matthew T James
- Division of Nephrology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michelle M Graham
- Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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Azzalini L, Chabot-Blanchet M, Southern DA, Nozza A, Wilton SB, Graham MM, Gravel GM, Bluteau JP, Rouleau JL, Guertin MC, Jolicoeur EM. A disease-specific comorbidity index for predicting mortality in patients admitted to hospital with a cardiac condition. CMAJ 2019; 191:E299-E307. [PMID: 30885968 DOI: 10.1503/cmaj.181186] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Comorbidity indexes derived from administrative databases are essential tools of research in global health. We sought to develop and validate a novel cardiac-specific comorbidity index, and to compare its accuracy with the generic Charlson-Deyo and Elixhauser comorbidity indexes. METHODS We derived the cardiac-specific comorbidity index from consecutive patients who were admitted to hospital at a tertiary-care cardiology hospital in Quebec. We used logistic regression analysis and incorporated age, sex and 22 clinically relevant comorbidities to build the index. We compared the cardiac-specific comorbidity index with refitted Charlson-Deyo and Elixhauser comorbidity indexes using the C-statistic and net reclassification improvement to predict in-hospital death, and the Akaike information criterion to predict length of stay. We validated our findings externally in an independent cohort obtained from a provincial registry of coronary disease in Alberta. RESULTS The novel cardiac-specific comorbidity index outperformed the refitted generic Charlson-Deyo and Elixhauser comorbidity indexes for predicting in-hospital mortality in the derivation population (n = 10 137): C-statistic 0.95 (95% confidence interval [CI] 0.94-0.9) v. 0.81 (95% CI 0.77-0.84) and 0.86 (95% CI 0.82-0.89), respectively. In the validation population (n = 17 877), the cardiac-specific comorbidity index was similarly better: C-statistic 0.92 (95% CI 0.89-0.94) v. 0.76 (95% CI 0.71-0.81) and 0.82 (95% CI 0.78-0.86), respectively, and also numerically outperformed the Charlson-Deyo and Elixhauser comorbidity indexes for predicting 1-year mortality (C-statistic 0.78 [95% CI 0.76-0.80] v. 0.75 [95% CI 0.73-0.77] and 0.77 [95% CI 0.75-0.79], respectively). Similarly, the cardiac-specific comorbidity index showed better fit for the prediction of length of stay. The net reclassification improvement using the cardiac-specific comorbidity index for the prediction of death was 0.290 compared with the Charlson-Deyo comorbidity index and 0.192 compared with the Elixhauser comorbidity index. INTERPRETATION The cardiac-specific comorbidity index predicted in-hospital and 1-year death and length of stay in cardiovascular populations better than existing generic models. This novel index may be useful for research of cardiology outcomes performed with large administrative databases.
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Affiliation(s)
- Lorenzo Azzalini
- Department of Medicine (Azzalini, Marquis Gravel, Rouleau, Jolicoeur), Montreal Heart Institute, Université de Montréal; Montreal Health Innovations Coordinating Center (Chabot-Blanchet, Guertin); Centre Intégré Universitaire de Santé et de Services Sociaux du Centre-Sud-de-l'île-de-Montréal (Bluteau), Montréal, Que.; O'Brien Institute for Public Health (Southern), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Libin Cardiovascular Institute of Alberta, Departments of Cardiac Sciences and Community Health Sciences (Wilton), University of Calgary, Calgary, Alta.; Department of Medicine, University of Alberta and Mazankowski Alberta Heart Institute (Graham), Edmonton, Alta.; Interventional Cardiology Unit, Cardio-Thoraco-Vascular Department (Azzalini), San Raffaele Scientific Institute, Milan, Italy
| | - Malorie Chabot-Blanchet
