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Background: Coronary artery disease (CAD) confers increased risks of premature mortality, non-fatal morbidity, and significant impairment in functional status and health-related quality of life. Routine administration of electronic patient-reported outcome measures (PROMs) and its real time delivery to care providers is known to have the potential to inform routine cardiac care and to improve quality of care and patient outcomes. This study describes a user-centered development and evaluation of the Alberta Provincial Project for Outcomes Assessment (APPROACH) electronic Patient Reported Outcomes Measurement (e-PROM) system. This e-PROM system is an electronic system for the administration of PROMs to patients with CAD and the delivery of the summarized information to their care providers to facilitate patient-physician communication and shared decision-making. This electronic platform was designed to be accessible via web-based and hand-held devices. Heuristic and user acceptance evaluation were conducted with patients and attending care providers., Results: The APPROACH e-PROM system was co-developed with patients and care providers, research investigators, informaticians and information technology experts. Five PROMs were selected for inclusion in the online platform after consultations with patient partners, care providers, and PROMs experts: the Seattle Angina Questionnaire, Patient Health Questionnaire, EuroQOL, and Medical Outcomes Study Social Support Survey, and Self-Care of Coronary Heart Disease Inventory. The heuristic evaluation was completed by four design experts who examined the usability of the prototype interfaces. User acceptance testing was completed with 13 patients and 10 cardiologists who evaluated prototype user interfaces of the e-PROM system., Conclusion: Both patients and physicians found the APPROACH e-PROM system to be easy to use, understandable, and acceptable. The APPROACH e-PROM system provides a user-informed electronic platform designed to incorporate PROMs into the delivery of individualized cardiac care for persons with CAD., (© 2024. The Author(s).)

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., (© 2023. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Purpose: The Seattle Angina Questionnaire (SAQ) is a widely used patient-reported measure of health status in patients with coronary artery disease. Comparisons of SAQ scores amongst population groups and over time rely on the assumption that its factorial structure is invariant. This study evaluates the measurement invariance of the SAQ across different demographic and clinical groups and over time., Methods: Data were obtained from the Alberta Provincial Project on Outcome Assessment in Coronary Heart Disease registry, a registry of patients who received coronary angiogram in Alberta, Canada. The study cohort consists of adult patients who completed the paper-based version of the 16-item Canadian version of the SAQ (SAQ-CAN) 2 weeks and 1-year post-coronary angiogram between 2009 and 2016. Multi-group confirmatory factor analysis was used to assess configural, weak, strong, and strict measurement invariance across age groups, sex, angina type, treatment, and over time. Model fit was assessed using the comparative fit index and root mean square error of approximation., Results: Of the 8101 patients included in these analysis, 1300 (16.1%) were at least 75 years old, while 1755 (21.7%) were female, 5154 (63.6%) were diagnosed with acute coronary syndrome, 1177 (14.5%) received coronary artery bypass graft treatment, and 3279 had complete data on the SAQ-CAN at both occasions. There was evidence of strict invariance across age, sex, and angina type, and treatment groups, but partial strict invariance was established over time., Conclusion: SAQ-CAN can be used to compare the health status of coronary artery disease patients across population groups and over time., (© 2021. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Background: The role of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with diabetes mellitus (DM) and multivessel coronary artery disease (CAD) has been established by large trials; however, these trials largely excluded patients with left ventricular dysfunction (LVD)., Objectives: The aim of this study was to determine whether treatment with PCI or CABG leads to improved outcomes in patients with DM, CAD, and LVD., Methods: In this propensity-matched study, outcomes were compared for patients with CAD, DM, and LVD treated with PCI or CABG between 2004 and 2016. The primary outcome was major adverse cardiac and cerebrovascular events, defined as the composite of death, stroke, myocardial infarction, and repeat revascularization. Secondary outcomes were the individual components of the primary outcome., Results: PCI compared with CABG was associated with a higher risk for major adverse cardiac and cerebrovascular events in cohorts with ejection fraction (EF) 35% to 49% (p < 0.001) and <35% (p < 0.001). Treatment with PCI was associated with an increased risk for death in both the EF 35% to 49% and the EF <35% cohorts. Stroke rate did not differ between PCI and CABG in either EF cohort. PCI was associated with an increased rate of MI in the EF <35% cohort, and repeat revascularization occurred more frequently in patients treated with PCI in both the EF 35% to 49% cohort and the EF <35% cohort., Conclusions: At long-term follow-up, patients with CAD, DM, and LVD treated with CABG exhibited a significantly lower incidence of major adverse cardiac and cerebrovascular events and better long-term survival over PCI, without a higher risk for stroke., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Coronary artery bypass grafting (CABG) with multiple distal target (MDT) grafts requires less graft material and reduces cardiopulmonary bypass time; however, there may be a higher incidence of graft failure. A real-world analysis reporting long-term outcomes associated with MDT grafts is lacking., Material and Methods: In 6262 consecutive patients who underwent an isolated first CABG from 2004-2012, patients with MDTs were propensity matched to those with single distal target (SDT) grafts. Logistic regression adjusted for traditional, anatomical, and functional definitions of complete revascularization (CR). Outcomes included 30-day, 1-year, and long-term mortality (median 6.29 years). Results: A total of 549 (8.8%) CABG patients had a MDT graft. CR defined using traditional (96.1% versus 92.0%, P = .005), anatomical (89.0% versus 80.20%, P < .001), and functional (90.7% versus 82.6, P < .001) definitions was more frequent in MDT patients. No significant differences in mortality were observed at 30 days (2% versus 3.3%, P = .18), 1-year (3.8% versus 4.9%, P = .37), or through end of follow-up (18.0% versus 16.6% P = .52) between the MDT and SDT groups, respectively. Similarly, no differences were observed after adjustment for all definitions of CR. Graft failure in MDT and SDT patients was 37.8% and 27.6%, respectively (P = .18)., Conclusion: In a contemporary population-based cohort, no differences in mortality were observed between CABG patients with MDT and SDT grafts. Our findings support the safety of MDT grafts to facilitate CR in patients and when graft material is limited.

