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Purpose: Cardiogenic shock secondary to acute myocardial infarction (AMI-CS) is associated with substantial short- and long-term morbidity and mortality. However, there are limited data on mental health sequelae that survivors experience following discharge. Methods: We conducted a retrospective, population-based cohort study in Ontario, Canada of critically ill adult (≥ 18 years) survivors of AMI-CS, admitted to hospital between April 1, 2009 and March 31, 2019. We compared these patients to AMI survivors without shock. We captured outcome data using linked health administrative databases. The primary outcome was a new mental health diagnosis (a composite of mood, anxiety, or related disorders; schizophrenia/psychotic disorders; and other mental health disorders) following hospital discharge. We secondarily evaluated incidence of deliberate self-harm and death by suicide. We compared patients using overlap propensity score-weighted, cause-specific proportional hazard models. Results: We included 7812 consecutive survivors of AMI-CS, from 135 centers. Mean age was 68.4 (standard deviation (SD) 12.2) years, and 70.3% were male. Median follow-up time was 767 days (interquartile range (IQR) 225–1682). Incidence of new mental health diagnosis among AMI-CS survivors was 109.6 per 1,000 person-years (95% confidence interval (CI) 105.4–113.9), compared with 103.8 per 1000 person-years (95% CI 102.5–105.2) among AMI survivors without shock. After propensity score adjustment, there was no difference in the risk of new mental health diagnoses following discharge [hazard ratio (HR) 0.99 (95% CI 0.94–1.03)]. Factors associated with new mental health diagnoses following AMI-CS included female sex, pre-existing mental health diagnoses, and discharge to a long-term hospital or rehabilitation institute. Conclusion: Survivors of AMI-CS experience substantial mental health morbidity following discharge. Risk of new mental health diagnoses was comparable between survivors of AMI with and without shock. Future research on interventions to mitigate psychiatric sequelae after AMI-CS is warranted. [ABSTRACT FROM AUTHOR]

Background: Methods to accurately predict the risk of in-hospital mortality are important for applications including quality assessment of healthcare institutions and research. Objective: To update and validate the Kaiser Permanente inpatient risk adjustment methodology (KP method) to predict in-hospital mortality, using open-source tools to measure comorbidity and diagnosis groups, and removing troponin which is difficult to standardize across modern clinical assays. Design: Retrospective cohort study using electronic health record data from GEMINI. GEMINI is a research collaborative that collects administrative and clinical data from hospital information systems. Participants: Adult general medicine inpatients at 28 hospitals in Ontario, Canada, between April 2010 and December 2022. Main Measures: The outcome was in-hospital mortality, modeled by diagnosis group using 56 logistic regressions. We compared models with and without troponin as an input to the laboratory-based acute physiology score. We fit and validated the updated method using internal-external cross-validation at 28 hospitals from April 2015 to December 2022. Key Results: In 938,103 hospitalizations with 7.2% in-hospital mortality, the updated KP method accurately predicted the risk of mortality. The c-statistic at the median hospital was 0.866 (see Fig. 3) (25th–75th 0.848–0.876, range 0.816–0.927) and calibration was strong for nearly all patients at all hospitals. The 95th percentile absolute difference between predicted and observed probabilities was 0.038 at the median hospital (25th–75th 0.024–0.057, range 0.006–0.118). Model performance was very similar with and without troponin in a subset of 7 hospitals, and performance was similar with and without troponin for patients hospitalized for heart failure and acute myocardial infarction. Conclusions: An update to the KP method accurately predicted in-hospital mortality for general medicine inpatients in 28 hospitals in Ontario, Canada. This updated method can be implemented in a wider range of settings using common open-source tools. [ABSTRACT FROM AUTHOR]

Cardiogenic shock secondary to acute myocardial infarction (AMI-CS) is associated with substantial short-term mortality; however, there are limited data on long-term outcomes and trends. This study sought to examine long-term outcomes of AMI-CS patients. This was a population-based, retrospective cohort study in Ontario, Canada of critically ill adult patients with AMI-CS who were admitted to hospitals between April 1, 2009 and March 31, 2019. Outcome data were captured using linked health administrative databases. A total of 9,789 consecutive patients with AMI-CS from 135 centers were included. The mean age was 70.5 ± 12.3 years, and 67.7% were male. The incidence of AMI-CS was 8.2 per 100,000 person-years, and it increased over the study period. Critical care interventions were common, with 5,422 (55.4%) undergoing invasive mechanical ventilation, 1,425 (14.6%) undergoing renal replacement therapy, and 1,484 (15.2%) receiving mechanical circulatory support. A total of 2,961 patients (30.2%) died in the hospital, and 4,004 (40.9%) died by 1 year. Mortality at 5 years was 58.9%. Small improvements in short- and long-term mortality were seen over the study period. Among survivors to discharge, 2,870 (42.0%) required increased support in care from their preadmission baseline, 3,244 (47.5%) were readmitted to the hospital within 1 year, and 1,047 (15.3%) died within 1 year. The mean number of days at home in the year following discharge was 307.9 ± 109.6. Short- and long-term mortality among patients with AMI-CS is high, with minimal improvement over time. AMI-CS survivors experience significant morbidity, with high risks of readmission and death. Future studies should evaluate interventions to minimize postdischarge morbidity and mortality among AMI-CS survivors. [Display omitted] [ABSTRACT FROM AUTHOR]

Background: Outcomes of diabetes screening in contemporary, multi-ethnic populations are unknown. We examined the association of prior outpatient diabetes screening with the risks of cardiovascular events and mortality in Ontario, Canada. Methods: We conducted a population-based cohort study using administrative databases among adults aged ≥ 20 years with incident diabetes diagnosed during 2014–2016. The exposure was outpatient diabetes screening performed within 3 years prior to diabetes diagnosis. The co-primary outcomes were (1) a composite of all-cause mortality and hospitalization for myocardial infarction, stroke, coronary revascularization, and (2) all-cause mortality (followed up until 2018). We calculated standardized rates of each outcome and conducted cause-specific hazard modelling to determine the adjusted hazard ratio (HR) of the outcomes, adjusting for prespecified confounders and accounting for the competing risk of death. Results: We included 178,753 Ontarians with incident diabetes (70.2% previously screened). Individuals receiving prior screening were older (58.3 versus 53.4 years) and more likely to be women (49.6% versus 40.0%) than previously unscreened individuals. Individuals receiving prior screening had relatively lower standardized event rates than those without prior screening across all outcomes (composite: 12.8 versus 18.1, mortality: 8.2 versus 11.1 per 1000 patient-years). After multivariable adjustment, prior screening was associated with 34% and 32% lower risks of the composite (HR 0.66, 0.63–0.69) and mortality (0.68, 0.64–0.72) outcomes. Among those receiving prior screening, a result in the prediabetes range was associated with lower risks of the composite (0.82, 0.77–0.88) and mortality (0.71, 0.66–0.78) outcomes than a result in the normoglycemic range. Conclusions: Previously screened individuals with diabetes had lower risks of cardiovascular events and mortality versus previously unscreened individuals. Better risk assessment tools are needed to support wider and more appropriate uptake of diabetes screening, especially among young adults. [ABSTRACT FROM AUTHOR]

