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It is unknown whether the annual number of primary care physician (PCP) unique outpatient assessments, hereto termed clinical volume, translates into better cardiovascular preventive care. We examined the relationship between PCP outpatient clinical volumes and cholesterol testing and major adverse cardiovascular event rates among guideline recommended eligible patients.This was a retrospective cohort study conducted as part of the Cardiovascular Health in Ambulatory Care Research Team (CANHEART) cohort, a population-based cohort of almost all adult residents of Ontario, Canada, followed between 2008 and 2012. For each clinical volume quintile, we compared cholesterol testing and major adverse cardiovascular events, defined as time to first event of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke.The 10,037 PCPs evaluated had an annualized median volume of 2303 clinical encounters (IQR, 1292-3680). Among 4,740,380 patients, 84% underwent guideline-concordant cholesterol testing at least once over 5 years, ranging from 73% among the lowest clinical volume quintile physicians to 86% among the highest. After multivariable adjustment, there was a 10.5% relative increase in the probability of cholesterol testing for every doubling of clinical volumes (95% CI, 9.7-11.4, P0.001). Patients treated by the lowest volume physicians had the highest rate of major adverse cardiovascular outcomes, compared with the highest quintile volume physicians (adjusted HR 1.15; 95% CI, 1.10-1.21; P0.001).Patients of physicians with the lowest clinical volumes received less frequent cholesterol testing and had the highest rate of incident cardiovascular events. Further research investigating the drivers of this relationship is warranted.

Background: The intent of the Canadian Alliance for Healthy Hearts and Minds (CAHHM) cohort is to understand the early determinants of subclinical cardiac and vascular disease and progression in adults selected from existing cohorts—the Canadian Partnership for Tomorrow’s Health, the Prospective Urban and Rural Evaluation (PURE) cohort, and the Montreal Heart Institute Biobank. We evaluated how well the CAHHM-Health Services Research (CAHHM-HSR) subcohort reflects the Canadian population. Methods: A cross-sectional design was used among a prospective cohort of community-dwelling adults aged 35-69 years who met the CAHHM inclusion criteria, and a cohort of adults aged 35-69 years who responded to the 2015 Canadian Community Health Survey-Rapid Response module. The INTERHEART risk score was calculated at the individual level with means and proportions reported at the overall and provincial level. Results: There are modest differences between CAHHM-HSR study participants and the 2015 Canadian Community Health Survey-Rapid Response respondents in age (56.3 vs 51.7 mean years), proportion of men (44.9% vs 49.3%), and mean INTERHEART risk score (9.7 vs 10.1). Larger differences were observed in postsecondary education (86.8% vs 70.2%), Chinese ethnicity (11.0% vs 3.3%), obesity (23.2% vs 29.3%), current smoker status (6.1% vs 18.4%), and having no cardiac testing (30.4% vs 55.9%). Conclusions: CAHHM-HSR participants are older, of higher socioeconomic status, and have a similar mean INTERHEART risk score, compared with participants in the Canadian Community Health Survey. Differing sampling strategies and missing data may explain some differences between the CAHHM-HSR cohort and Canadian community-dwelling adults and should be considered when using the CAHHM-HSR for scientific research. Résumé: Contexte: L’étude Alliance canadienne cœurs et cerveaux sains (CAHHM) vise à mieux comprendre les facteurs déterminants précoces et la progression de l’atteinte cardiovasculaire subclinique chez des adultes sélectionnés au sein de cohortes existantes – soit celles de l’étude menée par le Partenariat canadien pour la santé de demain, de l’étude PURE (Prospective Urban and Rural Evaluation) et de la biobanque de l’Institut de cardiologie de Montréal. Nous avons évalué la mesure dans laquelle la sous-cohorte du volet de recherche sur l’utilisation des services de santé de la CAHHM (CAHHM-HSR) représente la population canadienne. Méthodologie: Nous avons adopté une approche transversale pour étudier une cohorte prospective d’adultes vivant dans la communauté âgés de 35 à 69 ans et répondant aux critères d’inclusion de l’étude CAHHM, ainsi qu’une cohorte d’adultes âgés de 35 à 69 ans ayant participé au volet de réponse rapide de l’Enquête sur la santé dans les collectivités canadiennes (ESCC) de 2015. Le score de risque INTERHEART individuel des participants a été calculé à partir des moyennes et des proportions rapportées à l’échelle globale et à l’échelle provinciale. Résultats: Les différences entre les participants du volet CAHHM-HSR et ceux du volet de réponse rapide de l’ESCC de 2015 étaient minimes quant à l’âge (56,3 ans vs 51,7 ans en moyenne), à la proportion d’hommes (44,9 % vs 49,3 %) et au score de risque INTERHEART moyen (9,7 vs 10,1). On a toutefois noté des différences plus importantes en ce qui concerne les caractéristiques suivantes : éducation postsecondaire (86,8 % vs 70,2 %), origine ethnique chinoise (11,0 % vs 3,3 %), obésité (23,2 % vs 29,3 %), tabagisme actuel (6,1 % vs 18,4 %) et absence d’antécédents d’examen cardiaque (30,4 % vs 55,9 %). Conclusions: Les participants du volet CAHHM-HSR sont plus âgés et ont un statut socioéconomique plus élevé que ceux du volet de réponse rapide de l’ESCC, mais ont un score de risque INTERHEART moyen comparable. Les différences quant aux stratégies d’échantillonnage et des données manquantes pourraient expliquer certains des écarts observés entre la cohorte CAHHM-HSR et celle des adultes canadiens vivant dans la communauté; il conviendrait d’en tenir compte lorsqu’on utilise les données du volet CAHHM-HSR à des fins de recherche scientifique.