Aims: The aim of this study is to investigate the long-term relationship between revascularization technique and health status in diabetics with multivessel disease., Methods and Results: Using the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) registry, we captured 1319 diabetics with multivessel disease requiring revascularization for an acute coronary syndrome (January 2009-December 2012) and reported health status using the Seattle Angina Questionnaire (SAQ) at baseline, 1, 3 and 5-years [599 underwent coronary artery bypass grafting (CABG); 720 underwent percutaneous coronary intervention (PCI)]. Adjusted analyses were performed using a propensity score-matching technique. After adjustment (including baseline SAQ domain scores), 1-year mean (95% CI) SAQ scores (range 0-100 with higher scores reflecting improved health status) were significantly greater in selected domains for CABG compared to PCI (exertional capacity: 81.7 [79.5-84.0] vs. 78.8 [76.5-81.0], P = 0.07; angina stability: 83.1 [80.4-85.9] vs. 75.0 [72.3-77.8], P < 0.001]; angina frequency 93.2 [91.6-95.0] vs. 90.0 [87.8-91.3], P = 0.003; treatment satisfaction: 93.6 [92.2-94.9] vs. 90.8 [89.2-92.0], P = 0.003; quality of life [QOL]: 83.8 [81.7-85.8] vs. 77.2 [75.2-79.2] P < 0.001). At 3-years, these benefits were attenuated (exertional capacity: 79.3 [76.9-81.7] vs. 78.7 [76.3-81.1], P = 0.734; angina stability 79.3 [76.3-82.3] vs. 75.5 [72.5-78.5], P = 0.080; angina frequency: 93.2 [91.3-95.1] vs. 90.9 [89.0-92.8], P = 0.095; treatment satisfaction: 92.5 [91.0-94.0] vs. 91.5 [90.0-93.0] P = 0.382; QOL: 83.2 [81.1-85.2] vs. 80.3 [78.2-82.4], P = 0.057). At 5-years, majority of domains were similar (exertional capacity: 77.8 [75.0-80.6] vs. 76.3 [73.2-79.3], P = 0.482; angina stability: 78.0 [74.8-81.2] vs. 74.8 [71.4-78.2], P = 0.175; angina frequency: 94.2 [92.3-96.0] vs. 90.9 [89.0-92.9], P = 0.018; treatment satisfaction: 93.7 [92.2-95.1] vs. 92.2 [90.6-93.7], P = 0.167; QOL: 84.1 [82.0-86.3] vs. 81.1 [78.8-83.4], P = 0.058). Majority in both groups remained angina-free at 5-years (75.0% vs. 70.3%, P = 0.15)., Conclusion: Improvements in health status with CABG compared with PCI were not sustained long-term. This temporal sequence should be considered when contemplating a revascularization strategy in diabetics with multivessel disease., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For Permissions, please email: journals.permissions@oup.com.)

Background: The association between obesity and mortality risks following coronary revascularization is not clear. We examined the associations of BMI (kg/m 2 ) with short-, intermediate-, and long-term mortality following coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) in patients with different coronary anatomy risks and diabetes mellitus status., Methods and Results: Data from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) registry were analyzed. Using normal BMI (18.5-24.9) as a reference, multivariable-adjusted hazard ratios for all-cause mortality within 6 months, 1 year, 5 years, and 10 years were individually calculated for CABG and PCI with 4 prespecified BMI categories: overweight (25.0-29.9), obese class I (30.0-34.9), obese class II (35.0-39.9), and obese class III (≥40.0). The analyses were repeated after stratifying for coronary risks and diabetes mellitus status. The cohorts included 7560 and 30 258 patients for CABG and PCI, respectively. Following PCI, overall mortality was lower in patients with overweight and obese class I compared to those with normal BMI; however, 5- and 10-year mortality rates were significantly higher in patients with obese class III with high-risk coronary anatomy, which was primarily driven by higher mortality rates in patients without diabetes mellitus (5-year adjusted hazard ratio, 1.78 [95% CI, 1.11-2.85] and 10-year adjusted hazard ratio, 1.57 [95% CI, 1.02-2.43]). Following CABG, overweight was associated with lower mortality risks compared with normal BMI., Conclusions: Overweight was associated with lower mortality following CABG and PCI. Greater long-term mortality in patients with obese class III following PCI, especially in those with high-risk coronary anatomy without diabetes mellitus, warrants further investigation., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Background: While it has been identified that gender (socially manufactured roles, behaviors, expressions, and identities) plays a central role in men's and women's health, the distinction between gender and sex (biological attributes) has largely been ignored in health science research. The purpose of this study was to look at the unique contributions of sex, age, and the Gender Index (GI) to baseline health status in a cohort of patients with coronary artery disease (CAD)., Participants and Methods: Questions that comprised the GI were included in the follow-up questionnaire sent to patients in the APPROACH registry. To examine the relationship between sex, gender, and health status, a sequential linear regression modeling approach was used., Results: A total of 632 patients completed the GI between July and August 2015. The women were significantly older (68 years vs. 66 years, p = 0.02) and significantly more likely to have hypertension (50.8% vs. 38.8%, p = 0.02) compared to the men. Women reported significantly lower mean Seattle Angina Questionnaire (SAQ) scores compared to men. The inclusion of age into the models did not change the relationship between sex and the SAQ scales. However, the inclusion of the GI attenuated the relationship between sex and the SAQ scale scores., Conclusions: Our results support the concept that sex differences in health status outcomes may be better explained by patient's gender-related characteristics, than biological sex characteristics. More importantly, the GI offers a pragmatic composite score to assess the effects of psychosocial factors that researchers interested in measuring gender could use in studies of subjects with CAD.