Previous studies have failed to show a cardioprotective benefit of beta-blockers in patients with stable coronary artery disease (CAD). This study sought to determine the association between beta-blockers and cardiovascular events in patients with stable CAD using a new user design. All patients aged >66 years undergoing elective coronary angiography in Ontario, Canada, from 2009 to 2019 with diagnosed obstructive CAD were included. Exclusion criteria included heart failure or a recent myocardial infarction, as well as having a beta-blocker prescription claim in the previous year. Beta-blocker use was defined as having at least 1 beta-blocker prescription claim in the 90 days preceding or after the index coronary angiography. The main outcome was a composite of all-cause mortality and hospitalization for heart failure or myocardial infarction. Inverse probability of treatment weighting using the propensity score was used to account for confounding. This study included 28,039 patients (mean age: 73.0 ± 5.6 years; 66.2% male), and 12,695 of those (45.3%) were newly prescribed beta-blockers. The 5-year risks of the primary outcome were 14.3% in the beta-blocker group and 16.1% in the no beta-blocker group (absolute risk reduction: −1.8%; 95% CI: −2.8 to −0.8; HR: 0.92; 95% CI: 0.86-0.98 ; P = 0.006). This result was driven by reductions in myocardial infarction hospitalization (cause-specific HR: 0.87; 95% CI: 0.77-0.99 ; P = 0.031), whereas no differences were observed in all-cause death or heart failure hospitalization. In patients with angiographically documented stable CAD without heart failure or a recent myocardial infarction, beta-blockers were associated with a small but significant reduction in cardiovascular events at 5 years. [Display omitted] [ABSTRACT FROM AUTHOR]

Background: Multicentric approaches are widely used in clinical trials to assess the generalizability of findings, however, they are novel in laboratory-based experimentation. It is unclear how multilaboratory studies may differ in conduct and results from single lab studies. Here, we synthesized the characteristics of these studies and quantitatively compared their outcomes to those generated by single laboratory studies. Methods: MEDLINE and Embase were systematically searched. Screening and data extractions were completed in duplicate by independent reviewers. Multilaboratory studies investigating interventions using in vivo animal models were included. Study characteristics were extracted. Systematic searches were then performed to identify single lab studies matched by intervention and disease. Difference in standardized mean differences (DSMD) was then calculated across studies to assess differences in effect estimates based on study design (>0 indicates larger effects in single lab studies). Results: Sixteen multilaboratory studies met inclusion criteria and were matched to 100 single lab studies. The multicenter study design was applied across a diverse range of diseases, including stroke, traumatic brain injury, myocardial infarction, and diabetes. The median number of centers was four (range 2-6) and the median sample size was 111 (range 23-384) with rodents most frequently used. Multilaboratory studies adhered to practices that reduce the risk of bias significantly more often than single lab studies. Multilaboratory studies also demonstrated significantly smaller effect sizes than single lab studies (DSMD 0.72 [95% confidence interval 0.43-1]). Conclusions: Multilaboratory studies demonstrate trends that have been well recognized in clinical research (i.e. smaller treatment effects with multicentric evaluation and greater rigor in study design). This approach may provide a method to robustly assess interventions and the generaliz-ability of findings between laboratories. Funding: uOttawa Junior Clinical Research Chair; The Ottawa Hospital Anesthesia Alternate Funds Association; Canadian Anesthesia Research Foundation; Government of Ontario Queen Elizabeth II Graduate Scholarship in Science and Technology [ABSTRACT FROM AUTHOR]

OBJECTIVE: Cardiovascular risk reduction is an important focus in the management of people with diabetes. Although event rates have been declining over the long term, they have been observed to plateau or reverse in recent years. Furthermore, the impact of income-related disparities in cardiovascular events is unknown. The objective of this study is to evaluate age-, sex-, and income-related trends in cardiovascular hospitalization rates among people with diagnosed diabetes. RESEARCH DESIGN AND METHODS: We calculated rates of hospitalization for acute myocardial infarction, stroke, heart failure, and lower-extremity amputation in annual cohorts of the entire population of Ontario, Canada, with diagnosed diabetes, from 1995 to 2019. Event rates were stratified by age, sex, and income level. RESULTS: We studied nearly 1.7 million people with diabetes. The rate of acute myocardial infarction declined throughout the 25-year study period (P < 0.0001), such that the rate in 2019 was less than half the rate in 1995. Rates of stroke (P < 0.0001), heart failure (P < 0.0001), and amputation (P < 0.0001) also changed over time, but hospitalization rates stabilized through the 2010s. This apparent stabilization concealed a growing income-related disparity: wealthier patients showed continued declines in rates of these outcomes during the decade, whereas rates for lower-income patients increased (P for interaction < 0.0001 for all four outcomes). CONCLUSIONS: During a quarter-century of follow-up, cardiovascular hospitalization rates among people with diabetes fell. However, the apparent stabilization in rates of stroke, heart failure, and amputation in recent years masks the fact that rates have risen for lower-income individuals. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To describe risk factors for major cardiovascular events in adults following hospital discharge after sepsis. DESIGN: Population-based cohort study. SETTING: Ontario, Canada (2008–2017). PATIENTS: Adult patients (age 18 yr or older) who survived a first sepsis hospitalization without preexisting cardiovascular disease. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary composite outcome was myocardial infarction, stroke, or cardiovascular death up to 5 years following hospital discharge. We used cause-specific Cox proportional hazards models that accounted for the competing risk of noncardiovascular death to describe factors associated with major cardiovascular events. We identified 268,259 adult patients without cardiovascular disease (median age, 72 yr), of whom 10.4% experienced a major cardiovascular event during a median follow-up of 3 years. After multivariable adjustment, age (hazard ratio [HR], 1.53 for every 10 yr; 95% CI, 1.51–1.54), male sex (HR, 1.23; 95% CI, 1.20–1.26), diabetes mellitus (HR, 1.24; 95% CI, 1.21–1.27), hypertension (HR, 1.34; 95% CI, 1.30–1.38), prevalent atrial fibrillation (HR, 1.46; 95% CI, 1.40–1.52), and chronic kidney disease (HR, 1.11; 95% CI, 1.06–1.16) were associated with major cardiovascular events during long-term follow-up. Sepsis characteristics such as site of infection (pneumonia vs other: HR, 1.09; 95% CI, 1.05–1.12), septic shock (HR, 1.08; 95% CI, 1.05–1.11), and renal replacement therapy (HR, 1.51; 95% CI, 1.38–1.64) were also associated with subsequent cardiovascular events. In an analysis restricting to patients with troponin values measured during the hospitalization (26,400 patients), an elevated troponin was also associated with subsequent cardiovascular events (HR, 1.23; 95% CI, 1.13–1.33). CONCLUSIONS: Classic cardiovascular risk factors, comorbid conditions, and characteristics of the sepsis episode were associated with a higher hazard of major cardiovascular events in adult sepsis survivors. These findings may inform enrichment strategies for future studies. [ABSTRACT FROM AUTHOR]

Major bleeding is the most serious complication of oral anticoagulants (OACs). While consensus criteria to define major bleeding have been established by the International Society for Thrombosis and Haemostasis (ISTH), Bleeding Academic Research Consortium (BARC) and Thrombolysis in Myocardial Infarction (TIMI), significant variability exists across these definitions. We sought to evaluate the agreement of cases identified by the three definitions and to assess their effect on mortality and OAC resumption. We used a dataset of individuals ≥66 years in Ontario, Canada presenting with OAC-related bleeding from 2010 to 2015. For case agreement, we calculated Cohen's κ between the three major bleeding definitions. We used multivariate regression to determine differences in mortality and OAC resumption among ISTH, BARC and TIMI-defined major bleeds. Among 2002 cases of OAC-related bleeding, agreement in case identification between ISTH and BARC was substantial (Cohen's κ = 0.69); however, agreement between TIMI and other definitions were poor. Using 30-day mortality of clinically relevant non-major bleeds as comparator, ISTH-, BARC- and TIMI-defined major bleeds conferred 3.3-, 3.2- and 5.9-fold increased risk. Among survivors, 50% with ISTH- and BARC-defined major bleeds resumed OACs at 180 days, compared to 31% of TIMI-associated cases. Major bleeds identified by ISTH and BARC criteria showed good agreement and similar prognostic utility, whereas TIMI criteria identified patients at greater clinical risk. Our results highlight the need to revise major bleeding definitions based on criteria that are independently predictive of clinically relevant morbidity and mortality to more effectively reflect the risk associated with major bleeding and appropriately influence anticoagulant therapy decisions. [ABSTRACT FROM AUTHOR]