The increasing availability of large electronic population-based databases offers unique opportunities to conduct cardiovascular health surveillance traditionally done using surveys. We aimed to examine cardiovascular risk-factor burden, preventive care, and disease incidence among adults in Ontario, Canada-using routinely collected data-and compare estimates with health survey data.In the Cardiovascular Health in Ambulatory Care Research Team (CANHEART) initiative, multiple health administrative databases were linked to create a population-based cohort of 10.3 million adults without histories of cardiovascular disease. We examined cardiovascular risk-factor burden and screening and outcomes between 2016 and 2020. Risk- factor burden was also compared with cycles 3 to 5 (2012 to 2017) of the Canadian Health Measures Survey (CMHS), which included 9473 participants across Canada.Mean age of our study cohort was 47.9 ± 17.0 years, and 52.0% were women. Lipid and diabetes assessment rates among individuals 40 to 79 years were 76.6% and 78.2%, respectively, and lowest among men 40 to 49 years of age. Total cholesterol levels and diabetes and hypertension rates among men and women 20 to 79 years were similar to Canadian Health Measures Survey (CHMS) findings (total cholesterol: 4.80/4.98 vs 4.94/5.25 mmol/L; diabetes: 8.2%/7.1% vs 8.1%/6.0%; hypertension: 21.4%/21.6% vs 23.9%/23.1%, respectively); however, patients in the CANHEART study had slightly higher mean glucose (men: 5.79 vs 5.44; women: 5.39 vs 5.09 mmol/L) and systolic blood pressures (men: 126.2 vs 118.3; women: 120.6 vs 115.7 mm Hg).Cardiovascular health surveillance is possible through linkage of routinely collected electronic population-based datasets. However, further investigation is needed to understand differences between health administrative and survey measures cross-sectionally and over time.

Background Several known traditional cardiovascular risk factors contribute to the development of heart failure (HF); however, whether ethnicity is also an important predictor is not well established. We determined the incidence of hospitalization for HF among ethnic groups in Ontario, Canada, and examined differences in risk factor prevalence that may contribute to disparities in HF hospitalization incidence between groups. Methods and Results We conducted a retrospective observational study from 2008 to 2012 with the use of a linked cohort derived from population-based health administrative, clinical, and survey datasets. We followed 895,823 recent immigrants from 8 ethnic groups and 5.3 million long-term residents aged 40–105 years for incident HF hospitalization. Sex-stratified age-standardized HF incidence was lower among all immigrant groups than long-term residents. Among immigrants, Black men and West Asian women had the highest incidence of hospitalizations for HF (1.19 and 1.60 per 1000 person-years, respectively), and East Asians of both sexes had the lowest incidence. After adjusting for sociodemographic characteristics, comorbidities, and other risk factors, the association between ethnicity and HF hospitalization risk remained significant. Conclusions HF hospitalization incidence varies widely among ethnic immigrant groups, highlighting the importance of ethnicity as a potential independent risk factor for HF development.