Background: Unequivocally, cardiac rehabilitation (CR) in patients with established cardiovascular disease improves survival. However, its effect on higher-risk ethnic groups has not been explored. Accordingly, we evaluated the effect of CR on South Asian (SA) compared with European Canadians with coronary artery disease (CAD)., Methods: Using the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) registry, 26,167 patients from Edmonton, Alberta who received coronary angiography with documented CAD were reviewed (January 2002 to March 2012). After excluding Chinese patients, 1027 SA patients were compared with 11,992 European Canadian patients using validated surname algorithms. Adjustment was performed using a Cox proportional hazard model., Results: Of the SA cohort, 50.6% attended CR, compared with 43.0% of the European Canadian cohort (P < 0.001). After adjustment, CR was associated with long-term survival irrespective of ethnic group (total study population: hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.52-0.63; P < 0.001; SA population: HR, 0.63; 95% CI, 0.40-0.99; P = 0.045; European population: HR, 0.57; 95% CI, 0.52-0.63; P < 0.001). When comparing SA vs European Canadians attending CR, improved survival was observed in SA patients (HR, 0.58; 95% CI, 0.40-0.85; P < 0.001). This benefit appeared limited to SA patients who completed CR (complete CR: HR, 0.37; 95% CI, 0.17-0.85; P = 0.02; incomplete CR: HR, 0.78; 95% CI, 0.45-1.35; P = 0.38)., Conclusions: Overall, referral rates to CR remains low but attendance appears higher in SA patients. Among those who attended CR, there is a strong association with improved survival irrespective of ethnic status. In SA patients with CAD, attendance and completion of CR should be strongly endorsed because of its incremental benefit., (Copyright © 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Although patients with kidney disease have potential to benefit from revascularization, they are also at higher risk of complications, which may affect quality of life., Methods and Results: We studied a cohort of 8198 adults who underwent coronary angiography in Alberta, between 2004 and 2008, and completed health-related quality-of-life (HR-QOL) surveys. Changes in HR-QOL measures were most favorable among patients who received coronary artery bypass graft (CABG), but did not significantly differ by kidney function within groups of patients who received CABG, percutaneous coronary intervention (PCI), or medical therapy (P value for interaction between estimated glomerular filtration rate [eGFR] and revascularization status >0.10 for all outcomes). Among those who received CABG, the adjusted mean EuroQol 5 dimensions (EQ-5D) utility score for those with eGFR >90 mL/min per 1.73 m(2) increased by 0.11 (95% CI, 0.09-0.14) and for those with eGFR <30 mL/min per 1.73m(2) by 0.13 (95% CI, 0.05-0.21). The adjusted mean EQ-5D utility score also increased similarly at all levels of eGFR for those who received PCI and for those who received medical management. Mean changes in Seattle Angina Questionnaire (SAQ) scores were also similar across all levels of eGFR within each treatment group for the quality of life, angina frequency, angina stability, physical limitations, and treatment satisfaction domains of the SAQ. Among those who received CABG, the adjusted mean SAQ quality of life score for those with eGFR >90 mL/min per 1.73m(2) increased by 22.1 (95% CI, 18.5-25.7) and for those with eGFR <30 mL/min per 1.73m(2) by 14.0 (95% CI, 2.31-25.63)., Conclusions: Changes in HR-QOL do not vary by kidney function among patients selected for CABG, PCI, or medical management of coronary disease., (© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: In contemporary coronary artery bypass graft (CABG) surgery, the association between symptomatic graft failure (GF) and long-term clinical outcome remains unclear. We sought to identify the clinical characteristics and outcomes of GF in symptomatic patients requiring cardiac catheterization within 1 year of CABG surgery., Methods: Using the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease registry, 5,276 patients undergoing CABG surgery from September 2002 to August 2011 were identified. Clinical outcomes in patients with symptomatic GF were observed. Predictors of GF were analyzed at a graft level, whereas long-term survival was assessed at a patient level. A propensity score matching technique was used to adjust for baseline characteristics., Results: Of our CABG cohort, 5.3% (281 patients [285 arterial and 653 vein grafts]) required symptom based coronary angiography within 1 year of CABG surgery. Acute coronary syndrome was the most common presentation (64.4%). At angiography, 27.0% (77/285) of arterial and 34.5% (225/653) of vein grafts were occluded. Respectively, arterial and vein GFs were treated as follows: percutaneous coronary intervention 61.0% versus 41.8%, re-do CABG 9.1% versus 0%, and medically without intervention 29.9% versus 58.2%. A strong trend toward reduced patient survival was noted with "arterial graft failure" (arterial ± vein GF) compared to "vein graft failure only" (no arterial GF) (adjusted hazard ratio 2.2, 95% CI 0.98-5.0, P = .056)., Conclusion: Although the rate of cardiac catheterization within 1 year of CABG is infrequent, these patients exhibit high GF rates and commonly present with an acute coronary syndrome. In addition, "arterial graft failure" compared to "vein graft failure only" confers a higher risk of adverse long-term survival., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Smoking is an undertreated risk factor for coronary artery disease (CAD) and is associated with adverse outcomes after myocardial infarction. Aims of our study were to determine if management of CAD by medical therapy (MT) alone or with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) influence smoking status at one year following angiography and if a change in smoking status at one year influences long term survival., Methods: Prospective cohort study using the APPROACH registry. Two cohorts were examined: (1) 11,334 patients who returned a one year follow-up questionnaire; (2) 4,246 patients propensity-matched based on their post-angiography treatment - MT or revascularization (RV). Multivariate modeling and survival analysis were used., Results: In the propensity-matched cohort, quit rates at one year were greater among CABG patients (68%) than PCI (37%) or MT patients (47%). Smokers in the RV group, who self-reported quitting at one year, had a significantly reduced mortality compared to those who continued to smoke., Conclusions: CABG patients were more likely to quit smoking than those treated with MT alone or PCI. Quitting smoking was associated with improved long-term survival; smoking remains a key risk factor for mortality in patients with CAD. These data underscore the importance of nicotine addiction management in patients with CAD and the need to emphasize cessation particularly in those patients undergoing MT or PCI.

Objective: Coronary artery bypass grafting (CABG) with incomplete revascularization (ICR) is thought to decrease survival. We studied the survival of patients with ICR undergoing total arterial grafting., Methods: In a consecutive series of all-comer 1000 patients with isolated CABG, operative and midterm survival were assessed for patients undergoing complete versus ICR, with odds ratios and hazard ratios, adjusted for European System for Cardiac Operative Risk Evaluation category, CABG urgency, age, and comorbidities., Results: In this series of 1000 patients with 98% arterial grafts (2922 arterial, 59 vein grafts), 73% of patients with multivessel disease received bilateral internal mammary artery grafts. ICR occurred in 140 patients (14%). Operative mortality was 3.8% overall, 8.6% for patients with ICR, and 3.2% for patients with complete revascularization (P = .008). For operative mortality using multivariable logistic regression, after controlling for European System for Cardiac Operative Risk Evaluation category (P < .001) and CABG urgency (P = .03), there was no evidence of a statistically significant increased risk of death due to ICR (odds ratio, 1.73; 95% confidence interval, 0.80-3.77). For midterm follow-up (median, 54 months [interquartile range, 27-85 months]), after controlling for European System for Cardiac Operative Risk Evaluation category (P < .001) and comorbidities (P = .017) there was a significant interaction between age ≥ 80 years and ICR (P = .017) in predicting mortality. The adjusted hazard ratio associated with ICR for patients older than age 80 years was 5.7 (95% confidence interval, 1.8-18.0) versus 1.2 (95% confidence interval, 0.7-2.1) for younger patients., Conclusions: This is the first study to suggest that ICR in patients with mostly arterial grafts is not associated with decreased survival perioperatively and at midterm in patients younger than age 80 years. Arterial grafting, because of longevity, may balance survival between complete revascularization and ICR., (Crown Copyright © 2014. Published by Mosby, Inc. All rights reserved.)