- Department of Medicine (Azzalini, Marquis Gravel, Rouleau, Jolicoeur), Montreal Heart Institute, Université de Montréal; Montreal Health Innovations Coordinating Center (Chabot-Blanchet, Guertin); Centre Intégré Universitaire de Santé et de Services Sociaux du Centre-Sud-de-l'île-de-Montréal (Bluteau), Montréal, Que.; O'Brien Institute for Public Health (Southern), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Libin Cardiovascular Institute of Alberta, Departments of Cardiac Sciences and Community Health Sciences (Wilton), University of Calgary, Calgary, Alta.; Department of Medicine, University of Alberta and Mazankowski Alberta Heart Institute (Graham), Edmonton, Alta.; Interventional Cardiology Unit, Cardio-Thoraco-Vascular Department (Azzalini), San Raffaele Scientific Institute, Milan, Italy
| | - Danielle A Southern
- Department of Medicine (Azzalini, Marquis Gravel, Rouleau, Jolicoeur), Montreal Heart Institute, Université de Montréal; Montreal Health Innovations Coordinating Center (Chabot-Blanchet, Guertin); Centre Intégré Universitaire de Santé et de Services Sociaux du Centre-Sud-de-l'île-de-Montréal (Bluteau), Montréal, Que.; O'Brien Institute for Public Health (Southern), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Libin Cardiovascular Institute of Alberta, Departments of Cardiac Sciences and Community Health Sciences (Wilton), University of Calgary, Calgary, Alta.; Department of Medicine, University of Alberta and Mazankowski Alberta Heart Institute (Graham), Edmonton, Alta.; Interventional Cardiology Unit, Cardio-Thoraco-Vascular Department (Azzalini), San Raffaele Scientific Institute, Milan, Italy
| | - Anna Nozza
- Department of Medicine (Azzalini, Marquis Gravel, Rouleau, Jolicoeur), Montreal Heart Institute, Université de Montréal; Montreal Health Innovations Coordinating Center (Chabot-Blanchet, Guertin); Centre Intégré Universitaire de Santé et de Services Sociaux du Centre-Sud-de-l'île-de-Montréal (Bluteau), Montréal, Que.; O'Brien Institute for Public Health (Southern), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Libin Cardiovascular Institute of Alberta, Departments of Cardiac Sciences and Community Health Sciences (Wilton), University of Calgary, Calgary, Alta.; Department of Medicine, University of Alberta and Mazankowski Alberta Heart Institute (Graham), Edmonton, Alta.; Interventional Cardiology Unit, Cardio-Thoraco-Vascular Department (Azzalini), San Raffaele Scientific Institute, Milan, Italy
| | - Stephen B Wilton
- Department of Medicine (Azzalini, Marquis Gravel, Rouleau, Jolicoeur), Montreal Heart Institute, Université de Montréal; Montreal Health Innovations Coordinating Center (Chabot-Blanchet, Guertin); Centre Intégré Universitaire de Santé et de Services Sociaux du Centre-Sud-de-l'île-de-Montréal (Bluteau), Montréal, Que.; O'Brien Institute for Public Health (Southern), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Libin Cardiovascular Institute of Alberta, Departments of Cardiac Sciences and Community Health Sciences (Wilton), University of Calgary, Calgary, Alta.; Department of Medicine, University of Alberta and Mazankowski Alberta Heart Institute (Graham), Edmonton, Alta.; Interventional Cardiology Unit, Cardio-Thoraco-Vascular Department (Azzalini), San Raffaele Scientific Institute, Milan, Italy
| | - Michelle M Graham
- Department of Medicine (Azzalini, Marquis Gravel, Rouleau, Jolicoeur), Montreal Heart Institute, Université de Montréal; Montreal Health Innovations Coordinating Center (Chabot-Blanchet, Guertin); Centre Intégré Universitaire de Santé et de Services Sociaux du Centre-Sud-de-l'île-de-Montréal (Bluteau), Montréal, Que.; O'Brien Institute for Public Health (Southern), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Libin Cardiovascular Institute of Alberta, Departments of Cardiac Sciences and Community Health Sciences (Wilton), University of Calgary, Calgary, Alta.; Department of Medicine, University of Alberta and Mazankowski Alberta Heart Institute (Graham), Edmonton, Alta.; Interventional Cardiology Unit, Cardio-Thoraco-Vascular Department (Azzalini), San Raffaele Scientific Institute, Milan, Italy
| | - Guillaume Marquis Gravel
