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Background An effective and safe oral anticoagulation (OAC) strategy for patients with new postoperative AF (POAF) after noncardiac surgery remains unclear. We aimed to determine the association between OAC use and 1) thromboembolic events and 2) major bleeding in patients with POAF after noncardiac surgery. Methods A retrospective cohort (1999-2015) was used to identify patients with new POAF after inpatient noncardiac surgery. Initiation of OAC was defined as prescription of an OAC within 30 days following hospital discharge. Times to first hospital admission or emergency department visit for a thromboembolic or major bleeding event were compared using Cox proportional hazards models. Results We identified 22,007 patients with new POAF after inpatient noncardiac surgery. The majority of patients had intermediate (CHA2DS2-VASc 2-3: 45%) to high (CHA2DS2-VASc ≥ 4: 42%) thromboembolic risk. During a mean follow-up of 4 years, a total of 1099 (5%) thromboembolic and 3250 (15%) bleeding events occurred. Compared with patients not on anticoagulation, anticoagulation did not reduce the risk for thromboembolic events (adjusted hazard ratio [aHR] 0.89, 95% CI 0.73-1.07). In patients initiated on anticoagulation, there was an association with a higher risk for major bleeding (aHR 1.14, 95% CI 1.04-1.25). Conclusions In patients with new POAF after noncardiac surgery, anticoagulation was not associated with a reduction in long-term thromboembolic events; however, this was accompanied by an overall increased risk for major bleeding. Future prospective clinical studies are needed to better address the role for anticoagulation therapy in the setting of POAF after noncardiac surgery to understand the efficacy and safety of treatment.

Background Recent randomized control trials have described a protective cardiovascular effect of novel glucose lowering drugs in patients at high cardiovascular risk. Whether these second-line agents have similar effects in the general population is unknown. We aimed to compare the risk of major cardiovascular and adverse events in new users of sodium-glucose cotransporter-2 inhibitors (SGLT-2i), dipeptidyl peptidase-4 inhibitor (DPP-4i), glucagon-like peptide 1 agonist (GLP-1a), and sulfonylurea in T2DM patients not controlled on metformin therapy. Methods Retrospective cohort study using the MarketScan database (2011–2015). We selected T2DM individuals who were newly dispensed sulfonylureas, SGLT-2i, DPP-4i, or GLP-1a, as second-line therapy, added to metformin. Cohort entry was defined by date of first prescription of the second-line agent. Time to first non-fatal cardiovascular or adverse event was compared using Cox regression models adjusted for confounders. Results Among 118,341 T2DM patients using metformin (mean age: 56), most were at low cardiovascular risk (4% with previous cardiovascular or cerebrovascular event). During a median follow-up of 10 months compared with sulfonylureas users, cardiovascular risk was lower in users of SGLT-2i (aHR = 0.61; 95% CI: 0.40–0.97), DPP-4i (aHR = 0.79; 95% CI: 0.69–0.90) and GLP-1a (aHR = 0.65; 95% CI: 0.48–0.89). Serious adverse events were rare but compared with sulfonylurea, the risk was lower in new users of novel glucose lowering agents. Conclusion In our analyses, which included patients with and without prior cardiovascular disease, initiating novel glucose lowering drugs as second-line therapy for T2DM was associated with a lower risk of cardiovascular and adverse events than sulfonylurea initiation.

This study aimed to paradigmatically show the development of a gender score that can be used as either an adjustment or a matching variable to separate the effects of gender versus biological sex in a sample of older adults.Our sample comprised 1100 participants from the Berlin Aging Study II (52% women, mean [standard deviation] age = 75.6 [3.8] years). The gender score included a multitude of gender-related variables and was constructed via logistic regression. In models of health outcomes, it was used as an adjustment variable in regression analyses as well as a matching variable to match older men and women according to their gender.Matching by gender substantially reduced sample size to n = 340. Analyses (either adjusting for gender or matching men and women according to gender) revealed that female sex was independently associated with lower grip strength (B = -14.47, 95% confidence interval [CI] = -15.51 to -13.44), better cognitive performance (B = 3.47, 95% CI = 1.94 to 5.0), higher pulse wave velocity (B = 0.19, 95% CI = 0.06 to 0.31), lower body mass index (B = -0.97, 95% CI = -1.74 to -0.21), and lower rates of metabolic syndrome (odds ratio = 0.53, 95% CI = 0.37 to 0.77). In addition, both sex and gender were independently associated with cognitive performance and depression.Calculating a gender score allows for the inclusion of a large number of variables, creating parsimonious models that are adaptable to different data sets and alternative gender definitions. Depending on the research question and the sample properties, the gender score can be used as either an adjustment or a matching variable.Trial Registration: DRKS-Deutsches Register Klinischer Studien (Study ID: DRKS00016157).

Background The extent to which race influences in‐hospital quality of care for young adults (≤55 years) with acute myocardial infarction (AMI) is largely unknown. We examined racial disparities in in‐hospital quality of AMI care and their impact on 1‐year cardiac readmission. Methods and Results We used data from the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study enrolling young Black and White US adults with AMI (2008–2012). An in‐hospital quality of care score (QCS) was computed (standard AMI quality indicators divided by the total a patient is eligible for). Multivariable logistic regression was performed to identify factors associated with the lowest QCS tertile, including interactions between race and social determinants of health. Among 2846 young adults with AMI (median 48 years [interquartile range 44–52], 67.4% women, 18.8% Black race), Black individuals, especially women, exhibited a higher prevalence of cardiac risk factors and social determinants of health and were more likely to experience a non–ST‐segment–elevation myocardial infarction than White individuals. Black individuals were more likely in the lowest QCS tertile than White individuals (40.8% versus 34.7%; P =0.003). The association between Black race and low QCS (odds ratio [OR], 1.25; 95% CI, 1.02–1.54) was attenuated by adjustment for confounders. Employment was independently associated with better QCS, especially among Black participants (OR, 0.76; 95% CI, 0.62–0.92; P‐ interaction =0.02). Black individuals experienced a higher rate of 1‐year cardiac readmission (29.9% versus 20.0%; P Conclusions Black individuals with AMI received lower in‐hospital quality of care and exhibited a higher rate of cardiac readmissions than White individuals. Black individuals had a lower quality of care if unemployed, highlighting the intersection of race and social determinants of health.

Introduction: The extent to which race influences in-hospital quality of care among young adults with acute myocardial infarction (AMI) is unknown. We examined racial differences in in-hospital quality of AMI care in young adults and described the patient and/or clinical characteristics associated with potential disparities in care. Methods: Data from the GENESIS-PRAXY (Canada) and the VIRGO (U.S.) prospective cohorts of young adults with AMI were analyzed. Among a total of 4,048 adults with AMI (≤55 years) (median=49 years [IQR 44-52], 22% non-white, 58% women), we calculated an in-hospital quality of care score (QCS) for AMI (quality indicators divided by total, with higher scores indicating better care) based on AHA quality of care standards, reporting data disaggregated by race. We categorized race as white versus non-white, which included Black, Asian and North American Indigenous populations. Results: This cohort was comprised of 906 non-white individuals and 3142 white individuals. Non-white adults exhibited a clustering of adverse cardiac risk factors, psychosocial risk factors and comorbidities versus whites; they had higher rates of hypertension, diabetes, alcohol abuse and prior AMI and lower rates of physical activity. They were more likely to have a low SES and receive low social support, and were less likely to be employed, a primary earner, or married/living with a partner. Non-white individuals were also more likely to experience a NSTEMI and less likely to receive cardiac rehabilitation, smoking cessation counseling as well as dual antiplatelet therapy at discharge. Furthermore, non-white individuals had a lower crude QCS than whites (QCS=69.99 vs 73.29, P-value Conclusion: Non-white individuals with AMI exhibited higher rates of adverse psychosocial and clinical characteristics than white individuals yet non-white race was independently associated with lower in-hospital quality of care. Interventions are needed to improve quality of AMI care in non-white young adults.