This study sought to examine the prognostic significance of nonobstructive coronary artery disease (CAD) in patients with heart failure (HF), as a distinct category apart from those with normal coronary arteries.Individuals with HF are often dichotomized into ischemic versus nonischemic categories according to the underlying etiology. This binary classification creates a heterogeneous group, combining individuals with nonobstructive CAD with those with normal coronary arteries under the nonischemic label.A cohort of individuals with HF and reduced ejection fraction undergoing invasive coronary angiography was examined and linked to administrative databases for outcomes evaluation. Patients were divided into those with normal coronary arteries, nonobstructive disease, and obstructive disease. The primary outcome was the composite of cardiovascular death, nonfatal acute myocardial infarction, nonfatal stroke, or HF hospitalization.Of 12,814 individuals, 2,656 (20.7%) had normal coronary arteries, 2,254 (17.6%) had nonobstructive CAD, and 7,904 (61.7%) had obstructive CAD. The risk of the primary outcome was increased in the nonobstructive group (hazard ratio [HR]: 1.17; 95% confidence interval [CI]: 1.04 to 1.32; p = 0.01) relative to those with normal coronary arteries. Nonobstructive CAD was associated with an increased hazard of cardiovascular death (HR: 1.82; 95% CI: 1.27 to 2.62; p = 0.001) and death of any cause (HR: 1.18; 95% CI: 1.05 to 1.33; p = 0.005). There were no significant differences in the rate of acute myocardial infarction, stroke, or HF hospitalization.Among HF patients with reduced ejection fraction, the presence of nonobstructive CAD was independently associated with an increased hazard of the primary composite outcome and death of any cause.

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

Objectives The uptake of endovascular aortic repair for elective and ruptured abdominal aortic aneurysm repair is not well studied. We aimed to examine the trends in open surgical repair and endovascular aortic repair of eAAA and rAAA and to examine the effects of randomized trial publications on elective open surgical repair and endovascular aortic repair rates. Methods We conducted a population-based time-series analysis of eAAA and rAAA repairs in Ontario, Canada from 2003 to 2016. We examined changes in overall and approach-specific rates of eAAA and rAAA repair using exponential smoothing models. Interventional autoregressive integrated moving average models were fit to the eAAA rates to examine the impact of randomized trial results on these rates. Results We identified 19,489 eAAA (12,232 open (63%) and 7257 endovascular (37%)) and 2732 rAAA (2466 open (90%) and 266 endovascular (10%)) repairs from 2003 to 2016. The rate of eAAA repair declined from 6.39/100,000 in 2003 to 5.59/100,000 in 2016 (13% decrease, p = 0.17). The rate of elective open surgical repair decreased nearly three-fold from 6.07/100,000 to 2.12/100,000 ( p Conclusions While elective open surgical repair use has significantly decreased from 2003 to 2016, elective endovascular aortic repair use has significantly increased. The DREAM and EVAR-1 results significantly impacted the observed rates of elective open surgical repair only. The reasons for these trends require further characterization.

Heterozygous familial hypercholesterolemia (HeFH) is a common genetic disorder predisposing affected individuals to lifelong low-density lipoprotein cholesterol (LDL-C) elevation and coronary heart disease. However, whether HeFH increases the risk of peripheral arterial disease (PAD) and ischemic stroke is undetermined. We examined associations between HeFH and these outcomes in a comprehensive systematic review and meta-analysis. We searched MEDLINE, EMBASE, Global Health, the Cochrane Library, and PubMed (for ahead-of-print publications) for relevant English-language studies. Maximally adjusted risk estimates were pooled under random- and fixed-effects meta-analysis to derive odds ratios (ORs) and 95% confidence intervals (CIs). We included 6 studies representing 183 388 participants. Heterozygnous familial hypercholesterolemia was associated with a higher risk of PAD (OR: 3.59 [95% CI: 1.30-9.89]). This trend was nonsignificantly preserved (OR: 2.96 [95% CI: 0.68-12.88]) in sensitivity analyses of genetically defined HeFH. Genetic HeFH was not associated with increased ischemic stroke risk (OR: 0.76 [95% CI: 0.37-1.58]) although possessing an LDL-C >4.9 mmol/L (190 mg/dL) was (OR: 1.42 [95% CI: 1.06-1.89]). We found clinical and genetic diagnoses of HeFH to be associated with increased PAD risk. Genetically confirmed HeFH may not confer an increased risk of ischemic stroke. Modest associations may exist between LDL-C and ischemic stroke risk in HeFH.