- Department of Medicine (Azzalini, Marquis Gravel, Rouleau, Jolicoeur), Montreal Heart Institute, Université de Montréal; Montreal Health Innovations Coordinating Center (Chabot-Blanchet, Guertin); Centre Intégré Universitaire de Santé et de Services Sociaux du Centre-Sud-de-l'île-de-Montréal (Bluteau), Montréal, Que.; O'Brien Institute for Public Health (Southern), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Libin Cardiovascular Institute of Alberta, Departments of Cardiac Sciences and Community Health Sciences (Wilton), University of Calgary, Calgary, Alta.; Department of Medicine, University of Alberta and Mazankowski Alberta Heart Institute (Graham), Edmonton, Alta.; Interventional Cardiology Unit, Cardio-Thoraco-Vascular Department (Azzalini), San Raffaele Scientific Institute, Milan, Italy
| | - Jean-Pierre Bluteau
- Department of Medicine (Azzalini, Marquis Gravel, Rouleau, Jolicoeur), Montreal Heart Institute, Université de Montréal; Montreal Health Innovations Coordinating Center (Chabot-Blanchet, Guertin); Centre Intégré Universitaire de Santé et de Services Sociaux du Centre-Sud-de-l'île-de-Montréal (Bluteau), Montréal, Que.; O'Brien Institute for Public Health (Southern), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Libin Cardiovascular Institute of Alberta, Departments of Cardiac Sciences and Community Health Sciences (Wilton), University of Calgary, Calgary, Alta.; Department of Medicine, University of Alberta and Mazankowski Alberta Heart Institute (Graham), Edmonton, Alta.; Interventional Cardiology Unit, Cardio-Thoraco-Vascular Department (Azzalini), San Raffaele Scientific Institute, Milan, Italy
| | - Jean-Lucien Rouleau
- Department of Medicine (Azzalini, Marquis Gravel, Rouleau, Jolicoeur), Montreal Heart Institute, Université de Montréal; Montreal Health Innovations Coordinating Center (Chabot-Blanchet, Guertin); Centre Intégré Universitaire de Santé et de Services Sociaux du Centre-Sud-de-l'île-de-Montréal (Bluteau), Montréal, Que.; O'Brien Institute for Public Health (Southern), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Libin Cardiovascular Institute of Alberta, Departments of Cardiac Sciences and Community Health Sciences (Wilton), University of Calgary, Calgary, Alta.; Department of Medicine, University of Alberta and Mazankowski Alberta Heart Institute (Graham), Edmonton, Alta.; Interventional Cardiology Unit, Cardio-Thoraco-Vascular Department (Azzalini), San Raffaele Scientific Institute, Milan, Italy
| | - Marie-Claude Guertin
- Department of Medicine (Azzalini, Marquis Gravel, Rouleau, Jolicoeur), Montreal Heart Institute, Université de Montréal; Montreal Health Innovations Coordinating Center (Chabot-Blanchet, Guertin); Centre Intégré Universitaire de Santé et de Services Sociaux du Centre-Sud-de-l'île-de-Montréal (Bluteau), Montréal, Que.; O'Brien Institute for Public Health (Southern), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Libin Cardiovascular Institute of Alberta, Departments of Cardiac Sciences and Community Health Sciences (Wilton), University of Calgary, Calgary, Alta.; Department of Medicine, University of Alberta and Mazankowski Alberta Heart Institute (Graham), Edmonton, Alta.; Interventional Cardiology Unit, Cardio-Thoraco-Vascular Department (Azzalini), San Raffaele Scientific Institute, Milan, Italy
| | - E Marc Jolicoeur
- Department of Medicine (Azzalini, Marquis Gravel, Rouleau, Jolicoeur), Montreal Heart Institute, Université de Montréal; Montreal Health Innovations Coordinating Center (Chabot-Blanchet, Guertin); Centre Intégré Universitaire de Santé et de Services Sociaux du Centre-Sud-de-l'île-de-Montréal (Bluteau), Montréal, Que.; O'Brien Institute for Public Health (Southern), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Libin Cardiovascular Institute of Alberta, Departments of Cardiac Sciences and Community Health Sciences (Wilton), University of Calgary, Calgary, Alta.; Department of Medicine, University of Alberta and Mazankowski Alberta Heart Institute (Graham), Edmonton, Alta.; Interventional Cardiology Unit, Cardio-Thoraco-Vascular Department (Azzalini), San Raffaele Scientific Institute, Milan, Italy