Background The quality of care among young adults with acute myocardial infarction (AMI) may be related to biological sex, psycho-socio-cultural (gender) determinants or healthcare system-level factors. Purpose To examine whether sex, gender, and the type of healthcare system influence the quality of AMI care among young adults. Methods A total of 4,564 AMI young adults ( Results Women in the multipayer system had the highest risk factor burden. Across the phases of care for AMI, 20% of quality indicators were missed in both sexes. High stress, earner status, and social support were associated with a higher QCS in the pre-AMI phase, whereas only employment and earner status were associated with QCS in all other phases. In the pre-AMI phase, women had higher QCS than men, mainly in the single-payer system (adjusted-OR=1.85, 95% CI 1.46,2.35 vs. 1.07, 95% CI 0.84,1.36, P-interaction= 0.002). Regardless of sex, only employment status had a greater effect in the multipayer system (adjusted-OR=0.59, 95% CI 0.44,0.78 vs 1.13, 95% CI 0.89,1.44, P-interaction 0.05). Finally, in the post-AMI phase, men and women had a lower QCS, predominantly in the multipayer system. However, primary earners had higher QCS regardless of system. Conclusion Sex, gender, and healthcare system affected the quality of care after AMI. Women had a poorer in-hospital than men and both women and men had suboptimal post-discharge care. Being unemployed lowered the quality of care, more so in the multipayer system. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Canadian Institutes of Health and Research (CIHR)

Background: The quality of care among young adults with acute myocardial infarction (AMI) may be related to biological (sex) or psycho-socio-cultural (gender) determinants or healthcare system-level factors. Objectives: To examine whether sex, gender, and the type of healthcare system influence the quality of AMI care among young adults. Methods: A total of 4,564 AMI young adults ( Results: Women in the multipayer system had the highest risk factor burden. Across the phases of care for AMI, 20% of quality indicators were missed in both sexes. High stress, earner status, and social support were associated with a higher QCS in the pre-AMI phase, whereas only employment and earner status were associated with QCS in all other phases. In the pre-AMI phase, women had higher QCS than men, mainly in the single-payer system (adjusted-OR=1.85, 95%CI 1.46,2.35 vs. 1.07, 95%CI 0.84,1.36, P-interaction=0.002). Regardless of sex, only employment status had a greater effect in the multipayer system (adjusted-OR=0.59, 95%CI 0.44,0.78 vs 1.13, 95%CI 0.89,1.44, P-interaction0.05). Finally, in the post-AMI phase, men and women had a lower QCS, predominantly in the multipayer system. However, primary earners had higher QCS regardless of the healthcare system. Conclusion: Sex, gender, and the healthcare system affected the quality of care after AMI. Women had a poorer in-hospital than men and young adults had suboptimal post-discharge care. Being unemployed lowered the quality of care, more so in the multipayer healthcare system.

Background Catheter ablation (CA) is an established therapy for atrial fibrillation (AF). Studies regarding long-term real-world outcomes post-CA have inconsistently accounted for oral anticoagulation (OAC). Objectives To describe patterns of OAC use post-CA and to compare the OAC-adjusted long-term risk of stroke and major bleeding in AF patients with and without CA. Methods A population-based cohort of AF patients was constructed in Quebec and Ontario, Canada (1999-2014). Propensity score matching was performed to determine the incidence rates of stroke and major bleeding among those undergoing CA, adjusted for time-dependent OAC use. Results From the entire cohort, 6391 patients were identified as having undergone CA as compared to 482 977 patients who did not. Of these, 1240 patients with government medical insurance undergoing CA were matched with 2427 patients without CA. Post-CA, 78%, 65%, and 61% remained on an OAC at 1, 2, and 5 years, while 75%, 71%, and 68% of patients not undergoing CA were on OACs at 1, 2, and 5 years. At follow-up, there was no statistically significant difference for stroke (adjusted hazard ratio [HR], 0.88; 95% CI, 0.63 to 1.21) or major bleeding (adjusted HR, 0.88; 95% CI, 0.73 to 1.06). Conclusion No evidence was found that CA significantly decreases the risk of stroke or major bleeding when adjusting for OAC use over time. It may be prudent to continue anticoagulation post-CA based on patient-risk profile until randomized trials demonstrate both reduced stroke rates with CA, and improved safety (balancing stroke and bleeding risk) with OAC discontinuation post-CA.

Key Points Question Among young adults with acute myocardial infarction (AMI) in the US and Canada, is quality of care associated with sex, social determinants of health (SDOH), and health care systems? Findings In this cohort study of 4048 adults 55 years or younger with AMI, being treated in the US (multipayer system) relative to Canada (single-payer system) was associated with a lower in-hospital and post-AMI quality-of-care score, regardless of all SDOH factors except unemployment. Lower in-hospital quality of care was associated with 1-year readmission rates in the US only. Meaning These findings suggest that health care systems and unemployment are associated with quality of AMI care., This cohort study of young adults aged 55 years or younger with acute myocardial infarction (AMI) in the US and Canada examines whether quality of care for AMI is associated with sex, social determinants of health, and health care systems., Importance Quality of care of young adults with acute myocardial infarction (AMI) may depend on health care systems in addition to individual-level factors such as biological sex and social determinants of health (SDOH). Objective To examine whether the quality of in-hospital and postacute care among young adults with AMI differs between the US and Canada and whether female sex and adverse SDOH are associated with a low quality of care. Design, Setting, and Participants This retrospective cohort analysis used data from 2 large cohorts of young adults (aged ≤55 years) receiving in-hospital and outpatient care for AMI at 127 centers in the US and Canada. Data were collected from August 21, 2008, to April 30, 2013, and analyzed from July 12, 2019, to March 10, 2021. Exposures Sex, SDOH, and health care system. Main Outcomes and Measures Opportunity-based quality-of-care score (QCS), determined by dividing the total number of quality indicators of care received by the total number for which the patient was eligible, with low quality of care defined as the lowest tertile of the QCS. Results A total of 4048 adults with AMI (2345 women [57.9%]; median age, 49 [interquartile range, 44-52] years; 3004 [74.2%] in the US) were included in the analysis. Of 3416 patients with in-hospital QCS available, 1061 (31.1%) received a low QCS, including more women compared with men (725 of 2007 [36.1%] vs 336 of 1409 [23.8%]; P