Background Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is implicated in elevating the risk for cardiovascular (CV) disease; whether the elevated risk applies to all types of CV diseases or specific types is unclear. This study examined the association of AAV and adverse CV outcomes compared with the non-AAV population. Methods We conducted a population-based, retrospective cohort study of adults (mean age 61 years, 51% female) with a new diagnosis of AAV in Ontario, Canada from 2007 to 2017. Weighted models were used to examine the association of AAV (n  = 1520) and CV events in a matched (1:4) control cohort (n  = 5834). The main outcomes were major adverse CV events (MACE), defined as myocardial infarction (MI), stroke or CV death, its components, atrial fibrillation (AF) and congestive heart failure (CHF). Results Over a mean follow-up of 3.8 years, AAV (compared with non-AAV) was associated with a higher risk of stroke: cumulative incidence 7.0% versus 5.2%, sub-distribution hazard ratio (sHR) 1.49 [(95% confidence interval (95% CI) 1.10–2.02]; AF: cumulative incidence 16.4% versus 11.5%, sHR 1.51, 95% CI 1.30–1.75; and CHF: cumulative incidence 20.8% versus 13.3%, sHR 1.41, 95% CI 1.22–1.62; but not for MACE, MI or CV death. The risks for all CV events, except CV death, were significantly elevated in the early period after AAV diagnosis, in particular AF (365-day sHR 2.06, 95% CI 1.71–2.48; 90-day sHR 3.33, 95% CI 2.66–4.18) and CHF (365-day sHR 1.75, 95% CI 1.48–2.07; 90-day sHR 2.65, 95% CI 2.15–3.26). Conclusion AAV is associated with a high risk of certain types of CV events, particularly in the early period following diagnosis. [ABSTRACT FROM AUTHOR]

Purpose: To determine whether surviving a first sepsis hospitalization is associated with long-term cardiovascular events. Methods: Population-based matched cohort study conducted in Ontario, Canada (2008–2017). Adult survivors (older than 18 years) of a first sepsis hospitalization were matched to adult survivors of a non-sepsis hospitalization using hard-matching and propensity score methods. Patients with pre-existing cardiovascular disease were excluded. The primary composite outcome was myocardial infarction, stroke, or cardiovascular death up to 5 years of follow-up. Secondary outcomes included venous thromboembolism and all-cause death. Cox proportional hazards models with robust standard errors were used to estimate the association of sepsis with all outcomes of interest; hazard ratios (HR) and 95% confidence intervals (CI) were calculated. Sensitivity analyses included Fine and Gray models to account for the competing risk of all-cause death and probabilistic bias analyses. Results: 254,241 adult sepsis survivors were matched to adult survivors of non-sepsis hospitalization episodes. Sepsis survivors experienced an increased hazard of major cardiovascular events compared to non-sepsis survivors (HR 1.30; 95% CI 1.27–1.32), which was more pronounced in younger patients (HR 1.66; 95% CI 1.36–2.02 for patients aged 40 or younger; HR 1.21; 95% CI 1.18–1.24 for patients older than 80 years). Sepsis survivors also faced an increased hazard of venous thromboembolism (HR 1.61; 95% CI 1.55–1.67) and all-cause death (HR 1.26; 95% CI 1.25–1.27). Sensitivity analyses yielded consistent results. Conclusions: Adult sepsis survivors experience an increased hazard of major cardiovascular events compared to survivors of a non-sepsis hospitalization. [ABSTRACT FROM AUTHOR]

Introduction: The benefit of partial nephrectomy (PN) compared to radical nephrectomy (RN) for T1a renal cell carcinoma (RCC) remains uncertain, with observational studies conflicting with level 1 evidence. Therefore, the purpose of this population-based study was to compare long-term outcomes in patients undergoing PN or RN for T1a RCC. Methods: We studied 5670 patients in Ontario, Canada undergoing PN or RN for T1a RCC. The primary outcome was overall survival (OS). Secondary outcomes were cancer-specific survival (CSS), chronic kidney disease (CKD), renal replacement therapy, and myocardial infarction (MI). We used multivariable Cox proportional hazard models to evaluate the association between PN or RN and these outcomes. A sensitivity analysis was performed in patients with a preoperative serum creatinine available. Results: Median followup was 77 months. Compared to RN, PN was associated with significantly improved OS (hazard ratio [HR] 0.73, 95% confidence interval [CI] 0.63-0.84), reduced risk of CKD (HR 0.18, 95% CI 0.12-0.27), and improved CSS (HR 0.45, 95% CI 0.30-0.65). The risk of MI was not significantly different between groups (HR 0.91, 95% CI 0.62-1.34). Few patients (n=15) required renal replacement therapy. In the sensitivity analysis, the association between type of surgery and OS and CKD persisted, while the association with CSS did not. Conclusions: Our study found that in patients undergoing surgery for T1a RCC, PN was associated with improved OS and reduced risk of CKD compared to RN. However, few patients in either group required renal replacement therapy. [ABSTRACT FROM AUTHOR]

BACKGROUND: Epidemiological evidence for the association between traffic-related noise and the incidence of major cardiovascular events such as acute myocardial infarction (AMI) and congestive heart failure (CHF) is inconclusive, especially in North America. OBJECTIVES: We evaluated the associations between long-term exposure to road traffic noise and the incidence of AMI and CHF. METHODS: Our study population comprised ~1 million people 30–100 years of age who lived in Toronto, Canada, from 2001 to 2015 and were free of AMI (referred to as the AMI cohort) or CHF (the CHF cohort) at baseline. Outcomes were ascertained from health administrative databases using validated algorithms. Annual average noise levels were estimated as the A-weighted equivalent sound pressure level over the 24-h period (LAeq24) and during nighttime (LAeqNight), respectively, using propagation modeling, and assigned to participants’ annual six-digit postal code addresses during follow-up. We calculated hazard ratios (HRs) and 95% confidence intervals (CIs) for incident AMI and CHF in relation to LAeq24 and LAeqNight using random-effects Cox proportional hazards models adjusting for individual- and census tract–level covariates, including traffic-related air pollutants [e.g., ultrafine particles (UFPs) and nitrogen dioxide]. RESULTS: During follow-up, there were 37,441 AMI incident cases and 95,138 CHF incident cases. Each interquartile range change in LAeq24 was associated with an increased risk of incident AMI (HR = 1:07; 95% CI: 1.06, 1.08) and CHF (HR = 1:07; 95% CI: 1.06, 1.09). Similarly, LAeqNight was associated with incident AMI (HR = 1:07; 95% CI: 1.05, 1.08) and CHF (HR = 1:06; 95% CI: 1.05, 1.07). These results were robust to various sensitivity analyses and remained elevated after controlling for long-term exposure to UFPs and nitrogen dioxide. We found near-linear relationships between noise and the incidence of AMI and CHF with no evidence of threshold values. CONCLUSION: In this large cohort study in Toronto, Canada, chronic exposure to road traffic noise was associated with elevated risks for AMI and CHF incidence. [ABSTRACT FROM AUTHOR]

Administrative healthcare databases are increasingly being used for research purposes. When used to estimate the effects of treatments and interventions, an important limitation of these databases is the lack of information on important confounding variables. The high-dimensional propensity score (hdPS) is an algorithm that generates a large number of empirically-derived covariates using administrative healthcare databases. The hdPS has been described as enabling adjustment by proxy, in which a large number of empirically-derived covariates may serve as proxies for unmeasured confounding variables. We examined the validity of this assumption using samples of patients hospitalized with acute myocardial infarction (AMI) and congestive heart failure (CHF), for whom both administrative data and detailed clinical data were available. We considered three treatments in AMI patients: angiotensin-converting enzyme inhibitors, beta-blockers, and statins, while the first two treatments were also considered in CHF patients. We considered three propensity scores: (a) one derived using detailed clinical data; (b) the hdPS derived from administrative data; and (c) one derived from administrative data using expert opinion. Using each propensity score, we estimated inverse probability of treatment (IPT) weights. For each sample and treatment combination, and for each of the two propensity scores derived using administrative data, there were clinical variables not measured in administrative data that remained imbalanced after incorporating the IPT weights. However, the propensity score derived using clinical data always resulted in all clinical variables being balanced. When estimating hazard ratios, for some samples and treatment combinations, the hazard ratios estimated using the hdPS were more similar to those obtained using the clinical propensity score than were those obtained using the expert-derived propensity score. However, for other combinations, the effects estimated using the expert-derived propensity score were more similar to those obtained using the clinical propensity score than were those derived using the hdPS. [ABSTRACT FROM AUTHOR]