Background: Although ACC/AHA guidelines recommend a low threshold for catheterization after coronary artery bypass surgery (CABG), in clinical practice repeat revascularization often appears unfeasible and data on outcomes are scarce., Methods: Using APPROACH, a clinical data collection and outcome monitoring initiative in Alberta, Canada, we analyzed nonemergency repeat catheterization, revascularization, and mortality rates of all patients with previous CABG, grouped by indication (acute coronary syndromes [ACS], stable angina [SA]) and compared to those of the cohort without previous CABG., Results: Of 7,127 patients, 31.5%, and 11% received percutaneous revascularization (PCI), or reoperation, respectively. Significantly more post-CABG patients were managed medically as compared with the overall APPROACH cohort of coronary disease patients (57.5% vs. 41.5%-P < 0.001). Post CABG patients with ACS received PCI more often than those with SA (36.4% vs. 24.8%). PCI was associated with improved both non-adjusted and adjusted mortality by 22 and 19%, respectively (P < 0.001) during a follow-up of up to 14 years. Patients with diabetes had a higher mortality rate than those without at 1-, 5-, and 10-year follow-up in every treatment group. However PCI was associated with a similar improvement in mortality (HR: 0.76 [95% SD: 0.65-0.90]) in diabetic patients (HR: 0.85 [95% SD: 0.75-0.96]) when compared to medical management., Conclusion: Significantly fewer post-CABG patients received repeat revascularization than all-comers however; PCI was associated with improved mortality in both the diabetic and the nondiabetic patient population. These findings support the practice of attempting revascularization in post-CABG patients, particularly in those with an ACS., (Copyright © 2012 Wiley Periodicals, Inc.)

Background: Although bilateral internal thoracic artery (BITA) grafting in coronary artery bypass grafting (CABG) is associated with low morbidity and good long-term results, controversy exists about the age after which BITA grafting is no longer beneficial. We sought to determine if such an age cutoff point exists., Methods: The study cohort consisted of 5,601 consecutive patients from a cardiac surgery registry who underwent isolated CABG (1,038 [19%] BITA grafts, 4,029 [72%] single internal thoracic artery [SITA] grafts, 534 [10%] vein-only grafts) between 1995 and 2008. A Cox model was used to compare survival by use of bilateral, single, or no internal thoracic artery (ITA) grafts, adjusting for baseline clinical and demographic characteristics., Results: Mean follow-up was 7.1 years. Patients undergoing BITA grafting had the lowest 1-year mortality (2.4% versus 4.3% SITA grafting and 8.2% vein-only grafting; p < 0.0001). Relative to SITA grafting, a crude survival benefit of 54% existed for BITA grafting (hazard ratio [HR] 0.46; 95% confidence interval [CI], 0.37 to 0.57; p < 0.0001) with worse survival for vein-only grafts (HR, 1.16; 95% CI, 0.99 to 1.37; p = 0.07). After adjustment, the benefit of BITA grafting was no longer statistically significant (HR, 0.87; 95% CI, 0.69 to 1.08; p = 0.2). However age may be an effect modifier: a spline analysis plotting HR (BITA grafting versus SITA grafting) against age suggested a potential survival advantage associated with BITA grafting in patients younger than 69.9 years., Conclusions: Bilateral internal thoracic artery grafting is a reasonable revascularization strategy in suitable patients up to age 70 years. As benefits of arterial grafting become more obvious over time, a longer period of follow-up will be needed to confirm the advantage of a BITA grafting strategy. In the meantime the BITA grafting advantage for patients older than 70 years is not clear., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: People of South Asian (SA) ancestry are susceptible to coronary artery disease (CAD). Although studies suggest that SA with CAD has a worse prognosis compared with Europeans, it is unknown whether corresponding differences in functional status and quality-of-life (QOL) measures exist. Accordingly, we compared symptoms, function, and QOL in SA and European Canadians with CAD using the Seattle Angina Questionnaire (SAQ)., Methods: Using the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease, an outcomes registry that captures patients undergoing cardiac catheterization in Alberta, Canada, we identified 635 SA and 18,934 European patients with angiographic CAD from January 1995 to December 2006 who reported health status outcomes using the SAQ at 1 year after the index catheterization. To obtain comparable clinical variables among SA and Europeans, we used a propensity score-matching technique., Results: One-year adjusted mean (SD) scores were significantly lower in SA compared with European Canadians for most SAQ domains: exertional capacity (75 [23] vs 80 [23], P = .011), anginal stability (77 [28] vs 77 [27], P = .627), anginal frequency (86 [23] vs 88 [20], P < .001), treatment satisfaction (86 [19] vs 89 [16], P < .001), and SAQ QOL (71 [24] vs 76 [21], P < .001). These results could not be accounted for by differences in baseline QOL scores or changes in health status from baseline to 1 year., Conclusion: South Asian Canadians with established CAD have significantly worse health status outcomes at 1 year after angiography compared with European Canadians. Further studies are warranted to improve functional outcomes in SA with CAD., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Background: The clinical correlates of coronary collaterals and the effects of coronary collaterals on prognosis are incompletely understood., Methods: We performed a study of 55,751 patients undergoing coronary angiography to evaluate the correlates of angiographically apparent coronary collaterals, and to evaluate their association with survival., Results: The characteristic most strongly associated with the presence of collaterals was a coronary occlusion (odds ratio [OR], 28.9; 95% confidence interval [CI], 27.1-30.6). Collaterals were associated with improved adjusted survival overall (hazard ratio [HR] 0.89; 95% CI, 0.85-0.95), and in both acute coronary syndrome (ACS) (HR 0.90; 95% CI, 0.84-0.96) and non-ACS (HR 0.84; 95% CI, 0.77-0.92) patients. Collaterals were associated with improved survival in those receiving angioplasty (HR 0.78; 95% CI, 0.71-0.85) and those with low risk anatomy treated medically (HR 0.84; 95% CI, 0.72-0.98), but not for those treated with coronary bypass graft surgery or those with high-risk anatomy treated without revascularization., Conclusions: The major correlate of coronary collaterals is the presence/extent of obstructive coronary artery disease. Collaterals are associated with better survival overall and in both ACS and non-ACS presentations, but not for those treated with coronary artery bypass graft (CABG) or those with high-risk anatomy who are not revascularized., (Copyright © 2011 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: The Seattle Angina Questionnaire (SAQ), a descriptive quality of life instrument, is often used in coronary artery disease studies. In its current form, however, it cannot be used in economic evaluations. The investigators sought to create a mapping algorithm that would allow translation of SAQ scores into EQ-5D utility scores., Methods: Data from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) database were used to examine the relationship between scores in each of the 5 domains of the SAQ (physical limitation, anginal stability, anginal frequency, treatment satisfaction, and disease perception) and the EQ-5D utility score. The cohort was divided into 80% derivation and 20% validation sets. Mapping algorithms were developed using simple linear regression and Tobit models. To account for the skewed distribution of the EQ-5D scores and the presence of heteroscedasticity, Bayesian extensions were applied to each model by specifying a nonconstant variance for the error term. Model performance was assessed by comparing predicted and observed mean EQ-5D scores in the validation set, and the unadjusted R2., Results: The cohort consisted of 1992 patients. The simple linear regression model had the best predictive performance, with an R2 of 0.38. The nonconstant variance term did not improve overall performance for any of the models. The linear regression model accurately estimated the mean EQ-5D score in the validation set (predicted score 0.81 v. observed score 0.81)., Conclusions: Mean EQ-5D utility weights can be accurately estimated from the SAQ using a simple linear regression mapping algorithm.