The authors compared the effectiveness of thiazide diuretic (TD), angiotensin‐converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), and calcium channel blocker (CCB) monotherapies for the treatment of nondiabetic hypertension using MarketScan Databases 2010–2014. Multivariable Cox regression models assessed whether the addition of a new antihypertensive drug, treatment discontinuation, or switch and major cardiovascular or cerebrovascular events varied across groups. A total of 565 009 patients started monotherapy with ACEIs (43.6%), CCBs (23.6%), TDs (18.8%), or ARBs (14.0%). Patients who took TDs had a higher risk for either drug addition or discontinuation than patients who took ACEIs (hazard ratio [HR], 0.69 [95% CI, 0.68–0.70] vs HR, 0.81 [95% CI, 0.80–0.81]), ARBs (HR, 0.67 [95% CI, 0.66–0.68] vs HR, 0.66 [95% CI, 0.65–0.67]), and CCBs (HR, 0.85 [95% CI, 0.84–0.87] vs HR, 0.94 [95% CI, 0.93–0.95]). Conversely, patients who took TDs experienced a lower risk of clinical events compared with patients who took ACEIs (HR, 1.24 [95% CI, 1.15–1.33]), ARBs (HR, 1.28 [95% CI, 1.18–1.39]), and CCBs (HR, 1.35 [95% CI, 1.25–1.46]). Our results provide a strong rationale for choosing TDs as first‐line monotherapy for the control of hypertension.

Background Randomized controlled trials showed that newer glucose‐lowering agents are cardioprotective, but most participants were men. It is unknown whether benefits are similar in women. Methods and Results Among adults with type 2 diabetes mellitus not controlled with metformin with no prior use of insulin, we assessed for sex differences in the cardiovascular effectiveness and safety of sodium‐glucose‐like transport‐2 inhibitors ( SGLT ‐2i), glucagon‐like peptide‐1 receptor agonists ( GLP ‐1 RA ), dipeptidyl peptidase‐4 inhibitors, initiated as second‐line agents relative to sulfonylureas (reference‐group). We studied type 2 diabetes mellitus American adults with newly dispensed sulfonylureas, SGLT ‐2i, GLP ‐1 RA , or dipeptidyl peptidase‐4 inhibitors (Marketscan‐Database: 2011–2017). We used multivariable Cox proportional hazards models with time‐varying exposure to compare time to first nonfatal cardiovascular event (myocardial infarction/unstable angina, stroke, and heart failure), and safety outcomes between drugs users, and tested for sex–drug interactions. Among 167 254 type 2 diabetes mellitus metformin users (46% women, median age 59 years, at low cardiovascular risk), during a median 4.5‐year follow‐up, cardiovascular events incidence was lower in women than men (14.7 versus 16.7 per 1000‐person‐year). Compared with sulfonylureas, hazard ratios ( HR s) for cardiovascular events were lower with GLP ‐1 RA (adjusted HR ‐women: 0.57, 95% CI : 0.48–0.68; aHR ‐men: 0.82, 0.71–0.95), dipeptidyl peptidase‐4 inhibitors ( aHR ‐women: 0.83, 0.77–0.89; aHR ‐men: 0.85, 0.79–0.91) and SGLT ‐2i ( aHR ‐women: 0.58, 0.46–0.74; aHR ‐men: 0.69, 0.57–0.83). A sex‐by‐drug interaction was statistically significant only for GLP ‐1 RA ( P =0.002), suggesting greater cardiovascular effectiveness in women. Compared with sulfonylureas, risks of adverse events were similarly lower in both sexes for GLP ‐1 RA ( aHR ‐women: 0.81, 0.73–0.89; aHR ‐men: 0.80, 0.71–0.89), dipeptidyl peptidase‐4 inhibitors ( aHR ‐women: 0.82, 0.78–0.87; aHR ‐men: 0.83, 0.78–0.87) and SGLT ‐2i ( aHR ‐women: 0.68, 0.59–0.78; aHR ‐men: 0.67, 0.59–0.78) (all sex–drug interactions for adverse events P >0.05). Conclusions Newer glucose‐lowering drugs were associated with lower risk of cardiovascular events than sulfonylureas, with greater effectiveness of GLP ‐1 RA in women than men. Overall, they appeared safe, with a better safety profile for SGLT ‐2i than for GLP ‐1 RA regardless of sex.

In addition to biological sex, gender, the sociocultural dimension of being a woman or a man, plays a central role in health. However, there are so far no approaches to quantify gender in a retrospective manner in existing study datasets. We therefore aimed to develop a methodology that can be retrospectively applied to assess gender in existing cohorts. We used baseline data from the Berlin Aging Study II (BASE-II), obtained in 2009-2014 from 1869 participants aged 60 years and older. We identified 13 gender related variables and used them to construct a gender score (GS) by primary component and logistic regression analysis. Of these, 9 variables contributed to a gender score: chronic stress, marital status, risk taking behavior, agreeableness, neuroticism, extraversion, loneliness, conscientiousness, and education. GS differed significantly between females and males as defined by sex. Next, we calculated linear regressions to investigate associations between sex, GS, and selected biological and well-being variables. Sex, but not GS was significantly associated with LDL-C and TC. GS, but not sex, was significantly associated with cortisol levels, CES-depression, negative affect, life satisfaction. Thus, we were able to develop a GS in a retrospective manner from available study variables that characterized women and men in addition to biological sex. This approach will allow us to introduce the notion of gender retrospectively into a large number of studies.

SummaryIn elderly patients (≥75 years), evidence of dabigatran efficacy is lacking and increased vigilance is warranted. We aimed to assess dabigatran effectiveness and safety in elderly patients in real-world practice. We conducted a population-based study using administrative databases, in Quebec (1999–2013). Dabigatran users (110/150 mg) were compared with matched warfarin users with regard to stroke and bleeding events. Age was categorised into < 75 or ≥ 75 years. Propensity score adjusted models were used. The cohort consisted of 15,918 dabigatran users and 47,192 matched warfarin users, with 67.3 % being elderly patients. The elderly predominantly used the lower dose (80.1 %) while younger patients mainly used the higher dose (80.0 %). In multivariable analyses adjusted for propensity score, the risk of stroke in elderly patients using dabigatran, was no different than the risk in warfarin users (HR 1.05, 95 % CI: 0.93, 1.19) regardless of dabigatran dose. However, dabigatran was associated with lower rates of intracranial haemorrhage (HR 0.60, 95 % CI: 0.47–0.76) and higher rates of gastrointestinal bleeding (HR 1.30 95 % CI: 1.14–1.50) when compared to warfarin. Based on real-life experience, dabigatran can offer an alternative to warfarin in elderly patients, with fewer intracranial bleeding events. However, caution is warranted for gastrointestinal bleeding.