Background: Rates of cardiovascular disease among people with diabetes have declined over the last 20-30 years. To determine whether First Nations people have experienced similar declines, we compared time trends in rates of cardiac event and disease management among First Nations people with diabetes and other people with diabetes in Ontario, Canada.Methods: We conducted a retrospective cohort study of patients aged 20 to 105 years with diabetes between 1996 and 2015, using linked health administrative databases. Outcomes compared were the annual incidence of each admission to hospital for myocardial infarction and heart failure, and death owing to ischemic heart disease. Management indicators were coronary revascularization and prescription rates for cardioprotective medications. Overall rates and annual percent changes were compared using Poisson regression.Results: Incidence rates for all cardiac outcomes decreased over the study period. The greatest relative annual decline among First Nations men and women were observed in ischemic heart disease death (4.4%, 95% confidence interval [CI] 3.0 to 5.9) and heart failure (5.4%, 95% CI 4.5 to 6.4), respectively. Among other men and women, the greatest annual declines were seen in ischemic heart disease death (6.3%, 95% CI 6.1 to 6.5 and 7.3%, 95% CI 7.1 to 7.6, respectively). However, all absolute cardiac event rates were higher among First Nations people (p < 0.001). Coronary artery revascularization procedures and prescriptions for cardioprotective medications increased among First Nations people, while only prescriptions increased among other people.Interpretation: Over the last 20 years, the incidence of cardiac events has declined among First Nations people with diabetes, but remains higher than other people with diabetes in Ontario. For continued reductions in incidence, future efforts need to recognize First Nations people's unique social and cultural determinants of health. [ABSTRACT FROM AUTHOR]

Aims: Although the prevention and treatment of cardiovascular conditions have significantly improved over the past decade, whether they have reduced the incidence of sudden cardiac death (SCD) is not known. We sought to evaluate the temporal trends of SCD in a large unselected population.Methods: We conducted a population-based cohort study using multiple linked longitudinal data in Ontario Canada. We included patients aged 35-74 years who had SCD from April 1st 2003 to March 31st 2014. SCD was defined as those who died of cardiac causes outside of the hospital or the emergency department, and had no recent hospitalization, no serious illness, and who were not residing in long-term care facilities.Results: We identified 36,334 patients who fulfilled criteria for SCD. The overall age and sex-standardized rate of SCD declined from 57.9/100,000 in fiscal year 2003 to 42.4/100,000 in 2013. Men and women had similar declining trends in SCD incidence. Larger reductions were seen among the older age groups. Patients who had prior heart failure experienced the largest decline in SCD incidence from 829/100,000 to 533/100,000 from 2003 to 2013. Patients who had prior myocardial infarction also had significant reduction from 484/100,000 to 381/100,000. In contrast, individuals with cardiac risk factors without disease had much smaller declines in SCD incidence.Conclusions: Although significant progress to reduce SCD among patients with cardiac conditions was made in the past decade, additional effort should focus on the prevention of SCD in individuals without heart disease. [ABSTRACT FROM AUTHOR]

Chaim M. Bell and Lauren Lapointe-Shaw discuss the meaning of the "weekend effect" in outcomes for hospital admissions and surgeries, and comment on surprising new results published in PLOS Medicine this week. [ABSTRACT FROM AUTHOR]

Background: Secondary prevention after stroke and transient ischemic attack (TIA) has focused on high early risk of recurrence, but survivors of stroke can have substantial long-term morbidity and mortality. We quantified long-term morbidity and mortality for patients who had no early complications after stroke or TIA and community-based controls.Methods: This longitudinal case-control study included all ambulatory or hospitalized patients with stroke or TIA (discharged from regional stroke centres in Ontario from 2003 to 2013) who survived for 90 days without recurrent stroke, myocardial infarction, all-cause admission to hospital, admission to an institution or death. Cases and controls were matched on age, sex and geographic location. The primary composite outcome was death, stroke, myocardial infarction, or admission to long-term or continuing care. We calculated 1-, 3- and 5-year rates of composite and individual outcomes and used cause-specific Cox regression to estimate long-term hazards for cases versus controls and for patients with stroke versus those with TIA.Results: Among patients who were initially stable after stroke or TIA (n = 26 366), the hazard of the primary outcome was more than double at 1 year (hazard ratio [HR] 2.4, 95% confidence interval [CI] 2.3-2.5), 3 years (HR 2.2, 95% CI 2.1-2.3) and 5 years (HR 2.1, 95% CI 2.1-2.2). Hazard was highest for recurrent stroke at 1 year (HR 6.8, 95% CI 6.1-7.5), continuing to 5 years (HR 5.1, 95% CI 4.8-5.5), and for admission to an institution (HR 2.1, 95% CI 1.9-2.2). Survivors of stroke had higher mortality and morbidity, but 31.5% (1789/5677) of patients with TIA experienced an adverse event within 5 years.Interpretation: Patients who survive stroke or TIA without early complications are typically discharged from secondary stroke prevention services. However, these patients remain at substantial long-term risk, particularly for recurrent stroke and admission to an institution. Novel approaches to prevention, potentially embedded in community or primary care, are required for long-term management of these initially stable but high-risk patients. [ABSTRACT FROM AUTHOR]

Background: Variations in the prevalence of traditional cardiac risk factors only partially account for geographic variations in the incidence of cardiovascular disease. We examined the extent to which preventive ambulatory health care services contribute to geographic variations in cardiovascular event rates.Methods: We conducted a cohort study involving 5.5 million patients aged 40 to 79 years in Ontario, Canada, with no hospital stays for cardiovascular disease as of January 2008, through linkage of multiple population-based health databases. The primary outcome was the occurrence of a major cardiovascular event (myocardial infarction, stroke or cardiovascular-related death) over the following 5 years. We compared patient demographics, cardiac risk factors and ambulatory health care services across the province's 14 health service regions, known as Local Health Integration Networks (LHINs), and evaluated the contribution of these variables to regional variations in cardiovascular event rates.Results: Cardiovascular event rates across LHINs varied from 3.2 to 5.7 events per 1000 person-years. Compared with residents of high-rate LHINs, those of low-rate health regions received physician services more often (e.g., 4.2 v. 3.5 mean annual family physician visits, p value for LHIN-level trend = 0.01) and were screened for risk factors more often. Low-rate LHINs were also more likely to achieve treatment targets for hypercholes-terolemia (51.8% v. 49.6% of patients, p = 0.03) and controlled hypertension (67.4% v. 53.3%, p = 0.04). Differences in patient and health system factors accounted for 74.5% of the variation in events between LHINs, of which 15.5% was attributable to health system factors alone.Interpretation: Preventive ambulatory health care services were provided more frequently in health regions with lower cardiovascular event rates. Health system interventions to improve equitable access to preventive care might improve cardiovascular outcomes. [ABSTRACT FROM AUTHOR]