Background: The increased recognition of significant sex/gender differences in health status outcomes, and the implications for clinical practice and service delivery, has led to calls for more gender sensitivity and specificity in research endeavors as well as within clinical practice. Previous investigations by our research group have consistently identified important sex differences in both changes in health status from baseline to 1 year and in health status outcomes of patients treated for coronary artery disease (CAD), with women reporting poorer health-related quality of life (HRQoL) compared with men., Objective: The objective of this study was to examine whether persistent sex differences in the health status of patients with CAD may be attributed to social factors such as gender roles., Methods: Sex differences in baseline clinical and demographic characteristics of patients who completed the 1-year follow-up survey were examined using t tests and χ(2) analyses. Structural equation modeling, an inclusive statistical modeling approach for testing hypotheses about relationships among measured and latent variables (concepts not observed or measured directly), was used to test our theoretical model., Results: HRQoL data were collected on 2403 patients 1 year after index catheterization. The results indicated that the model fit was substantially improved by the addition of the conceptualized gender-role variable. Furthermore, there was a significant effect of gender role on QoL (-0.106; P < 0.05). Age, coronary anatomy, ejection fraction, physical limitation, anginal frequency, and gender role variables in this model were able to explain 51% of the variance in HRQoL. In particular, reported physical limitations, anginal frequency, and gender role had large statistically significant direct effects on HRQoL., Conclusions: Advances in the treatment of CAD have led to significant decreases in mortality rates. Our current challenge is to minimize the long-term impact of CAD on HRQoL outcomes. While a substantial body of literature has examined the correlations between gender-role attributes and a wide variety of both positive and negative outcomes, this area has not been explored in patients with cardiovascular disease. These findings suggest that further study of the influence of gender role (using a gender-role measurement) on HRQoL is needed., (Copyright © 2010 Excerpta Medica Inc. All rights reserved.)

Aims Our objective was to examine the association between body mass index (BMI) and survival according to the type of treatment in individuals with established coronary artery disease (CAD). Methods and results Patients with CAD were identified in the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) registry between January 2001 and March 2006. Analyses were conducted separately by treatment strategy [medical management only, percutaneous coronary intervention (PCI), or coronary artery bypass grafting (CABG)]. Patients were grouped according to six BMI categories. Multivariable-adjusted hazard ratios (HRs) for mortality were calculated using the Cox regression with the referent group for all analyses being normal BMI (18.5-24.9 kg/m(2)). The cohort included 31 021 patients with a median follow-up time of 46 months. In the medically managed only group, BMIs of 25.0-29.9 and 30.0-34.9 kg/m(2) were associated with significantly lower mortality compared with normal BMI patients (adjusted HR 0.72; 95% CI 0.63-0.83 and adjusted HR 0.82; 95% CI 0.69.0-0.98, respectively). In the CABG group, BMI of 30.0-34.9 kg/m(2) had the lowest risk of mortality (adjusted HR 0.75; 95% CI 0.61-0.94), whereas in the PCI group, BMI of 35.0-39.9 kg/m(2) had the lowest risk of mortality (adjusted HR 0.65; 95% CI 0.47-0.90). Patients who were overweight or have mild or moderate obesity were also more likely to undergo revascularization procedures compared with those with normal BMI, despite having lower risk coronary anatomy. Conclusion A paradoxical association between BMI and survival exists in patients with established CAD irrespective of treatment strategy. Patients with obesity may be presenting earlier and receiving more aggressive treatment compared with those with normal BMI.

Background: Because patients with coronary artery disease (CAD) could benefit from interventions to decrease psychological distress, it is important to identify these individuals. Both salivary cortisol level and the Hospital Anxiety and Depression Scale (HADS) are recognized measures of stress/anxiety and depression., Objectives: This study was designed to determine whether there is an association between anxiety and depression, as measured by the HADS, and salivary cortisol levels among patients with CAD, and whether this association is affected by gender., Methods: All adult residents of Alberta, Canada, undergoing their first cardiac catheterization for CAD (>or=50% occlusion of >or=2 coronary arteries) were eligible for participation in this study. A 14-question survey (the HADS) and 3 saliva-collection devices (a 1-day supply) were sent to the participants' home within 1 week of their initial cardiac catheterization. Participants were asked to take saliva samples for determination of cortisol levels on waking and at 30 and 60 minutes after waking, and then return the completed questionnaire and saliva samples using a prepaid express mailing envelope., Results: Seventy-one adults (52 men and 19 women) participated in the study. Mean (SD) ages were 68.4 (4.6) years for men and 69.1 (4.4) years for women. Among the women, significant negative correlations were found between the HADS anxiety score and the wake-up and 30-minute cortisol levels (higher HADS scores were associated with lower cortisol levels) (all, P < 0.05). Also among women, negative correlations were found between the HADS depression score and the salivary cortisol values, but the differences were not statistically significant. Conversely, among the men, nonsignificant positive correlations were found between the HADS anxiety scores and the salivary cortisol levels (higher HADS scores were associated with higher cortisol levels), and statistically significant positive correlations were observed between the HADS depression scores and all 3 salivary cortisol values (all, P < 0.05)., Conclusions: Our findings suggest that the HADS is an appropriate screening instrument for anxiety and depression in patients with CAD. In particular, the scale appears to be sensitive for measuring anxiety in women and depression in men. When the HADS is used clinically as a screening tool, it should be examined through a "gender-based lens."., Competing Interests: The authors have indicated that they have no other conflicts of interest regarding the content of this article.