Background “Gender” reflects social norms for women and men, whereas “sex” defines biological characteristics. Gender-related characteristics explain some differences in access to care for premature acute coronary syndrome (ACS); whether they are associated with cardiovascular outcomes is unknown. Objectives This study estimated associations between gender and sex with recurrent ACS and major adverse cardiac events (MACE) (e.g., ACS, cardiac mortality, revascularization) over 12 months in patients with ACS. Methods We studied 273 women and 636 men age 18 to 55 years from GENESIS-PRAXY (GENdEr and Sex determInantS of cardiovascular disease: from bench to beyond-Premature Acute Coronary SYndrome), a prospective observational cohort study, who were hospitalized for ACS between January 2009 and April 2013. Gender-related characteristics (e.g., social roles) were assessed using a self-administered questionnaire, and a composite measure of gender was derived. Outcomes included recurrent ACS and MACE over 12 months. Results Feminine roles and personality traits were associated with higher rates of recurrent ACS and MACE compared with masculine characteristics. This difference persisted for recurrent ACS, after multivariable adjustment (hazard ratio from score 0 to 100: 4.50; 95% confidence interval: 1.05 to 19.27), and was a nonstatistically significant trend for MACE (hazard ratio: 1.54; 95% confidence interval: 0.90 to 2.66). A possible explanation is increased anxiety, the only condition that was more prevalent in patients with feminine characteristics and that rendered the association between gender and recurrent ACS nonstatistically significant (hazard ratio: 3.56; 95% confidence interval: 0.81 to 15.61). Female sex was not associated with outcomes post-ACS. Conclusions Younger adults with ACS with feminine gender are at an increased risk of recurrent ACS over 12 months, independent of female sex.

Studies on dietary changes and their associated factors are limited, particularly with respect to younger cardiovascular patients. Our objective was to evaluate the factors associated with fruit and vegetable intake among adults with premature acute coronary syndrome (ACS) 1 year after the event. We used data from GENESIS-PRAXY, a multicentre prospective study of adults aged 18-55 years, hospitalised for ACS. Participants were 704 adults from 24 centres in Canada, 1 in USA and 1 in Switzerland. Data were collected through questionnaires and chart reviews at baseline and 1 year post-ACS. Fruit and vegetable intake was low among adults with premature ACS, and remained suboptimal at 1 year post-ACS, with only 21% meeting the minimum recommendations of at least 5 daily servings. The findings suggest that patient lifestyle characteristics, such as the number of hours spent at work and baseline intake are factors that may be associated with the intake of fruits and vegetables. More research is needed to assess effective strategies to increase fruit and vegetable intake among patients with premature ACS so that they meet dietary recommendations.

Aim Diabetes is a stronger risk factor for acute coronary syndrome for women than men. We investigate whether behavioural and psychosocial factors contribute to the disparity in acute coronary syndrome risk and outcomes among women with diabetes relative to women without diabetes and men. Methods Among 939 participants in the GENESIS-PRAXY cohort study of premature acute coronary syndrome (age ≤ 55 years), we compared the prevalence of traditional and non-traditional factors by sex and Type 2 diabetes status. In a case-only analysis, we used generalized logit models to investigate the influence of traditional and non-traditional factors on the interaction of sex and diabetes. Results In 287 women (14.3% with diabetes) and 652 men (10.4% with diabetes), women and men with diabetes showed a heavier burden of traditional cardiac risk factors compared with individuals without diabetes. Women with diabetes were more likely to be the primary earner and have more anxiety relative to women without diabetes, and reported worse perceived health compared with women without diabetes and men with diabetes. The interaction term for sex and diabetes (odds ratio (OR) 1.40, 95% confidence intervals (95% CI) 0.83–2.36) was diminished after additional adjustment for non-traditional factors (OR 1.12, 95% CI 0.54–2.32), but not traditional factors alone (OR 1.41, 95% CI 0.84–2.36). Conclusions We observed trends toward a more adverse psychosocial profile among women with diabetes and incident acute coronary syndrome compared with women without diabetes and men with diabetes, which may explain the increased risk of acute coronary syndrome in women with diabetes and may also contribute to worse outcomes. This article is protected by copyright. All rights reserved.

Background Most rheumatoid arthritis (RA) patients initiate therapy with methotrexate (MTX), but only 1/3 will have low disease activity with this agent alone. Several therapeutic options are available for patients with MTX-resistant RA, including new Janus kinase (JAK) inhibitors (eg.: tofacitinib). Objectives To compare the effectiveness of traditional disease-modifying antirheumatic drugs (DMARDs), biologic DMARDs and tofacitinib for RA patients with inadequate response to MTX. Methods We used MarketScan® databases (2011–2014) to study adult RA individuals previously treated with methotrexate (oral or SQ) and newly prescribed one of the medications under study. The date of first filled prescription or infusion drug was defined as the cohort entry and a 12-month pre-period was used to exclude prior users of biologics or tofacitinib. We required subjects to be continuously enrolled in the medical and pharmacy plan 12 months before and after the cohort entry. Effectiveness was access through an algorithm previously validated 1 , based on the following criteria: 1) non-adherence; 2) switching/adding a new biologic or tofacitinib; 3) switching/adding a new DMARD; 4) increasing of the dose of the starting therapy; 5) use of glucocorticoid joint injections; and 6) increasing the dose of oral glucocorticoid. A patient9s therapy was defined as not effective if at least one of the criterion occurred during the first year of follow-up. Results 16,305 RA patients were included; 2,879 began therapy with DMARD, 13,345 with biologics and 81 with tofacitinib. Among all patients, 77.5% were female and the mean age was 56.2 years (standard deviation 12.6). Table 1 shows the proportion of patients that meet the individual criterion and that achieved effectiveness at the end of one-year follow-up. Conclusions Similar rates of therapy effectiveness were observed among groups, although the rates for the individual criteria differed. Fewer patients initiating biologic agents were non-adherent compared to DMARD and tofacitinib therapy, but switch/adding and injections tended to be higher in this group. References Curtis JR et al. Derivation and preliminary validation of an administrative claims-based algorithm for the effectiveness of medications for rheumatoid arthritis. Arthritis Res Ther. 2011;13(5). Disclosure of Interest None declared

Objectives The purpose of this study was to determine if anticoagulation of patients with new onset secondary atrial fibrillation (AF) occurring with acute coronary syndromes (ACS), acute pulmonary disease, or sepsis is associated with a reduction in ischemic stroke or an increase in bleeding risk. Background Studies evaluating the benefits and risks of anticoagulation in secondary AF are infrequent, and the optimal management of these patients is not well understood. Methods A retrospective study cohort was identified of 2,304 patients age 65 years or older, hospitalized with a primary diagnosis of ACS, acute pulmonary disease (chronic obstructive pulmonary disease, pneumonia/influenza, pulmonary embolism, or pleural effusion) or sepsis, and a complication of new-onset AF during admission from 1999 to 2015. Results Over a follow-up of ∼3 years, we did not identify any association between anticoagulation and a lower incidence of ischemic stroke in patients with new-onset AF occurring with ACS, acute pulmonary disease, or sepsis (odds ratio [OR]: 1.22 [95% confidence interval (CI): 0.65 to 2.27], OR: 0.97 [95% CI: 0.53 to 1.77], and OR: 1.98 [95% CI: 0.29 to 13.47]), after adjusting for confounders. However, anticoagulation was associated with a higher risk of bleeding in patients with AF associated with acute pulmonary disease (OR: 1.72 [95% CI: 1.23–2.39]), but not in ACS or sepsis (OR: 1.42 [95% CI: 0.94–2.14], OR: 0.96 [95% CI: 0.29–3.21]). Conclusions Our study demonstrates that the benefit of anticoagulation in secondary AF is not strong and can be associated with a higher risk of bleeding. Careful individual assessment regarding decisions on anticoagulation is warranted in these patients.