Background: Improved risk stratification of acute heart failure in the emergency department may inform physicians’ decisions regarding patient admission or early discharge disposition. We aimed to validate the previously-derived Emergency Heart failure Mortality Risk Grade for 7-day (EHMRG7) and 30-day (EHMRG30-ST) mortality. Methods: We conducted a multicenter, prospective validation study of patients with acute heart failure at 9 hospitals. We surveyed physicians for their estimates of 7-day mortality risk, obtained for each patient before knowledge of the model predictions, and compared these with EHMRG7 for discrimination and net reclassification improvement. We also prospectively examined discrimination of the EHMRG30-ST model, which incorporates all components of EHMRG7 as well as the presence of ST-depression on the 12-lead ECG. Results: We recruited 1983 patients seeking emergency department care for acute heart failure. Mortality rates at 7 days in the 5 risk groups (very low, low, intermediate, high, and very high risk) were 0%, 0%, 0.6%, 1.9%, and 3.9%, respectively. At 30 days, the corresponding mortality rates were 0%, 1.9%, 3.9%, 5.9%, and 14.3%. Compared with physician-estimated risk of 7-day mortality (PER7; c-statistic, 0.71; 95% CI, 0.64–0.78) there was improved discrimination with EHMRG7 (c-statistic, 0.81; 95% CI, 0.75–0.87; P =0.022 versus PER7) and with EHMRG7 combined with physicians’ estimates (c-statistic, 0.82; 95% CI, 0.76–0.88; P =0.003 versus PER7). Model discrimination increased nonsignificantly by 0.014 (95% CI, −0.009–0.037) when physicians’ estimates combined with EHMRG7 were compared with EHMRG7 alone ( P =0.242). The c-statistic for EHMRG30-ST alone was 0.77 (95% CI, 0.73–0.81) and 30-day model discrimination increased nonsignificantly by addition of physician-estimated risk to 0.78 (95% CI, 0.73–0.82; P =0.187). Net reclassification improvement with EHMRG7 was 0.763 (95% CI, 0.465–1.062) when assessed continuously and 0.820 (0.560–1.080) using risk categories compared with PER7. Conclusions: A clinical model allowing simultaneous prediction of mortality at both 7 and 30 days identified acute heart failure patients with a low risk of events. Compared with physicians’ estimates, our multivariable model was better able to predict 7-day mortality and may guide clinical decisions. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02634762.

BackgroundData are limited regarding the risk of heart failure (HF) requiring hospital-based care after early stage breast cancer (EBC) and its relationship to other types of cardiovascular disease (CVD).MethodsWe conducted a population-based, retrospective cohort study of EBC patients (diagnosed April 1, 2005–March 31, 2015) matched 1:3 on birth-year to cancer-free control subjects. We identified hospitalizations and emergency department visits for CVD through March 31, 2017. We used cumulative incidence function curves to estimate CVD incidence and cause-specific regression models to compare CVD rates between cohorts. All statistical tests were two-sided.ResultsWe identified 78 318 EBC patients and 234 954 control subjects. The 10-year incidence of CVD hospitalization was 10.8% (95% confidence interval [CI] = 10.5% to 11.1%) after EBC and 9.1% (95% CI = 8.9% to 9.2%) in control subjects. Ischemic heart disease was the most common reason for CVD hospitalization after EBC. After regression adjustment, the relative rates compared with control subjects remained statistically significantly elevated for HF (hazard ratio [HR] = 1.21, 95% CI = 1.14 to 1.29, P < .001), arrhythmias (HR = 1.31, 95% CI = 1.23 to 1.39, P < .001), and cerebrovascular disease (HR 1.10, 95% CI = 1.04 to 1.17, P = .002) hospitalizations. It was rare for HF hospital presentations (2.9% of cases) to occur in EBC patients without recognized risk factors (age >60 years, hypertension, diabetes, prior CVD). Anthracycline and/or trastuzumab were used in 28 950 EBC patients; they were younger than the overall cohort with lower absolute rates of CVD, hypertension, and diabetes. However, they had higher relative rates of CVD in comparison with age-matched control subjects.ConclusionsAtherosclerotic diagnoses, rather than HF, were the most common reasons for CVD hospitalization after EBC. HF hospital presentations were often preceded by risk factors other than chemotherapy, suggesting potential opportunities for prevention.