The purpose of this study is understanding women's experiences regarding health-related quality of life (HRQOL) in the context of living with coronary artery disease (CAD). Sampling was purposive and continued until data saturation. The women participated in semistructured interviews that were tape-recorded and completed in less than 1 hour. Conventional content analysis was used to analyze the data. Results indicate that CAD influenced the participants' HRQOL. This occurred through categories the investigators labeled "dealing with one more thing," "surrendering roles and pleasures," "managing the health system," "understanding CAD," and "resolving to be strong." The thoughtful responses of the women in this study suggest that understanding the HRQOL of women who have CAD lies in the context of considering their quality and quantity of social support. Thus, it behooves health care providers to assess patients' levels of social support and intervene as appropriate.

Background: Studies have identified prevalence rates of major depression in patients with cardiovascular disease to range from 16% to 23%, whereas 65% of patients report some symptoms after a myocardial event. Depression has been shown to be strongly related to overall poorer outcomes in patients with coronary artery disease., Purpose: The purpose of this pilot study was to assess the potential benefit of providing follow-up information regarding mental health resources to patients who had undergone cardiac catheterization and had reported significant levels of depression symptoms. Two methods of providing this follow-up information (personal telephone interaction and mailed-out written information) were compared., Methods: As part of the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry, patients completed baseline questionnaires, including the 10-item Center for Epidemiologic Studies Depression (CES-D) Scale. Patients reporting a score of 10 or higher were randomly assigned to one of three groups. Group A patients were contacted by mail, whereas Group B patients were contacted through a telephone follow-up call by a nurse. Both groups received information regarding community- and hospital-based mental health resources. Six weeks after the initial contact, patients in Groups A and B and those in a third control group (Group C) were called and asked to complete a repeat CES-D via telephone interview. Logistic regression modeling was used to determine the influence of the intervention on the change in depression scores from baseline to 6 weeks., Results: Ninety-eight respondents had both baseline and 6-week CES-D scores. The mean age of the respondents was 64.9 years, and women constituted 27% of the sample. There was no statistically significant clinical difference between the three groups. Regression analysis demonstrated that patients who were contacted by either telephone or mail were significantly more likely to report improvement in the CES-D scores (odds ratio = 3.03, p = .03) as compared with the control group. Furthermore, respondents who were phoned reported the highest percentage of improved CES-D scores as compared with the mailed and control groups., Conclusions: This pilot study demonstrated that early recognition strategies and referral protocols that address mental health needs are effective in decreasing the reported depressive symptomatology of this high-risk population. Proactively addressing mental health issues as an integral part of the overall treatment with patients with coronary artery disease could potentially improve the health outcomes in this population.

Background: Although eradicating discrepancies in health is of unquestioned importance, there are few studies examining health-related quality of life (HRQOL) among men and women with coronary artery disease (CAD), a highly prevalent and morbid condition among industrialized nations. This study compares the HRQOL outcomes of men and women in Alberta, Canada, 1 year after the documentation of coronary artery disease by cardiac catheterization., Method and Results: Patients' disease-specific HRQOL was assessed 1 year after angiography using the Seattle Angina Questionnaire, whereas their generic health status, burden of depressive symptoms, and social support were respectively quantified with the EuroQol EQ-5D, the Center for Epidemiological Studies Depression Scale (short form), and the Medical Outcomes Study social support scale. The latter 2 instruments were used to adjust Seattle Angina Questionnaire outcomes for potential confounding characteristics hypothesized to be associated with sex and gender. General linear modeling and a change in Seattle Angina Questionnaire scores from baseline to 1 year were used to compare the HRQOL outcomes of men and women, after adjusting for demographics, clinical factors, depressive symptoms, and social support differences between groups. A total of 2394 (60% of those eligible) patients responded to the baseline and the 1-year follow-up survey. The adjusted mean 1-year Seattle Angina Questionnaire scores were significantly higher in men when compared with women, even after adjustment for all clinical factors, social support, depressive symptoms, and baseline HRQOL scales. Not only were women noted to have worse health status at the time of angiography, but despite adjusting for these differences, residual discrepancies in 1-year health status persisted., Conclusions: Women with coronary artery disease report worse HRQOL 1 year after coronary angiography when compared with men, and the discrepancies observed are only partially accounted for by sex differences in depression and social support. As a result, the measurement of gender roles and perceptions may be the best place to persist on the quest to identifying and understanding the noted discrepancies in cardiac recovery and HRQOL outcomes.

Background: Chelation therapy is frequently used by patients for the treatment of coronary artery disease. However, relatively little is known about patient attitudes and beliefs that underlie the use of this treatment. The aim of the present study was to document patients' opinions and beliefs about health care decision making, physician and patient communication and relationships, and reasons for using or not using chelation therapy as treatment for coronary artery disease., Methods: A mail survey was sent to patients who underwent coronary angiography between 1998 and 2000 in Alberta. Information was collected on self-reported reasons for chelation therapy use, sociodemographic characteristics, communication and relationships between patients and physicians, as well as beliefs regarding surgery, medications and chelation therapy., Results: Of the 780 patients who received surveys, 96 users and 264 nonusers of chelation therapy completed questionnaires. Among the users, 20.8% believed that chelation therapy could cure heart disease, 44.2% believed that it could relieve symptoms, 16.7% believed that it could have side effects and 58.4% believed that it could increase quality of life. Users and nonusers were similar in their beliefs about safety and benefits of heart surgery, but users of chelation therapy were less likely than nonusers to believe that using conventional medications could prevent worsening of heart disease (53.1% versus 67.4%), increase quality of life (74.0% versus 85.2%) and give a feeling of control over heart disease (61.5% versus 77.7%)., Conclusions: Many chelation therapy users appeared to have negative views toward the benefits of conventional medications and positive views toward the safety of chelation therapy. Users and nonusers of chelation therapy had the same views toward the benefits and safety of heart surgery.