Previous studies on digoxin use in patients with atrial fibrillation (AF) and the risk of all-cause mortality found conflicting results. We conducted a population-based, retrospective, cohort study of patients aged ≥65 years admitted to a hospital with a primary or secondary diagnosis of AF, in Quebec province, Canada, from 1998 to 2012. The AF cohort was grouped into patients with and without heart failure (HF) and into digoxin and no-digoxin users according to the first prescription filled for digoxin within 30 days after AF hospital discharge. We derived propensity score-matched digoxin and no-digoxin treatment groups for the groups of patients with and without HF, respectively, and conducted multivariable Cox proportional hazards regression analyses to determine association between digoxin use and all-cause mortality. The AF propensity score-matched cohorts of patients with and without HF were well balanced on baseline characteristics. In the propensity score-matched HF group, digoxin use was associated with a 14% greater risk of all-cause mortality (adjusted hazard ratio 1.14, 95% confidence interval 1.10 to 1.17). In the propensity score-matched no-HF group, digoxin use was associated with a 17% greater risk of all-cause mortality (adjusted hazard ratio 1.17, 95% confidence interval 1.14 to 1.19). In conclusion, our retrospective analyses found that digoxin use was associated with a greater risk for all-cause mortality in patients aged ≥65 years with AF regardless of concomitant HF. Large, multicenter, randomized controlled trials or prospective cohort studies are required to clarify this issue.

While post-operative atrial fibrillation is associated with a high incidence of long-term thromboembolic events, a lack of data exists to support an anticoagulation strategy in non-cardiac surgical patients. We aim to determine if anticoagulation use is associated with a reduction in thromboembolic

Background The Canadian Cardiology Society recommends that patients should be seen within 2 weeks after an emergency department (ED) visit for heart failure (HF). We sought to investigate whether patients who had an ED visit for HF subsequently consult a physician within the current established benchmark, to explore factors related to physician consultation, and to examine whether delay in consultation is associated with adverse events (AEs) (death, hospitalization, or repeat ED visit). Methods Patients were recruited by nurses at 8 hospital EDs in Quebec, Canada, and interviewed by telephone within 6 weeks of discharge and subsequently at 3 and 6 months. Clinical variables were extracted from medical charts by nurses. We used Cox regression in the analysis. Results We enrolled 410 patients (mean age 74.9 ± 11.1 years, 53% males) with a confirmed primary diagnosis of HF. Only 30% consulted with a physician within 2 weeks post-ED visit. By 4 weeks, 51% consulted a physician. Over the 6-month follow-up, 26% returned to the ED, 25% were hospitalized, and 9% died. Patients who were followed up within 4 weeks were more likely to be older and have higher education and a worse quality of life. Patients who consulted a physician within 4 weeks of ED discharge had a lower risk of AEs (hazard ratio 0.59, 95% CI 0.35-0.99). Conclusion Prompt follow-up post-ED visit for HF is associated with lower risk for major AEs. Therefore, adherence to current HF guideline benchmarks for timely follow-up post-ED visit is crucial.

BACKGROUND Catheter ablation (CA) is superior to antiarrhythmic therapy at reducing recurrence of atrial fibrillation (AF); however, there are limited data regarding whether this decrease translates into a reduction in health care resource utilization. OBJECTIVE To evaluate the impact of AF ablation on long-term health care resource utilization. METHODS A population-based cohort was constructed to include patients who underwent CA for AF in Quebec, Canada, between April 2005 and March 2011. Resource utilization was evaluated 24 months pre- and postindex CA procedure. RESULTS In a cohort of 1,556 patients, resource utilization increased progressively over the 24-month period leading to index CA (P for trend

Aims: Access to anti-depressants, and prognosis in younger depressed men and women with acute coronary syndrome (ACS) requires further investigation. We assessed the prevalence of depression, antidepressant prescription, and the association of depression with major adverse cardiovascular events (MACE) in men and women with premature ACS. Methods and results: 1071 ACS men and women (≤ 55 years) were recruited between January 2009 and April 2013 into GENESIS PRAXY, a multicentre prospective observational cohort study, from 24 hospitals in Canada, one in the US and one in Switzerland. Depression was measured by self-report using the Diagnostic and Statistical Manual of Mental Disorders criteria. Prescription of antidepressants at baseline and 12 months, and MACE over 12 months, were assessed using medical chart review and self-report. Depression was present in 20% of men and 32% of women. Only 1% of men and women with no antidepressants at hospital admission were prescribed antidepressants at hospital discharge. Depressed men were 3 times less likely than depressed women to be prescribed antidepressants. The determinants of antidepressants at 12 months included the presence of cardiovascular risk factors in men, and the presence of depression in women. In sex-specific Cox regressions, depressed men had a 2.57 times greater risk of MACE compared with non-depressed men (95% CI: 1.53-4.32), which difference was not seen in women (HR=0.71, 95% CI=0.28-1.81). Conclusion: Despite a decade of sensitization, depression still needs to be better treated after ACS, especially in young men, given that depression is a potent risk factor for adverse outcomes.

Objectives The purpose of this study was to evaluate the safety and incidence of periprocedural adverse events (AEs) among patients who underwent catheter ablation (CA) for atrial fibrillation (AF) in Quebec and Ontario, Canada. Background CA is evolving into the mainstay therapy for patients with symptomatic AF refractory to antiarrhythmic medication. However, the safety of CA at the population level over time requires further evaluation. Methods A population-based cohort was constructed using administrative databases of all patients who underwent CA between 1999 and 2014 in Quebec and Ontario, Canada. Incidence and predictors of AEs were assessed within 30 days of CA. Major AEs included all-cause mortality, cerebrovascular accident (CVA) including transient ischemic attack, pericardial effusion requiring drainage (PERD), vascular AEs, hemorrhage/hematoma, and pulmonary embolism. Results Of 6,388 patients who had a CA (mean age 57.3 years; mean CHA 2 DS 2 -VASc 1.1 ± 1.4; 27.6% female), 221 (3.5%) patients developed major AEs within 30 days of index CA. Hemorrhage/hematoma was the most frequent (1.4%), followed by PERD (1.0%) and CVA (0.6%). PERD was more likely to occur post-discharge than during the index CA (p Conclusions CA is a relatively safe procedure with low incidence of major AEs. The incidence of procedure-related CVA appeared to decline significantly over time. Incidence of PERD remained relatively stable and was more likely to be diagnosed after discharge and following repeat CA.