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Ma B, Allen DW, Graham MM, Har BJ, Tyrrell B, Tan Z, Spertus JA, Brown JR, Matheny ME, Hemmelgarn BR, Pannu N, James MT. Comparative Performance of Prediction Models for Contrast-Associated Acute Kidney Injury After Percutaneous Coronary Intervention. Circ Cardiovasc Qual Outcomes 2019; 12:e005854. [PMID: 31722540 DOI: 10.1161/circoutcomes.119.005854] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Identifying patients at increased risk of contrast-associated acute kidney injury (CA-AKI) can help target risk mitigation strategies toward these individuals during percutaneous coronary intervention. Illuminating which risk models best stratify risk is an important foundation for such quality improvement efforts. METHODS AND RESULTS Seven previously published risk prediction models for CA-AKI and 3 models for kidney injury requiring dialysis were validated using 2 definitions for CA-AKI (the Kidney Disease: Improving Global Outcomes definition of ≥0.3 mg/dL within 48 hours or ≥50% increase in serum creatinine from baseline within 7 days and the historical definition of ≥0.5 mg/dL or ≥25% increase in serum creatinine from baseline within 48 hours), and AKI requiring dialysis within 30 days of percutaneous coronary intervention. Model performance was compared based on discrimination, calibration, and categorical net reclassification index before and after model recalibration. Among 7888 patients who underwent percutaneous coronary intervention in Alberta Canada, CA-AKI occurred in 330 patients (4.2%) when CA-AKI was defined using the Kidney Disease: Improving Global Outcomes definition and 571 (7.3%) when using the historical definition. CA-AKI requiring dialysis occurred in 42 (0.6%) patients. When validated using the Kidney Disease: Improving Global Outcomes definition for CA-AKI, the 2 most recently published models for CA-AKI showed better discrimination (C statistics, 0.75-0.76) than older models (C statistics, 0.61-0.68). C statistics of models for kidney injury requiring dialysis ranged from 0.70 to 0.86. The calibration of all models for CA-AKI deviated from ideal, and the proportion of patients classified into different risk categories for CA-AKI differed substantially for the 2 most recent models. Recalibration significantly improved risk stratification of patients into clinical risk categories for some models. CONCLUSIONS Recent prediction models for CA-AKI show better discrimination compared with older models; however, model recalibration should be examined in external cohorts to improve the accuracy of predictions, particularly if predicted risk strata are used to guide management approaches.
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Affiliation(s)
- Bryan Ma
- Department of Medicine (B.M., Z.T., B.R.H., M.T.J.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - David W Allen
- Department of Cardiac Sciences, University of Manitoba, Winnipeg, Canada (D.W.A.)
| | - Michelle M Graham
- Department of Medicine, Faculty of Medicine, Mazinkowski Alberta Heart Institute, University of Alberta, Canada (M.M.G., B.T., N.P.)
| | - Bryan J Har
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta (B.J.H.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Ben Tyrrell
- Department of Medicine, Faculty of Medicine, Mazinkowski Alberta Heart Institute, University of Alberta, Canada (M.M.G., B.T., N.P.)
| | - Zhi Tan
- Department of Medicine (B.M., Z.T., B.R.H., M.T.J.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - John A Spertus
- Departments of Biomedical and Health Informatics, University of Missouri-Kansas City, Saint Luke's Mid America Heart Institute (J.A.S.)
| | - Jeremiah R Brown
- The Dartmouth Institute for Health Policy and Clinical Practice, Departments of Epidemiology and Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, NH (J.R.B.)
| | - Michael E Matheny
- Department of Biomedical Informatics, Vanderbilt University, Nashville, TN (M.E.M.)
| | - Brenda R Hemmelgarn
- Department of Medicine (B.M., Z.T., B.R.H., M.T.J.), Cumming School of Medicine, University of Calgary, Alberta, Canada.,Department of Medicine, Department of Community Health Sciences, O'Brien Institute for Public Health, Libin Cardiovascular Institute of Alberta (B.R.H., M.T.J.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Neesh Pannu
- Department of Medicine, Faculty of Medicine, Mazinkowski Alberta Heart Institute, University of Alberta, Canada (M.M.G., B.T., N.P.)