Aims: To describe health status outcomes at 4 years for a cohort of elderly patients with cardiac disease., Methods and Results: Using the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease, an outcomes initiative capturing all patients undergoing cardiac catheterization in Alberta, Canada, health status was measured using the Seattle Angina Questionnaire (SAQ) and crude and risk-adjusted outcomes were determined and compared for patients treated with percutaneous coronary intervention or coronary artery bypass surgery (CABG) vs. medical therapy. Response rates among surviving, consenting patients were 64.8% for patients <70 years (n=7883), 77.3% for patients aged 70-79 years (n=2940), and 77.7% for patients >or=80 years of age (n=439). For patients aged <70 years, and those aged 70-79 years, for all dimensions of the SAQ, scores were significantly better for patients treated with revascularization procedures than with medical therapy. For patients over the age of 80 years, scores for patients treated with CABG in particular were significantly better, with the exception of exertional capacity. At 3 years, all scores remained stable or improved, and continued to favour revascularization., Conclusion: Elderly patients undergoing revascularization have better health status at 4 years than do those in the same age group who do not undergo revascularization. These findings suggest that age should not deter against revascularization given the combined survival and quality-of-life benefits.

Background: The optimal population rate of cardiac catheterization is unknown. One potential way to determine it would be to examine whether there is a population rate beyond which the yield of high-risk coronary artery disease (CAD) does not rise., Methods: Using a detailed clinical registry that captures all patients undergoing cardiac catheterization in Alberta, we determined annual population rates of cardiac catheterization and the corresponding yield of cases of high-risk CAD in each of Alberta's 17 health regions from 1995 to 2002. Least squares linear regression analysis and hierarchical modelling methods were then used to assess the linear relation between catheterization rates and rates of high-risk CAD., Results: The age-adjusted average rate of cardiac catheterization among men ranged from 404.9 to 638.1 per 100,000 population aged over 20 years. Among women, the average rate ranged from 171.8 to 314.0 per 100,000. For both sexes, increased regional rates of catheterization were associated with a linearly increasing yield of high-risk CAD, with no evidence of a plateau in yield when more procedures were performed. One additional case of high-risk CAD was identified for every 2.5 additional cardiac catheterization procedures performed among men, and for every 3.7 additional procedures performed among women., Interpretation: The increasing yield of patients with high-risk CAD associated with increased regional population rates of cardiac catheterization, together with the absence of a plateau in yield, suggests that Alberta's population rates of cardiac catheterization are suboptimal to detect people with high-risk CAD.

This study on patients undergoing coronary angiography for acute myocardial infarction demonstrated that 2.8% of patients had angiographically normal coronary arteries and that these patients have a better prognosis than patients with angiographically verified coronary artery disease. The trend toward a higher prevalence of malignancy in this unique patient group raises the possibility of malignancy-induced hypercoagulability or inflammation as an underlying etiologic factor.

Objectives: This study was designed to examine the use of cardiovascular medications and outcomes in patients with heart failure (HF) and renal dysfunction., Background: Renal insufficiency is associated with poorer outcomes in patients with HF, but the mechanisms are uncertain. In particular, the degree of therapeutic nihilism in these patients, and whether it is appropriate, is unclear., Methods: This was a prospective cohort study with a one-year follow-up., Results: In 6,427 patients with cardiologist-diagnosed HF and angiographically proven coronary artery disease (mean age 69 years; 65% men; one-year mortality, 10%), 39% had creatinine clearances <60 ml/min. Patients with renal insufficiency were less likely to be prescribed angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, statins, or aspirin (all p < 0.001). However, users of aspirin (odds ratio [OR] 0.69, 95% confidence interval [CI] 0.57 to 0.85), statins (OR 0.79, 95% CI 0.64 to 0.97), and beta-blockers (OR 0.75, 95% CI 0.62 to 0.90) were less likely to die in the subsequent 12 months than nonusers, irrespective of renal function (all OR adjusted for covariates including atherosclerotic burden and ejection fraction). Although ACE inhibitor users with creatinine clearances > or =60 ml/min had lower 12-month mortality (OR 0.72, 95% CI 0.48 to 0.99), ACE inhibitor users with clearances <60 ml/min did not (OR 1.21, 95% CI 0.97 to 1.51)., Conclusions: Renal insufficiency is common in patients with HF and coronary artery disease, and these patients have more advanced coronary atherosclerosis. Patients with renal insufficiency are less likely to be prescribed efficacious therapies, but have better outcomes if they receive these medications.

Background: Given the repeated findings of little or no difference in mortality outcomes between percutaneous coronary intervention (PCI) with or without stent and coronary artery bypass graft surgery (CABG), there is a need to assess the health-related quality of life (HRQOL) outcomes associated with revascularization decisions., Objective: To compare risk-adjusted HRQOL outcomes by treatment strategy one year following cardiac catheterization., Methods: Using an inception cohort study design, the sample included all Alberta residents, 18 years of age or older, referred for cardiac catheterization, from January 1, 1996, to December 31, 1998, with two or more diseased coronary vessels at catheterization. Patients received a follow-up questionnaire including the Seattle Angina Questionnaire (SAQ), one year following their index catheterization. The SAQ comprises five dimensional scales measuring exertional capacity, anginal stability, anginal frequency, treatment satisfaction and quality of life., Results: Three thousand three hundred ninety-two (78.1%) patients responded to the follow-up survey. Responders who were revascularized consistently reported significantly better HRQOL compared with responders treated with medical management. Responders undergoing CABG reported significantly better HRQOL in all but one SAQ dimension compared with responders who had either a PCI with or without stent. Responders who had a PCI with stent reported better HRQOL compared with responders who underwent a PCI without a stent., Conclusion: The treatment decision to revascularize the coronary vessels, whether with PCI with or without a stent or with CABG, was consistently associated with significantly better HRQOL at one-year follow-up compared with patients treated with medical therapy.