Dabigatran and rivaroxaban are novel oral anticoagulants (NOACs) approved for stroke prevention in atrial fibrillation (AF). Although NOACs are more convenient than warfarin, their lack of monitoring may predispose patients to non-persistence. Limited information is available on NOAC non-persistence rates and related clinical outcomes in clinical practice.We conducted a retrospective cohort study using administrative data from Ontario, Canada, from January 1998 to March 2014 of patients with AF who were dispensed dabigatran or rivaroxaban. Non-persistence was defined as a gap in dabigatran or rivaroxaban prescriptions ≥14 days. A multivariable Cox proportional hazards model was used to estimate the primary composite outcome of stroke, transient ischaemic attack (TIA) and mortality associated with non-persistence.The cohort consisted of 15 857 dabigatran (age 80.7±6.7 year) and 10 119 rivaroxaban users (age 77.0±7.1 year) with women comprising 52% of each medication group. At 6 months, 36.4% of patients were non-persistent to dabigatran, while 31.9% of patients were non-persistent to rivaroxaban. Stroke/TIA/death was significantly higher for those non-persistent to dabigatran (HR 1.76 (95% CI 1.60 to 1.94); p0.0001) or rivaroxaban (HR 1.89 (95% CI 1.64 to 2.19); p0.0001) compared with those who were persistent. Risk of stroke/TIA was markedly higher in non-persistent patients to dabigatran (HR 3.75 (95% CI 2.59 to 5.43); p0.0001) and rivaroxaban (HR 6.25 (95% CI 3.37 to 11.58); p0.0001) than those persistent.NOAC non-persistence rates are high in clinical practice, with approximately one in three patients becoming non-persistent to dabigatran or rivaroxaban within 6 months after drug initiation. Non-persistence with either dabigatran or rivaroxaban is significantly associated with worse clinical outcomes of stroke/TIA/death.

Objectives. Patient centered care is recognized as central to a high-quality healthcare system. Satisfaction with healthcare services may be differentially experienced among young adults suffering from heart disease. The current study examined the association between patient satisfaction with healthcare services, utilization, and clinical outcomes in patients with premature acute coronary syndrome (ACS). Methods and Results. We used data from 1033 patients (≤ 55 years) hospitalized for ACS and enrolled into the prospective cohort study, GENESIS-PRAXY (GENdEr and Sex determInantS of cardiovascular disease: from bench to beyond PRemature Acute Coronary SYndrome). Participants were recruited between January 2009-April 2013, from 24 centers across Canada, 1 in the US, and 1 in Switzerland. Patient satisfaction with treatment and subsequent healthcare service utilization/clinical outcomes were assessed within 12 months post-index ACS through questionnaire and medical chart review. The median age of our cohort was 48 years and 30% were female. Ninety two percent of males and females reported high satisfaction with healthcare services; however, among patients with low satisfaction we observed lower social support (48% vs. 24%; p Conclusions. Patients with lower satisfaction with healthcare services at index ACS were more likely to visit the ER and to be rehospitalized for cardiac reasons. Patient satisfaction level was not associated with risk of adverse clinical outcomes. Our results suggest that the younger ACS population may be a tangible target for reducing healthcare utilization through increased patient satisfaction.

Background— Stroke is a debilitating condition with an increased risk in patients with atrial fibrillation. Although data from clinical trials suggest that both rate and rhythm control are acceptable approaches with comparable rates of mortality in the short term, it is unclear whether stroke rates differ between patients who filled prescriptions for rhythm or rate control therapy. Methods and Results— We conducted a population-based observational study of Quebec patients ≥65 years with a diagnosis of atrial fibrillation during the period 1999 to 2007 with the use of linked administrative data from hospital discharge and prescription drug claims databases. We compared rates of stroke or transient ischemic attack (TIA) among patients using rhythm (class Ia, Ic, and III antiarrhythmics), versus rate control (β-blockers, calcium channel blockers, and digoxin) treatment strategies (either current or new users). The cohort consisted of 16 325 patients who filled a prescription for rhythm control therapy (with or without rate control therapy) and 41 193 patients who filled a prescription for rate control therapy, with a mean follow-up of 2.8 years (maximum 8.2 years). A lower proportion of patients on rhythm control therapy than on rate control therapy had a CHADS 2 (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and previous stroke or TIA) score of ≥2 (58.1% versus 67.0%, P P 2 risk score. In multivariable Cox regression analysis, rhythm control therapy was associated with a lower risk of stroke/TIA in comparison with rate control therapy (adjusted hazard ratio, 0.80; 95% confidence interval, 0.74, 0.87). The lower stroke/TIA rate was confirmed in a propensity score–matched cohort. Conclusions— In comparison with rate control therapy, the use of rhythm control therapy was associated with lower rates of stroke/TIA among patients with atrial fibrillation, in particular, among those with moderate and high risk of stroke.

Estimates from clinical trials and small observational studies of the incidence of pulmonary toxicity (PT) associated with amiodarone range from 1% to 10%. We report a unique study of the population-based incidence and potential predictors of PT in a real-world atrial fibrillation (AF) population. We conducted a retrospective cohort study of patients ≥65 years old discharged with AF using linked administrative databases from Quebec, Canada from 1999 to 2007. "Users" and "nonusers" of amiodarone were identified by prescriptions dispensed within 7 days after hospital discharge. PT was defined through International Classification of Diseases, Ninth Revision and Tenth Revision codes for pulmonary fibrosis, alveolar/interstitial lung disease, and adult respiratory distress syndrome. Potential risk factors for PT were identified using multivariable Cox regression. PT occurred in 250 of 6,460 amiodarone users (3.87%) and 676 of 50,993 nonusers (1.33%). Age-standardized PT incidences were 28.30 and 16.02 per 1,000 person-years in men and women users, respectively, and 14.05 and 8.82 per 1,000 person-years in nonusers, respectively. It was associated with amiodarone exposure at all doses (≤200 mg/day, hazard ratio 1.62, 1.35 to 1.96; >200 mg/day, 1.46, 1.22 to 1.75). Other predictors of PT included increasing age (1.01 per year, 1.00 to 1.02), male gender (1.37, 1.19 to 1.57), chronic obstructive pulmonary disease (2.53, 2.21 to 2.89), and renal disease (1.26, 1.06 to 1.50). In conclusion, the population-based incidence of amiodarone PT is in the lower range of what has been previously reported. However, patients with AF who use amiodarone have an approximately 50% higher risk of PT than nonusers. Clinicians may be able to use the present results to identify patients at higher risk for PT and implement strategies to increase monitoring or select alternative therapy.

Background: Although prevalence of heart failure (HF) is similar in women and men, more men are admitted to specialized HF clinics, possibly owing to a perception that men benefit more. Our aim was to describe 1-year outcomes in men and women attending specialized HF clinics. Methods and Results: We enrolled 531 newly referred patients (mean age 66 years, 26% women) to 1 of 6 HF multidisciplinary clinics in Quebec. Data were collected at time of entry to the clinic and 6 and 12 months later. The 3 main outcomes, mortality, disease evolution (New York Heart Association functional class, quality of life, 6-minute walk), and number of hospital admissions/emergency department visits were analyzed separately. Survival was higher in women than in men (adjusted hazard ratio 2.53, 95% confidence interval 1.10e5.80). Both women and men improved over the 12-month period in terms of quality of life, 6-minute walk, and lower use of hospital and emergency department. Persons who at entry to the clinic had more severe disease showed more improvement. Deterioration over the year was associated with higher number of comorbidities, but not with age or gender. Conclusions: Both men and women with HF who attend specialized HF clinics improved, including those with more severe disease. (J Cardiac Fail 2011;17:540e546)

Background We compared severity of heart failure (HF) between men and women at entry to the multidisciplinary HF clinic based on 3 measures: New York Heart Association functional class, norm-referenced 6-minute walk distance, and health-related quality of life. Methods Newly admitted patients to 1 of 6 HF clinics were enrolled. Data were collected from a clinical database, questionnaires were administered to patients, and tests were administered by clinic nurses. We compared men and women with respect to the 3 severity indicators at entry to the clinic. Results In adjusted analyses, women had a lower health-related quality of life ( P = 0.04) but did not have lower norm-referenced 6-minute walk distance or lower New York Heart Association functional class on entry to the clinic. Having more comorbid conditions, being on medication, and having visited the emergency department or been admitted to hospital in the past 6 months were associated with higher severity at entry according to all 3 indicators. Conclusions Women report a lower health-related quality of life at entry to the clinic, although functional capacity does not seem to differ between women and men. Reasons for these discrepancies will need to be elucidated to better address women's health needs.