Background: Total plaque score (TPS) on coronary computed tomography angiography (CCTA) has been validated as a surrogate measure of coronary artery disease (CAD) burden and is prognostic. We propose a novel measure, percentage TPS adjusted to age (%TPS/age), that may reflect vascular age and potentially more rapidly progressive atherosclerosis and evaluate its potential prognostic value. Methods: %TPS/age was calculated for consecutive patients prospectively enrolled into our institutional CCTA registry and evaluated for primary composite outcome of cardiac death, nonfatal myocardial infarction, and late revascularization. Results: Of 1896 patients identified (mean age 57.7 ± 11.4 years, 50.1% male, median follow-up 18.6 months [interquartile range: 15.3, 32.4]), 552 (29%) had %TPS/age = 0 (no atherosclerosis), with 1 (0.2%) primary outcome observed (annual event rate [AER] = 0.1%). Two events (0.4%, AER = 0.3%) were observed in %TPS/age < 0.314 category, 22 (5.0%, AER = 2.2%) in %TPS/age 0.314 to 0.699 category, and 54 (12.0%, AER = 5.7%) in %TPS/age ≥ 0.700 category. After adjusting for clinical predictors and obstructive CAD, higher %TPS/age category was associated with hazard ratio 1.95 (1.31-2.88, P < .001) for primary outcome on multivariable analysis, Harrell-C-Statistic 0.87 (confidence interval 95%: 0.84-0.90), and net reclassification improvement of 0.71 (P < .001). Conclusion: %TPS/Age has incremental prognostic value to traditional risk factors and CCTA measures of CAD and improves evaluation of burden of coronary atherosclerosis and clinical risk. [ABSTRACT FROM AUTHOR]

BACKGROUND: Survivors of acute myocardial infarction (AMI) are at increased risk of dying within several hours to days following exposure to elevated levels of ambient air pollution. Little is known, however, about the influence of long-term (months to years) air pollution exposure on survival after AMI. OBJECTIVE: We conducted a population-based cohort study to determine the impact of long-term exposure to fine particulate matter ≤ 2.5 µm in diameter (PM2.5) on post-AMI survival. METHODS: We assembled a cohort of 8,873 AMI patients who were admitted to 1 of 86 hospital corporations across Ontario, Canada in 1999-2001. Mortality follow-up for this cohort extended through 2011. Cumulative time-weighted exposures to PM2.5 were derived from satellite observations based on participants' annual residences during follow-up. We used standard and multilevel spatial random-effects Cox proportional hazards models and adjusted for potential confounders. RESULTS: Between 1999 and 2011, we identified 4,016 nonaccidental deaths, of which 2,147 were from any cardiovascular disease, 1,650 from ischemic heart disease, and 675 from AMI. For each 10-µg/m³ increase in PM2.5, the adjusted hazard ratio (HR10) of nonaccidental mortality was 1.22 [95% confidence interval (CI): 1.03, 1.45]. The association with PM2.5 was robust to sensitivity analyses and appeared stronger for cardiovascular-related mortality: ischemic heart (HR10 = 1.43; 95% CI: 1.12, 1.83) and AMI (HR10 = 1.64; 95% CI: 1.13, 2.40). We estimated that 12.4% of nonaccidental deaths (or 497 deaths) could have been averted if the lowest measured concentration in an urban area (4 µg/m³) had been achieved at all locations over the course of the study. CONCLUSIONS: Long-term air pollution exposure adversely affects the survival of AMI patients. [ABSTRACT FROM AUTHOR]

Few studies have examined the acute cardiovascular effects of airborne allergens. We conducted a case-crossover study to evaluate the relationship between airborne allergen concentrations and emergency room visits for myocardial infarction (MI) in Ontario, Canada. In total, 17,960 cases of MI were identified between the months of April and October during the years 2004-2011. Daily mean aeroallergen concentrations (pollen and mold spores) were assigned to case and control periods using central-site monitors in each city along with daily measurements of meteorological data and air pollution (nitrogen dioxide and ozone). Odds ratios and their 95% confidence intervals were estimated using conditional logistic regression models adjusting for time-varying covariates. Risk of MI was 5.5% higher (95% confidence interval (CI): 3.4,7.6) on days in the highest tertile of total pollen concentrations compared with days in the lowest tertile, and a significant concentration-response trend was observed (P< 0.001). Higher MI risk was limited to same-day pollen concentrations, with the largest risks being observed during May (odds ratio =1.16, 95% CI: 1.00,1.35) and June (odds ratio =1.10, 95% CI: 1.00,1.22), when tree and grass pollen are most common. Mold spore concentrations were not associated with MI. Our findings suggest that airborne pollen might represent a previously unidentified environmental risk factor for myocardial infarction. [ABSTRACT FROM AUTHOR]

Objectives: Previous patient-level acute myocardial infarction (AMI) research has found higher hospital spending to be associated with improved survival; however, survivor-treatment selection bias traditionally has been overlooked. The purpose of this study was to examine the AMI cost-outcome relationship, taking into account this form of bias.Data Sources: Hospital Discharge Abstract data tracked costs for AMI hospitalizations. Ontario Vital Statistics data tracked patient mortality.Study Design: A standard Cox survival model was compared to an extended Cox model using hospital costs as a time-varying covariate to examine the impact of cost on 1-year survival in a cohort of 30,939 first-time AMI patients in Ontario, Canada, from 2007 to 2010.Principal Findings: Higher patient-level AMI spending decreased the hazard of dying (Standard Model: log-cost hazard ratio: 0.513, 95 percent CI: 0.479-0.549; Extended Model: log-cost hazard ratio: 0.700, 95 percent CI: 0.645-0.758); however, the protective effect was overestimated by 62 percent when survivor-treatment bias was overlooked. In the extended model, a 10 percent increase in spending was associated with a 3.6 percent decrease in hazard of death.Conclusion: The findings of this study suggest that if survivor-treatment bias is overlooked, future research may materially overstate the protective effect of patient-level spending on outcomes. [ABSTRACT FROM AUTHOR]

Introduction Cigarette smoking causes many chronic diseases that are costly and result in frequent hospitalisation. Hospital-initiated smoking cessation interventions increase the likelihood that patients will become smoke-free. We modelled the cost-effectiveness of the Ottawa Model for Smoking Cessation (OMSC), an intervention that includes in-hospital counselling, pharmacotherapy and posthospital follow-up, compared to usual care among smokers hospitalised with acute myocardial infarction (AMI), unstable angina (UA), heart failure (HF), and chronic obstructive pulmonary disease (COPD). Methods We completed a cost-effectiveness analysis based on a decision-analytic model to assess smokers hospitalised in Ontario, Canada for AMI, UA, HF, and COPD, their risk of continuing to smoke and the effects of quitting on re-hospitalisation and mortality over a 1-year period. We calculated short-term and long-term cost-effectiveness ratios. Our primary outcome was 1-year cost per quality-adjusted life year (QALY) gained. Results From the hospital payer's perspective, delivery of the OMSC can be considered cost effective with 1-year cost per QALY gained of $C1386, and lifetime cost per QALY gained of $C68. In the first year, we calculated that provision of the OMSC to 15 326 smokers would generate 4689 quitters, and would prevent 116 rehospitalisations, 923 hospital days, and 119 deaths. Results were robust within numerous sensitivity analyses. Discussion The OMSC appears to be cost-effective from the hospital payer perspective. Important consideration is the relatively low intervention cost compared to the reduction in costs related to readmissions for illnesses associated with continued smoking. [ABSTRACT FROM AUTHOR]