Background: Although there have been substantial medical advances that improve the outcomes following cardiac ischemic events, gender differences in the treatment and course of recovery for patients with coronary artery disease (CAD) continue to exist. There is a general paucity of data comparing the health related quality of life (HRQOL) in men and women undergoing treatment for CAD. The purpose of this study was to compare HRQOL outcomes of men and women in Alberta, at one-year following initial catheterization, after adjustment for known demographic, co-morbid, and disease severity predictors of outcome., Method: The HRQOL outcome data were collected by means of a self-reported questionnaire mailed to patients on or near the one-year anniversary of their initial cardiac catheterization. Using the Seattle Angina Questionnaire (SAQ), 5 dimensions of HRQOL were measured: exertional capacity, anginal stability, anginal frequency, quality of life and treatment satisfaction. Data from the APPROACH registry were used to risk-adjust the SAQ scale scores. Two analytical strategies were used including general least squares linear modeling, and proportional odds modeling sometimes referred to as the "ordinal logistic modeling"., Results: 3392 (78.1%) patients responded to the follow-up survey. The adjusted proportional odds ratios for men relative to women (PORs > 1 = better) indicated that men reported significantly better HRQOL on all 5 SAQ dimensions as compared to women. (PORs: Exertional Capacity 3.38 (2.75-4.15), Anginal Stability 1.23 (1.03-1.47), Anginal Frequency 1.70 (1.43-2.01), Treatment Satisfaction 1.27 (1.07-1.50), and QOL 1.74 (1.48-2.04)., Conclusions: Women with CAD consistently reported worse HRQOL at one year follow-up compared to men. These findings underline the fact that conclusions based on research performed on men with CAD may not be valid for women and that more gender-related research is needed. Future studies are needed to further examine gender differences in psychosocial adjustment following treatment for CAD, as adjustment for traditional clinical variables fails to explain sex differences in health related quality of life outcomes.

Background: Available cardiac surgery risk scores have not been validated in octogenarians. Our objective was to compare the predictive ability of the Society of Thoracic Surgeons (STS) score, EuroSCORE I, and EuroSCORE II in elderly patients undergoing isolated coronary artery bypass grafting surgery (CABG).Methods: All patients who underwent isolated CABG (2002 - 2008) were identified from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) registry. All patients aged 80 and older (n = 304) were then matched 1:2 with a randomly selected control group of patients under age 80 (n = 608 of 4732). Risk scores were calculated. Discriminatory accuracy of the risk models was assessed by plotting the areas under the receiver operator characteristic (AUC) and comparing the observed to predicted operative mortality.Results: Octogenarians had a significantly higher predicted mortality by STS Score (3 ± 2% vs. 1 ± 1%; p < 0.001), additive EuroSCORE (8 ± 3% vs. 4 ± 3%; p < 0.001), logistic EuroSCORE (15 ± 14% vs. 5 ± 6%; p < 0.001), and EuroSCORE II (4 ± 3% vs. 2 ± 2%; p < 0.001) compared to patients under age 80 years. Observed mortality was 2% and 1% for patients age 80 and older and under age 80, respectively (p = 0.323). AUC revealed areas for STS, additive and logistic EuroSCORE I and EuroSCORE II, respectively, for patients age 80 and older (0.671, 0.709, 0.694, 0.794) and under age 80 (0.829, 0.750, 0.785, 0.845).Conclusion: All risk prediction models assessed overestimated surgical risk, particularly in octogenarians. EuroSCORE II demonstrated better discriminatory accuracy in this population. Inclusion of new variables into these risk models, such as frailty, may allow for more accurate prediction of true operative risk. [ABSTRACT FROM AUTHOR]

A plethora of research has focused on the importance of seeking timely treatment in the event of an acute coronary syndrome. However, little attention has been given to symptom presentation in acute coronary syndromes, specifically among persons of South Asian descent. South Asians are of particular importance, as they have the highest burden of cardiovascular disease among any other ethnic group. A detailed analysis of typical versus atypical, location, characteristics, and intensity of symptoms in acute coronary syndromes is provided. The literature suggests that persons of South Asian descent are more likely to present with atypical symptoms, whereas Caucasian males typically present with classical symptoms. Further research is required and critical to creating awareness among health practitioners when considering differentials and timely treatment in acute coronary syndromes among South Asians. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Coronary artery bypass grafting (CABG) improves outcomes in patients with multivessel coronary artery disease. Bypass of angiographically significant lesions ≥70% is recommended, yet little is known about the incidence/outcomes with bypasses of 50-69% angiographically borderline lesions (ABLs) without fractional flow reserve testing. The objective of this study was to investigate the incidence and outcomes of bypass of 50-69% ABLs. METHODS: Between 2007 and 2013, 3195 patients underwent isolated first multivessel CABG. Patients with an isolated ABL of a major epicardial vessel were included. Outcomes of interest included time to all-cause mortality, and 30-day and 1-year mortality. RESULTS: Among 350 patients with an ABL, 268 (76.6%) had the vessel containing the ABL bypassed, while 82 (23.4%) did not. The mean follow-up was 4.2 years. Patients with a bypassed ABL were older (66.1 vs 62.5 mean years, P = 0.006) but otherwise similar in sex, comorbidities, diabetes, ejection fraction and number of coronary stenoses. Cardiopulmonary bypass time was longer in patients with bypassed ABLs (104.2 vs 90.4 min, mean, P < 0.001). Unadjusted overall mortality until the end of follow-up was higher among patients with bypassed ABLs (11.6 vs 3.7%, P = 0.034). After multivariable adjustment, the association between ABL bypass and mortality was attenuated (hazard ratio 2.84, 95% confidence interval: 0.87-9.23, P = 0.080). No differences were observed in unadjusted 30-day (1.1 vs 0.0%, P = 0.336) or 1-year mortality (4.1 vs 0.0%, P = 0.062). Repeat revascularization rate of patients with bypassed ABLs was numerically higher (4.1 vs 0.0%, P = 0.107). CONCLUSIONS: In an unselected cohort of patients with ABLs, bypass of borderline 50-69% lesions is frequently performed and not associated with improved long-term survival. Our findings suggest that the routine surgical revascularization of 50-69% ABLs may not be warranted. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Ordinal scales often generate scores with skewed data distributions. The optimal method of analyzing such data is not entirely clear. The objective was to compare four statistical multivariable strategies for analyzing skewed health-related quality of life (HRQOL) outcome data. HRQOL data were collected at 1 year following catheterization using the Seattle Angina Questionnaire (SAQ), a disease-specific quality of life and symptom rating scale. Study Design and Setting: In this methodological study, four regression models were constructed. The first model used linear regression. The second and third models used logistic regression with two different cutpoints and the fourth model used ordinal regression. To compare the results of these four models, odds ratios, 95% confidence intervals, and 95% confidence interval widths (i.e., ratios of upper to lower confidence interval endpoints) were assessed. Results: Relative to the two logistic regression analysis, the linear regression model and the ordinal regression model produced more stable parameter estimates with smaller confidence interval widths. Conclusion: A combination of analysis results from both of these models (adjusted SAQ scores and odds ratios) provides the most comprehensive interpretation of the data. [Copyright &y& Elsevier]