The long-term use of β blockers has been shown to improve the outcomes of patients with heart failure (HF). However, it is still disputed whether this is a class effect, and, specifically, whether carvedilol or bisoprolol are superior to metoprolol. The present study was a comparative effectiveness study of β blockers for patients with HF in a population-based setting. We conducted an observational cohort study using the Quebec administrative databases to identify patients with HF who were prescribed a β blocker after the diagnosis of HF. We used descriptive statistics to characterize the patients by the type of β blocker prescribed at discharge. The unadjusted mortality for users of each β blocker was calculated using Kaplan-Meier curves and compared using the log-rank test. To account for differences in follow-up and to control for differences among patient characteristics, a multivariate Cox proportional hazards model was used to compare the mortality. Of the 26,787 patients with HF, with a median follow-up of 1.8 years per patient, the crude incidence of death was 47% with metoprolol, 40% with atenolol, 41% with carvedilol, 36% with bisoprolol, and 43% with acebutolol. After controlling for several different covariates, we found that carvedilol (hazard ratio [HR] 1.04, 95% confidence interval [CI] 0.97 to 1.12, p = 0.22) and bisoprolol (HR 0.96, 95% CI 0.91 to 1.01, p = 0.16) were not superior to metoprolol in improving survival. Atenolol (HR 0.82, 95% CI 0.77 to 0.87, p

Background Congestive heart failure (CHF) is a common cause of hospitalization and has a poor prognosis. Specialized multidisciplinary clinics are effective in the management of CHF. Objectives To measure time of admission to the specialized clinics and explore factors related to the time of admission to these clinics. Methods Patients who were newly admitted to one of six CHF multidisciplinary clinics in the province of Quebec were enrolled in the study. Data were collected from the common clinical database used at these clinics as well as from questionnaires administered to the patients. Results A total of 531 patients with a mean age of 65.9 years were enrolled. Only 26% were women. The median duration of disease before admission to the CHF clinic was 1.2 years. The majority of patients (62%) were referred by a cardiologist or an internist, while 24% were referred by other specialists, and 14% by general practitioners. One-fifth of patients did not have regular follow-up for their CHF before being admitted to the clinic. Factors associated with shorter disease duration at admission to the clinic were referral by a specialist, not having regular medical follow-up for CHF, having a higher income and having visited the emergency room for CHF. Conclusion There may be a need to improve dissemination of information regarding availability and benefits of CHF clinics and criteria for referral.

BACKGROUND Drug-reimbursement policies may have an adverse effect on patient outcomes if they interfere with timely access to efficacious medications for acute medical conditions. Clopidogrel in combination with aspirin is the recommended standard of care for patients receiving coronary stents to prevent thrombosis. We examined the population-level effect of a change by a Canadian provincial government in a pharmacy-benefits program from a prior-authorization policy to a less restrictive, limited-use policy on access to clopidogrel among patients undergoing percutaneous coronary intervention (PCI) with stenting after acute myocardial infarction. METHODS We conducted a population-based, retrospective, time-series analysis from April 1, 2000, to March 31, 2005, of all patients 65 years of age or older with acute myocardial infarction who underwent PCI with stenting in Ontario, Canada. The primary outcome was the composite rate of death, recurrent acute myocardial infarction, PCI, and coronary-artery bypass grafting at 1 year, with adjustment for sex and age. The secondary outcome was major bleeding. RESULTS The rate of clopidogrel use within 30 days after hospital discharge following myocardial infarction increased from 35% in the prior-authorization period to 88% in the limited-use period. The median time to the first dispensing of a clopidogrel prescription decreased from 9 days in the first period to 0 days in the second period. The 1-year composite cardiovascular outcome significantly decreased from 15% in the prior-authorization group to 11% in the limited-use group (P=0.02). Rates of bleeding in the two groups did not change. CONCLUSIONS The removal of a prior-authorization program led to improvement in timely access to clopidogrel for coronary stenting and improved cardiovascular outcomes.

Background Long-term treatment with statins reduces mortality in patients with congestive heart failure (CHF). Whether statin agents exert a class effect is unknown. Methods We analyzed long-term mortality in Canadian patients aged ≥65 years who were discharged from hospital with a diagnosis of CHF from January 1998 to December 2002. Administrative data from Quebec, Ontario, and British Columbia were merged. We compared patients prescribed with atorvastatin, simvastatin, pravastatin, and lovastatin. Results A total of 15 368 patients hospitalized with a diagnosis of CHF fulfilled the inclusion criteria for this study. In this final dataset, 6670 (43.4%) filled a prescription for atorvastatin, 4261 (27.7%) for simvastatin, 3209 (20.9%) for pravastatin, and 1228 (8.0%) for lovastatin. Clinical characteristics and proportion of days covered with a statin prescription were similar across groups. Drug dosages were relatively low, with 82% of patients who received the agent at a dose of ≤20 mg. Although controlling for time-dependent covariates representing current use and dosage, as well as for age, sex, coronary artery disease, and several other comorbidities, treatment with pravastatin (adjusted hazards ratio [HR] 0.94, 95% CI 0.83-1.07), lovastatin (adjusted HR 1.02, 95% CI 0.88-1.17), or simvastatin (adjusted HR 0.92, 95% CI 0.83-1.01) had a similar effectiveness to prevent mortality compared to atorvastatin (reference in this analysis) in this population with CHF. Time-dependent exposure to a statin was highly protective against mortality. Conclusions Statins exert a class effect in patients with CHF, when used at a relatively low dose. The favorable effects appear largely independent of drug dosage.

Background: Angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) have been shown to improve survival in patients with congestive heart failure (CHF). We wish to determine whether there are sex-related differences in the optimal treatment of congestive heart failure. Methods: Using administrative databases, all patients > >=65 years of age discharged with a diagnosis of CHF between January 1998 and March 2003 and who filled a prescription for an ARB or an ACE inhibitor within 90 days of discharge were identified. Time to all-cause death in women and men on ACE inhibitors or ARBs was compared. Results: There were 10,223 women (8627 ACE inhibitors and 1596 ARBs) and 9475 men (8484 ACE inhibitors and 991 ARBs). Hypertension was more common in women (50.1%) than men (33.1%). Women on ARBs had better survival than those on ACE inhibitors (adjusted hazard ratio (HR) 0.69, 95% confidence interval (CI) 0.59, 0.80). There was no difference in survival in men prescribed ARBs compared to ACE inhibitors (HR 1.10, 95% CI 0.95, 1.30). Conclusion These sex differences in treatment-related outcome are important but should be confirmed in a randomized trial before ARBs are preferentially prescribed to women with CHF.