Background: Despite evidence-based recommendations supporting long-term use of cardiac medications in patients post ST-elevation myocardial infarction, adherence is known to decline over time. Discontinuation of cardiac medications in such patients is associated with increased mortality. Methods/design: This is a pragmatic, cluster-randomized controlled trial with blinded outcome assessment and embedded qualitative process evaluation. Patients from one health region in Ontario, Canada who undergo a coronary angiogram during their admission for ST-elevation myocardial infarction and who survive their initial hospitalization will be included. Allocation of eligible patients to intervention or usual care will take place within one week after the angiogram using a computer-generated random sequence. To avoid treatment contamination, patients treated by the same family physician will be allocated to the same study arm. The intervention consists of recurrent, personalized, paper-based educational messages and reminders sent via post on behalf of the interventional cardiologist to the patient, family physician, and pharmacist urging long-term adherence to secondary prevention medications. The primary outcome is the proportion of patients who report in a phone interview taking all relevant classes of cardiac medications at twelve months. Secondary outcomes to be measured at three and twelve months include proportions of patients who report: actively taking each cardiac medication class of interest (item-by-item); stopping medications due to side effects; taking one or two or three medication classes concurrently; a perfect Morisky Medication Adherence Score for cardiac medication compliance; and having a discussion with their family physician about long-term adherence to cardiac medications. Self-reported measures of adherence will be validated using administrative data for prescriptions filled. Discussion: This intervention is designed to be easily generalizable. If effective, it could be implemented broadly. If it does not change medication utilization, the process evaluation will offer insights regarding how such an intervention could be optimized in future. [ABSTRACT FROM AUTHOR]

Objectives: The goal of this study was to analyze health-related quality of life (HRQL) data from a Canadian population with type 2 diabetes in order to estimate the disutility associated with experiencing a diabetes-related complication. Methods: The EQ-5D, a standardized instrument for use as a measure of health outcome, was administered to 1,147 patients in Hamilton, Ontario, with type 2 diabetes. After controlling for age, gender, and duration of diabetes, changes in utility values were estimated by regressing the EQ-5D scores onto binary indicators for the presence of an event. The primary method of analysis was Ordinary Least Squares (OLS) and due to concerns over non-Normality, bootstrap standard errors (SE) were calculated. Results: The analysis included 1,143 participants. Based on the OLS model, reductions in HRQL were associated with duration of diabetes (−0.0015, SE = 0.0006), experiencing a myocardial infarction (MI) (−0.059, SE = 0.017), amputation (−0.063, SE = 0.059), stroke (−0.046, SE = 0.023), and kidney failure (−0.102, SE = 0.047). Conclusion: This study estimated the reductions in HRQL associated with several important complications commonly experienced in patients with diabetes. The greatest impacts on HRQL were associated with kidney failure and MI. The utility values calculated here can be used to assess the outcome of interventions that reduce these diabetes-related complications and will have a useful impact on future economic evaluations of diabetes management strategies in Canada. [ABSTRACT FROM AUTHOR]

The cause of increased post-AMI (acute myocardial infarction) mortality associated with depression remains poorly elucidated. The objective of this study was to examine the extent to which self-reported cardiac functional status accounted for depression-mortality associations following AMI. Using a prospective cohort design ( n = 1941), the authors obtained self-reported measures of depression and developed profiles of the patients' pre-hospitalization cardiac risks, co-morbid conditions and drugs and revascularization procedures during or following index AMI hospitalization. To create these profiles, the patients' self-reports were retrospectively linked to no less than 12 years' worth of previous hospitalization data. Mortality rates 2 years after acute MI were examined with and without sequential risk adjustment for age, sex, income, cardiovascular risk, co-morbid conditions, selected process-of-care factors and self-reported cardiac functional status. Depression was strongly correlated with 2-year mortality rate [crude hazard ratio (HR) of severe vs. minimal depression category, 2.48 (95% CI 1.20-5.15); P = 0.01]. However, after sequential adjustment for age, sex, income and self-reported cardiac functional status, the effect of depression was greatly attenuated [adjusted HR for severe vs. minimal depression category, 1.35 (95% CI 0.63-2.87); P = 0.44]. Cardiac risk factors and non-cardiac co-morbidities had negligible explanatory effect. The main factor determining the increased mortality rate in depressed patients is self-reported cardiac functional status. Efforts to address increased mortality in depressed patients with cardiovascular illnesses should focus on processes that impact cardiac functional status. [ABSTRACT FROM AUTHOR]

Objective: The American Heart Association (AHA) recommends a benchmark door-to-electrocardiogram (ECG) time of 10 minutes for acute myocardial infarction patients, but this is based on expert opinion (level of evidence C). We sought to establish an evidence-based benchmark door-to- ECG time. Methods: This retrospective cohort study used a population- based sample of patients who suffered an ST elevation myocardial infarction (STEMI) in Ontario between 1999 and 2001. Using cubic smoothing splines, we described (1) the relationship between door-to-ECG time and ECG-to-needle time and (2) the proportion of STEMI patients who met the benchmark door-to-needle time of 30 minutes based on their door-to-ECG time. We hypothesized nonlinear relationships and sought to identify an inflection point in the latter curve that would define the most efficient (benefit the greatest number of patients) door-to-ECG time. Results: In 2,961 STEMI patients, the median door-to-ECG and ECG-to-needle times were 8.0 and 27.0 minutes, respectively. There was a linear increase in ECG-to-needle time as the door-to-ECG time increased, up to approximately 30 minutes, after which the ECG-to-needle time remained constant at 53 minutes. The inflection point in the probability of achieving the benchmark door-to-needle time occurred at 4 minutes, after which it decreased linearly, with every minute of door-to-ECG time decreasing the average probability of achievement by 2.2%. Conclusions: Hospitals that are not meeting benchmark reperfusion times may improve performance by decreasing door-to-ECG times, even if they are meeting the current AHA benchmark door-to-ECG time. The highest probability of meeting the reperfusion target time for fibrinolytic administration is associated with a door-to-ECG time of 4 minutes or less. [ABSTRACT FROM AUTHOR]

Background: Few studies have examined the impact of antismoking legislation on respiratory or cardiovascular conditions other than acute myocardial infarction. We studied rates of hospital admission attributable to three cardiovascular conditions (acute myocardial infarction, angina, and stroke) and three respiratory conditions (asthma, chronic obstructive pulmonary disease, and pneumonia or bronchitis) after the implementation of smoking bans. Methods: We calculated crude rates of admission to hospital in Toronto, Ontario, from January 1996 (three years before the first phase of a smoking ban was implemented) to March 2006 (two years after the last phase was implemented. We used an autoregressive integrated moving-average (ARIMA) model to test for a relation between smoking bans and admission rates. We compared our results with similar data from two Ontario municipalities that did not have smoking bans and with conditions (acute cholecystitis, bowel obstruction and appendicitis) that are not known to be related to second-hand smoke. Results: Crude rates of admission to hospital because of cardiovascular conditions decreased by 39% (95% CI 38%-40%) and admissions because of respiratory conditions decreased by 33% (95% CI 32%-34%) during the ban period affecting restaurant settings. No consistent reductions in these rates were evident after smoking bans affecting other settings. No significant reductions were observed in control cities or for control conditions. Interpretation: Our results serve to expand the list of health outcomes that may be ameliorated by smoking bans. Further research is needed to establish the types of settings in which smoking bans are most effective. Our results lend legitimacy to efforts to further reduce public exposure to tobacco smoke. [ABSTRACT FROM AUTHOR]

The impact of secondary prevention initiatives on survival in higher-risk socioeconomically disadvantaged patients after acute myocardial infarction (AMI) may depend on behavioral adaptive responsiveness, uptake, and adherence to healthier lifestyles. From December 1999 to February 2003, 1,801 patients in Ontario, Canada were interviewed regarding their lifestyle behaviors at 30 days after their index AMI hospitalization. Data were obtained using self-reported surveys, medical chart abstraction, and administrative data linkage. Multivariate analyses were adjusted for baseline sociodemographic, cardiac risk severity, and co-morbid conditions. Socioeconomically disadvantaged patients had greater cardiac risk severity at baseline than did their wealthier better-educated counterparts. Compared with lower-income patients, patients with higher incomes were less likely to smoke (adjusted odds ratio [OR] for highest vs lowest income tertiles 0.36, 95% confidence interval [CI] 0.21 to 0.63, p <0.001), more likely to participate in exercise (adjusted OR 1.40, 95% CI 1.07 to 1.85, p = 0.02), and more likely to decrease or discontinue alcohol use (adjusted OR 1.64, 95% CI 1.16 to 2.34, p = 0.06). The relation between education and lifestyle behaviors was less pronounced for education than for income. After adjustment for baseline factors, patients who acknowledged participation in regular physical exercise at 1 month had a significantly lower long-term mortality than those who did not. In conclusion, socioeconomically disadvantaged patients were sicker at baseline and less behaviorally responsive to embarking on healthy lifestyle changes after AMI than were those of higher socioeconomic status. [Copyright &y& Elsevier]