| | - Matthew T James
- Department of Medicine (B.M., Z.T., B.R.H., M.T.J.), Cumming School of Medicine, University of Calgary, Alberta, Canada.,Department of Medicine, Department of Community Health Sciences, O'Brien Institute for Public Health, Libin Cardiovascular Institute of Alberta (B.R.H., M.T.J.), Cumming School of Medicine, University of Calgary, Alberta, Canada
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van Diepen S, Norris CM, Zheng Y, Nagendran J, Graham MM, Gaete Ortega D, Townsend DR, Ezekowitz JA, Bagshaw SM. Comparison of Angiotensin-Converting Enzyme Inhibitor and Angiotensin Receptor Blocker Management Strategies Before Cardiac Surgery: A Pilot Randomized Controlled Registry Trial. J Am Heart Assoc 2019; 7:e009917. [PMID: 30371293 PMCID: PMC6474971 DOI: 10.1161/jaha.118.009917] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Postoperative clinical outcomes associated with the preoperative continuation or discontinuation of angiotensin‐converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) before cardiac surgery remain unclear. Methods and Results In a single‐center, open‐label, randomized, registry‐based clinical trial, patients undergoing nonemergent cardiac surgery were assigned to ACEI/ARB continuation or discontinuation 2 days before surgery. Among the 584 patients screened, 261 met study criteria and 126 (48.3%) patients were enrolled. In total,121 patients (96% adherence; 60 to continuation and 61 to ACEI/ARB discontinuation) underwent surgery and completed the study protocol, and follow‐up was 100% complete. Postoperative intravenous vasopressor use (78.3% versus 75.4%, P=0.703), vasodilator use (71.7% versus 80.3%, P=0.265), vasoplegic shock (31.7% versus 27.9%, P=0.648), median duration of vasopressor (10 versus 5 hours, P=0.494), and vasodilator requirements (10 versus 9 hours, P=0.469) were not significantly different between the continuation and discontinuation arms. No differences were observed in the incidence of acute kidney injury (1.7% versus 1.6%, P=0.991), stroke (no events, mortality (1.7% versus 1.6%, P=0.991), median duration of mechanical ventilation (6 versus 6 hours, P=0.680), and median intensive care unit length of stay (43 versus 27 hours, P=0.420) between the treatment arms. Conclusions A randomized study evaluating the routine continuation or discontinuation of ACEIs or ARBs before cardiac surgery was feasible, and treatment assignment was not associated with differences in postoperative physiological or clinical outcomes. These preliminary findings suggest that preoperative ACEI/ARB management strategies did not affect the postoperative course of patients undergoing cardiac surgery. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02096406.
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Affiliation(s)
- Sean van Diepen
- 1 Department of Critical Care Medicine Faculty of Medicine and Dentistry University of Alberta Edmonton Alberta Canada.,2 Division of Cardiology Department of Medicine University of Alberta Edmonton Alberta Canada.,3 Canadian VIGOUR Center University of Alberta Edmonton Alberta Canada
| | - Colleen M Norris
- 1 Department of Critical Care Medicine Faculty of Medicine and Dentistry University of Alberta Edmonton Alberta Canada.,4 Division of Cardiac Surgery University of Alberta Hospital Edmonton Alberta Canada.,5 Faculty of Nursing University of Alberta Edmonton Alberta Canada
| | - Yinggan Zheng
- 3 Canadian VIGOUR Center University of Alberta Edmonton Alberta Canada
| | - Jayan Nagendran
- 4 Division of Cardiac Surgery University of Alberta Hospital Edmonton Alberta Canada
| | - Michelle M Graham
- 2 Division of Cardiology Department of Medicine University of Alberta Edmonton Alberta Canada
| | - Damaris Gaete Ortega
- 1 Department of Critical Care Medicine Faculty of Medicine and Dentistry University of Alberta Edmonton Alberta Canada
| | - Derek R Townsend
- 1 Department of Critical Care Medicine Faculty of Medicine and Dentistry University of Alberta Edmonton Alberta Canada
| | - Justin A Ezekowitz
- 2 Division of Cardiology Department of Medicine University of Alberta Edmonton Alberta Canada.,3 Canadian VIGOUR Center University of Alberta Edmonton Alberta Canada
| | - Sean M Bagshaw
- 1 Department of Critical Care Medicine Faculty of Medicine and Dentistry University of Alberta Edmonton Alberta Canada
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