Background Indications for pulmonary vein isolation for the treatment of atrial fibrillation (AF) have expanded over the years. Objective We aimed to describe trends in demographic and clinical characteristics of patients undergoing ablation, with a particular focus on sex differences. Methods Patients who underwent first AF ablation between 2003 and 2012 were identified within an AF cohort by using Quebec administrative databases. Descriptive statistics and multivariable analysis were used to examine sex differences and temporal trends in demographic and clinical characteristics, as well as independent predictors of the ablation procedure. Results A total of 2438 of 173,689 patients in the AF cohort underwent AF ablation. In the span of 10 years, the rate of AF ablation increased from 8.5 to 57.2 per million persons—an almost 7-fold increase. Patients undergoing ablation were younger than patients in the general AF cohort (57.4 ± 12.2 years vs 75.3 ± 12.0 years) and had fewer baseline comorbidities (56.7% vs 88.4%). Representing 42.9% of the general AF cohort, the annual proportion of women in the AF ablation cohort has not surpassed 30%, and men had a higher likelihood of undergoing ablation than did women (odds ratio 1.54; 95% confidence interval 1.40–1.69). Over the decade of observation, there were slight increases in patient age, comorbidities, and CHADS 2 score, some of which reached clinical significance for men and/or women. Conclusion The uptake of AF ablation over 10 years has expanded, with an increasingly greater number of older patients and with increased presence of comorbidities; however, there has been no increase in the relatively low proportion of women undergoing AF ablation.

Objectives. To compare the performance of prostate-specific antigen (PSA), the free/total PSA (F/T PSA) ratio, and complexed PSA (cPSA) in prostate cancer detection. Methods. Five hundred thirty-five patients evaluated at the UROMED prostate cancer detection clinic had total PSA, free PSA, and cPSA measured before undergoing transrectal ultrasonography and sextant prostate biopsies. A direct comparison was performed between the different PSA assays to evaluate their ability to detect prostate cancer. Results. Of the 535 patients evaluated, 38.1% had prostate cancer detected. The mean age of the entire population was 63.6 years (range 35 to 86). Abnormal digital rectal examination findings were present in 33.4% of the patients. The mean and median values of PSA and cPSA were significantly higher and the F/T PSA ratio was lower in patients with prostate cancer. The F/T PSA ratio performed better than either cPSA or total PSA. A higher specificity was observed with the F/T PSA ratio than with cPSA using either the entire patient population or subsets of patients with PSA levels between 4.0 and 10 ng/mL or 4.0 to 6.0 ng/mL. Conclusions. The use of the F/T PSA ratio offers improved prostate cancer detection compared with either cPSA or total PSA.

We propose to determine cut-off scores for the Incontinence Impact Questionnaire (IIQ) based on the neural network (NN) approach. These cut-off scores should discriminate between patients having poor, moderate, or good quality of life (QoL) secondary to their incontinence problems. Data from two prospectively completed QoL questionnaires, the IIQ (n = 237) and the MOS 36-Item Short-Form Health Survey (SF-36) (n = 237), were analyzed using NN and conventional statistical tools. Kohonen networks identified three distinct clusters of IIQ scores. The three clusters represent the full spectrum of possible scores on the IIQ. We interpreted these clusters as reflecting good, moderate, and poor QoL. We estimated that a score of less than 50 on the IIQ would be representative of good QoL, between 50 and 70 would be moderate QoL, and greater than 70 would be indicative of poor QoL. Validation with the SF-36 data confirmed these categories. The present study demonstrated that the NN approach is opening new areas in the interpretation and clinical usefulness of QoL questionnaires. NN allowed the identification of three levels of QoL and should be useful in clinical decision making.

Qureshi and colleagues mentioned that they observed a 72% increase in the risk of gastrointestinal bleeding in hemodialysis patients with atrial fibrillation (AF) who were on warfarin compared with those not on warfarin and questioned the only 44% increase in the risk of bleeding in dialysis patients with AF who were on warfarin compared with those not on warfarin in our study.1,2 Contrary to only gastrointestinal bleeding in the study by Khalid et al,1 the “bleeding” definition in our study included intracerebral bleeding, gastrointestinal bleeding, intraocular bleeding, hematuria, and unspecified location of bleeding, which could be a possible reason for the difference in bleeding risk between the 2 studies.1,2 Similar to Khalid et al,1 Winkelmayer and colleagues3 studied the association …

Background Limited information is available on the health behavior profile of patients with premature acute coronary syndrome (ACS). The purpose of this study is to desribe the health bahvior of young patients with ACS at the baseline and 1 year post-ACS and examine sex differences. Methods GENESIS-PRAXY is a prospective cohort study of adults (18-55 years old) hospitalized with ACS from 26 centers located in Canada, United States, and Switzerland. Data on diet, physical activity, smoking, alcohol consumption, and recreational drug use were collected through self-administered questionnaires at baseline and 1 year post-ACS. Results Our analysis included 740 patients with complete data. At baseline, the health behavior profile of young patients with ACS was worse than that of the general population. Men had a lower fruit and vegetable intake, consumed alcohol more, and used recreational drugs more than women. Conversely, fewer men than women were smokers (34% vs 42%). At 1 year post-ACS, the proportion of those consuming ≥5 daily servings of fruits and vegetables increased modestly (+5% vs +1%, for men vs women) but remained lower than the general population. Among women, the prevalence of smoking remained about twice as high as the general population. Recreational drug use also remained higher than in the general population. Conclusions Despite small improvements at 1 year post-ACS, the health behavior profile of young patients remained worse than that of the general population. Greater efforts to improve health behaviors post-ACS among young patients are needed, and a sex-based approach may be required to ensure successful behavioral changes.

Background Limited data exist as to the relative contribution of sex and gender on health‐related quality of life ( HRQL ) among patients with acute coronary syndrome ( ACS ). This study aims to evaluate the effect of sex and gender‐related variables on long‐term HRQL among young adults with ACS . Methods and Results GENESIS ‐ PRAXY ( GENdE r and Sex determInantS of cardiovascular disease: from bench to beyond‐Premature Acute Coronary SY ndrome) is a multicenter, prospective cohort study (January 2009 to August 2013) of adults aged 18 to 55 years, hospitalized with ACS . HRQL was measured at baseline, 1, 6, and 12 months using the Short Form‐12 and Seattle Angina Questionnaire (SAQ) among 1213 patients. Median age was 49 years. Women reported worse HRQL than men over time post‐ ACS , both in terms of physical and mental functioning. Gender‐related factors were more likely to be predictors of HRQL than sex. Femininity score, social support, and housework responsibility were the most common gender‐related predictors of HRQL at 12 months. We observed an interaction between female sex and social support (β=0.44 [95% confidence interval , 0.01, 0.88]; P =0.047) for the physical limitation subscale of the SAQ. Conclusions Young women with ACS report significantly poorer HRQL than young men. Gender appears to be more important than sex in predicting long‐term HRQL post‐ ACS . Specific gender‐related factors, such as social support, may be amenable to interventions and could improve the HRQL of patients with premature ACS .