Objective: Acute myocardial infarction (AMI) remains a major cause of death and β-blockers are known to reduce long-term mortality in post-AMI patients. We sought to determine whether patients receiving β-blockers acutely (within 72 h) following AMI had a lower mortality rate at 6 weeks than patients receiving placebo. Methods: We conducted a systematic review of randomized controlled clinical trials that assessed 6-week mortality and compared β-blockers with placebo in patients randomized within the first 72 hours following AMI. We searched these databases: MEDLINE (1966-2006), EMBASE (1980-2007), Cochrane Central Register of Controlled Trials, Health Star (1966-2007), Cochrane Database for Systematic Reviews, ACP Journal Club (1991-2007), Database of Abstracts of Reviews of Effect (< 1st quarter 2007) and Conference Papers Index (1984-2007). Two blinded reviewers extracted the data and rated study quality using the Jadad score and the adequacy of allocation concealment score, which was adopted by the Cochrane group. We calculated pooled odds ratios (ORs) using a random effect model and performed sensitivity analyses to explore the stability of the overall treatment effect. Results: We included 18 studies (13 were rated high-quality) with 74 643 enrolled participants and had 5095 deaths. Compared with placebo, adding β-blockers to other interventions within 72 hours after AMI did not result in a statistically significant reduction in 6-week mortality (OR 0.95, 95% confidence interval [CI] 0.90-1.01). When restricted to high quality studies, the OR for 6-week mortality reduction was 0.96 (95% CI 0.91-1.02). We found similar results including studies that enrolled patients within 24 hours after AMI. However, a subgroup analysis that excluded high-risk patients with Killip class III and above showed that β-blockers resulted in a significant reduction in short-term mortality (OR 0.93, 95% CI 0.88-0.99). Conclusion: Acute intervention with β-blockers does not result in a statistically significant short-term survival benefit following AMI but may be beneficial for low-risk (Killip class I) patients. [ABSTRACT FROM AUTHOR]

The article investigates the growth in the use of coronary angiography services and the use of statins following acute myocardial infarction (AMI) in patients older than 65 year in Ontario between 1992-2004. Results reveal that the use of post-AMI coronary angiography reflected temporal increases in cardiac catheterization capacity. It is concluded that the proliferation of cardiac catheterization in Ontario is attributable to factors other than the emergence of published scientific evidence.

OBJECTIVE -- To compare recent trends in cardiovascular disease (CVD) outcomes among men and women with diabetes with those in the nondiabetic population. RESEARCH DESIGN AND METHODS -- We conducted a retrospective cohort study using provincial health claims data to identify adults with (n = 670,602) and without (n = 9,190,721) diabetes living in Ontario, Canada, between 1 April 1992 and 31 March 2000. We compared changes in the annual age-/sex-adjusted rates and numbers of subjects admitted for acute myocardial infarction (AMI) and stroke and of deaths from AMI, stroke, and all causes between those with and without diabetes. RESULTS -- Over the 8-year period, the rate of patients admitted for AMI and stroke fell to a greater extent in the diabetic than the nondiabetic population (AMI: -15.1 vs. -9.1%, P < 0.0001; stroke: -24.2 vs. 19.4%, P < 0.0001). Diabetic patients experienced similar reductions in case-fatality rates related to AMI and stroke than those without diabetes (-44.1 vs. -33.2%, P = 0.1; - 17.1 vs. -16.6%, P = 0.9, respectively). Declines in all-cause mortality were also comparable in the two populations. Over the same period, the number of diabetes cases increased from 405,471 to 670,602. Thus, while CVD rates fell, the number of events occurring in this population rose substantially (AMI: +44.6%, stroke: +26.1%, AMI deaths: +17.2%, and stroke deaths: +13.2%). CONCLUSIONS -- Our findings demonstrate a significant reduction in the rate of people affected by CVD within the diabetic population. However, as the number of people with diabetes rises, so may the absolute burden of CVD in our society. [ABSTRACT FROM AUTHOR]

Background: Disease management programs (DMPs) that use multidisciplinary teams and specialized clinics reduce hospital admissions and improve quality of life and functional status. Evaluations of cardiac DMPs delivered by home health nurses are required. Methods: Between August 1999 and August 2000 we identified consecutive patients admitted to hospital with elevated cardiac enzymes. Patients who agreed were randomly assigned to participate in a DMP or to receive usual care. The DMP included 6 home visits by a cardiac-trained nurse, a standardized nurses' checklist, referral criteria for specialty care, communication with the family physician and patient education. We measured readmission days per 1000 follow-up days for angina, congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD); all-cause readmission days; and provincial claims for emergency department visits, physician visits, diagnostic or therapeutic services and laboratory services. Results: We screened 715 consecutive patients admitted with elevated cardiac markers between August 1999 and August 2000. Of those screened 71 DMP and 75 usual care patients met the diagnostic criteria for myocardial infarction, were eligible for visits from a home health nurse and consented to participate in the study. Readmission days for angina, CHF and COPD per 1000 follow-up days were significantly higher for usual care patients than for DMP patients (incidence density ratio [IDR] = 1.59, 95% confidence interval [CI] 1.27-2.00, p < 0.001). All-cause readmission days per 1000 follow-up days were significantly higher for usual care patients than for DMP patients (IDR = 1.53, 95% CI 1.37-1.71, p< 0.001). The difference in emergency department encounters per... [ABSTRACT FROM AUTHOR]

OBJECTIVE — To compare the health service utilization and long-term outcomes of acute myocardial infarction (AMI) patients with and without diabetes in Ontario. RESEARCH DESIGN AND METHODS — We examined 25,697 patients from Ontario (6,052 and 19,645 patients with and without diabetes, respectively) who were hospitalized because of AMI between 1 April 1992 and 31 December 1993. Using linked administrative databases, we determined the use of invasive cardiac procedures at 1 year as well as the intensity of specialty follow-up care and use of evidence-based pharmacotherapies (among elderly individuals) within the first 90 days of hospital discharge. Outcomes examined included mortality and recurrent cardiac admissions at 30 days and 5 years post AMI. Muhivariable analyses adjusted for sociodemographic and case-mix characteristics, attending physician specialty, and admitting hospital characteristics. RESULTS — Despite being at significantly higher risk for death at baseline, diabetic patients were less likely to be followed-up by a cardiologist (22.2 vs. 25.6%, P < 0.001), to receive myocardial revascularization (12.6 vs. 14.9%, P < 0.001), to receive β-blockers (34.2 vs. 44.0%, P < 0.001), and to receive aspirin therapy (59.7 vs. 63.5%, P < 0.001) after AMI than their nondiabetic counterparts. Diabetes was an important independent predictor of 5-year morbidity (adjusted hazard ratio 1.52, 95% CI 1.45-1.59) and 5-year mortality outcomes (1.57, 1.501.63). Variations in processes of care were marginally associated with higher nonfatal complication rates for diabetic patients. CONCLUSIONS — When managing AMI patients with diabetes in Ontario, physician treatment aggressiveness does not correspond appropriately to the baseline risk of patients. [ABSTRACT FROM AUTHOR]

Objective: To examine how physicians in Ontario, Canada, have altered their referral patterns for coronary angiography after acute myocardial infarction (AMI) over time.Design: Retrospective analysis of multilinked administrative data.Setting: Province of Ontario, Canada.Patients: 146 365 Ontario AMI patients hospitalised between 1 April 1992 and 31 March 1999.Main Outcome Measures: Utilisation trends of coronary angiography among all patients, as well as within six subgroups: elderly (versus young), women (versus men), high (versus low) risk of 30 day mortality, high (versus low) socioeconomic status, cardiology (versus non-cardiology) attending physician specialty, and hospitals with (versus without) onsite revascularisation capacity. Cox proportional hazard models were adjusted for variations in patient, physician, and hospital characteristics over time.Results: Angiography rates in Ontario increased from 23.2% in 1992 to 35.5% in 1999 (p < 0.0001). Increases in utilisation of coronary angiography were most pronounced among the elderly (12.4-24.3% v 39.3-54.4% for non-elderly patients, p < 0.0001), the affluent (24.6-38.7% v 22.0-32.3% for less affluent patients, p = 0.01), and those tended to by cardiologists (32.0-47.1% v 20.3-30.1% for non-cardiology attending specialties, p < 0.0001) after adjusting for changes in baseline patient, physician, and hospital characteristics over time.Conclusions: Despite universal health care availability, not all patients benefited equally from increases in service capacity for coronary angiography after AMI in Ontario. Wider implementation of data monitoring and explicit management systems may be required to ensure that appropriate utilisation of cardiac services is allocated to patients who are most in need. [ABSTRACT FROM AUTHOR]

SummaryBackground: Many older people do not receive b-blocker therapy after myocardial infarction or receive doses lower than those tested in trials, perhaps because physicians fear that b-blockers may precipitate heart failure. We examined the relation between use of b-blockers, the dose used, and hospital admission for heart failure and 1-year survival in a cohort of all older patients surviving myocardial infarction in Ontario, Canada.Methods: We collected data on a cohort of 13 623 patients aged 66 years or older who were discharged from hospital after a myocardial infarction and who did not receive b-blocker therapy or received low, standard, or high doses. We used Cox's proportional-hazards models to study the association of dose with admission for heart failure and survival with adjustment for factors including age, sex, and comorbidity.Findings: Among 8232 patients with no previous history of heart failure, dispensing of b-blocker therapy was associated with a 43% reduction in subsequent admission for heart failure (adjusted risk ratio 0.57 [95% CI 0.48-0.69]) compared with patients not dispensed this therapy. Among the 4681 patients prescribed b-blockers, the risk of admission was greater in the high-dose than in the low-dose group (1.53 [1.01-2.31]). Among all 13 623 patients in the cohort, 2326 (17.1%) died by 1 year. Compared with those not dispensed b-blocker therapy, the adjusted risk ratio for mortality was lower for all three doses (low 0.40 [0.34-0.47], standard 0.36 [0.31-0.42], high 0.43 [0.33-0.56]).Interpretation: Compared with high-dose b-blocker therapy, low-dose treatment is associated with a lower rate of hospital admission for heart failure and has a similar 1-year survival benefit. Our findings support the need for a randomised controlled trial comparing doses of b-blocker therapy in elderly patients. [ABSTRACT FROM AUTHOR]

Reports the development, testing and clinical utility of a risk stratification tool for evaluation of patients with unstable angina/non--ST-segment elevation myocardial infarction. Methods; Results; Conclusion that the Thrombolysis in Myocardial Infarction (TIMI) risk score is a simple prognostic scheme that categorizes a patient's risk of death and ischemic events and provides a basis for therapeutic decision making.

Examines the incidence of ischemic heart disease (IHD) among Native Americans in Ontario. Trends in admission rates for IHD in Native populations; Comparison with IHD incidence for residents in the province; Relationship with rates of acute myocardial infarction. INSET: SUBJECTS AND METHODS..

Develops and tests indicators of the quality of care for patients with acute myocardial infarction. Background of monitoring of quality of care; Methods of the studies; Details of the results.

Presents research which studied various components of the delay to thrombolytic treatment for patients with acute myocardial infarction (MI). Identification of hospital and patient characteristics related to delay; Design; Setting; Subjects; Main outcome measures; Hesitation of patients to seek medical attention; Median time for decision making; Delay in cardiological evaluation; Permitting specialty consultation; Special cases.

Presents a study which evaluates the use of emergency medical services (EMS) for the treatment of acute myocardial infarction (AMI). Multimedia campaign to promote use of (EMS); Theoretical foundation of media intervention; How its effectiveness was assessed; Statistics from American Heart Association on heart disease deaths.

Presents a study to assess the independent value of the initial electrocardiogram (ECG) for short-term risk stratification after acute myocardial infarction. Design; Setting; Patients; Main outcome measures; Results; Conclusion.

Reports on medical research designed to study determinants and adverse outcomes, such as mortality and rehospitilization, of beta-blocker underuse in elderly patients with myocardial infarction. The determination of the relative risks of survival associated with beta-blocker use comparable to those reported in a the large randomized controlled trials; Setting; Design; Patients; Main outcome measures; Results; Conclusions.

Presents a study which compared the quality of medical care of both generalists and cardiologists when working separately or together in the management of patients with acute myocardial infarction (AMI). Increase of public and scientific debate of the rapid expansion of managed care in the United States; Abstracting of medical records of 1839 patients admitted to 20 hospitals for AMI between September 1992 and August 1993; Information on results.

Part II. Presents data that should be included in the risk stratification of patients who had acute myocardial infarction. Includes the baseline clinical and demographic risk factors in the acute evaluation phase; 24-hour assessment in the cardiac care unit phase; Identification of candidates for treatment and early discharge in the hospital phase; Cost considerations in the predischarge phase.

Part I. Outlines the risk-stratification processes that occur during the four phases of the hospitalization of a patient with acute myocardial infarction. Acute evaluation phase; Cardiac care unit phase; Hospital phase; Predischarge phase; Interventions during each phase.

Long-term exposure to ambient air pollution has been linked to cardiovascular mortality, but the associations with incidence of major cardiovascular diseases are not fully understood, especially at low concentrations. We aimed to investigate the associations between exposure to fine particulate matter (PM 2.5), nitrogen dioxide (NO 2), ozone (O 3), redox-weighted average of NO 2 and O 3 (O x) and incidence of congestive heart failure (CHF) and acute myocardial infarction (AMI). Our study population included all long-term residents aged 35–85 years who lived in Ontario, Canada, from 2001 to 2015 (~5.1 million). Incidence of CHF and AMI were ascertained from validated registries. We assigned estimates of annual concentrations of pollutants to the residential postal codes of subjects for each year during follow-up. We estimated hazard ratios (HRs) and 95% CIs for each pollutant separately using Cox proportional hazards models. We examined the shape of concentration-response associations using shape-constrained health impact functions. From 2001 to 2015, there were 422,625 and 197,628 incident cases of CHF and AMI, respectively. In the fully adjusted analyses, the HRs of CHF corresponding to each interquartile range increase in exposure were 1.05 (95% CI: 1.04–1.05) for PM 2.5 , 1.02 (95% CI: 1.01–1.04) for NO 2 , 1.03 (95% CI: 1.02–1.03) for O 3 , and 1.02 (95% CI: 1.02–1.03) for O x, respectively. Similarly, exposure to PM 2.5 , O 3 , and O x were positively associated with AMI. The concentration-response relationships were different for individual pollutant and outcome combinations (e.g., for PM 2.5 the relationship was supralinear with CHF, and linear with AMI). • PM 2.5 , NO 2 , O 3 , and O x were associated to increased congestive heart failure incidence. • Exposure to PM 2.5 , O 3 , and O x was associated with acute myocardial infarction (AMI). • A near-linear concentration-response relationship was found for PM 2.5 and AMI. • Non-linear patterns were observed for other pollutant and outcome combinations. • There was some evidence of effect modification by age and income. [ABSTRACT FROM AUTHOR]

Examines the course of rehabilitation in patients with complicated acute myocardial infarction after primary ventricular fibrillation in Kingston, Ontario. Resumption of work, sexual activity and driving; Examination of the mortality rate; Consideration of age, occupation, time of ventricular fibrillation and site of infarct.