Current data from individual studies present conflicting evidence about the relationship between risk factors and cardiovascular disease (CVD) in heterozygous familial hypercholesterolemia (FH).We conducted a systematic review and meta-analysis to quantify the association between various CVD risk factors and CVD in FH.We searched MEDLINE, EMBASE, Global Health, the Cochrane Library, and PubMed for English-language studies reporting adjusted-associations between cardiovascular, behavioral, or clinical risk factors and CVD with ≥ 100 participants. We calculated pooled odds ratios (ORs) with 95% confidence intervals (CIs) for selected risk factors with random-effects meta-analysis, from which we derived attributable risk estimates.We identified 27 studies representing 41,831 unique participants and 6629 CVD events. Age (OR: 1.07; 95% CI: 1.03, 1.10), male sex (OR: 1.95; 95% CI: 1.68, 2.23), hypertension (OR: 2.11; 95% CI: 1.64, 2.58), diabetes (OR: 1.95; 95% CI: 1.33, 2.57), body mass index (OR: 1.04; 95% CI: 1.03, 1.05), smoking (OR: 1.71; 95% CI: 1.30, 2.12), elevated lipoprotein(a) (OR: 1.90; 95% CI: 1.10, 2.71), low high-density lipoprotein cholesterol (OR: 1.39; 95% CI: 1.24, 1.53), and a family history of CVD (OR: 1.83, 95% CI: 1.58, 2.07) were found to be significant CVD risk factors in FH. Smoking, hypertension, and diabetes accounted for more than a quarter of CVD risk in FH individuals, whereas low-density lipoprotein cholesterol4.0 mmol/L accounted for 1 in 3 CVD cases. Meta-regression analyses found associations between low-density lipoprotein cholesterol (P = .045) and total cholesterol (P .001) and CVD. Results were broadly consistent in sensitivity analyses.Several clinical risk factors are significantly and independently associated with CVD risk in patients with FH and should be targeted for modification. These data can also inform the selection of variables for prediction models to aid in risk stratifying patients.

OBJECTIVEIntracranial hemorrhage (ICH) associated with cerebral hyperperfusion syndrome is a rare but major complication of carotid artery revascularization. The objective of this study was to compare the rate of ICH after carotid artery stenting (CAS) with that after endarterectomy (CEA).METHODSThe authors performed a retrospective population-based cohort study of patients who underwent carotid artery revascularization in the province of Ontario, Canada, between 2002 and 2015. The primary outcome was the rate of ICH that occurred within 90 days after carotid artery intervention among patients who underwent CAS versus that of those who underwent CEA. The authors used inverse probability of treatment weighting and propensity scores to account for selection bias. In sensitivity analyses, patients who had postprocedure ischemic stroke were excluded, and the following subgroups were examined: patients with symptomatic and asymptomatic carotid artery stenosis, patients treated between 2010 and 2015, and patients aged ≥ 66 years (to account for antiplatelet and anticoagulant use).RESULTSA total of 16,688 patients underwent carotid artery revascularization (14% CAS, 86% CEA). Patients with more comorbid illnesses, symptomatic carotid artery stenosis, or cardiac disease and those who were taking antiplatelet agents or warfarin before surgery were more likely to undergo CAS. Among the overall cohort, 80 (0.48%) patients developed ICH within 90 days (0.85% after CAS, 0.42% after CEA). The 180-day mortality rate after ICH in the overall cohort was 2.7%, whereas the 180-day mortality rate among patients who suffered ICH was 42.5% (40% for CAS-treated patients, 43.3% for CEA-treated patients). In the adjusted analysis, patients who underwent CAS were significantly more likely to have ICH than those who underwent CEA (adjusted OR 1.77; 95% CI 1.32–2.36; p < 0.001). These results were consistent after excluding patients who developed postprocedure ischemic stroke (adjusted OR 1.90; 95% CI 1.41–2.56) and consistent among symptomatic (adjusted OR 1.74; 95% CI 1.16–2.63) and asymptomatic (adjusted OR 1.75; 95% CI 1.16–2.63) patients with carotid artery stenosis, among patients treated between 2010 and 2015 (adjusted OR 2.21; 95% CI 1.45–3.38), and among the subgroup of patients aged ≥ 66 years (adjusted OR 1.53; 95% CI 1.05–2.24) after adjusting for medication use.CONCLUSIONSCAS is associated with a rare but higher risk of ICH relative to CEA. Future research is needed to devise strategies that minimize the risk of this serious complication after carotid artery revascularization.

Familial hypercholesterolemia (FH) is the most common monogenic disorder causing premature atherosclerotic cardiovascular disease. It affects 1 in 250 individuals worldwide, and of the approximately 145,000 Canadians estimated to have FH, most are undiagnosed. Herein, we provide an update of the 2014 Canadian Cardiovascular Society position statement on FH addressing the need for case identification, prompt recognition, and treatment with statins and ezetimibe, and cascade family screening. We provide a new Canadian definition for FH and tools for clinicians to make a diagnosis. The risk of atherosclerotic cardiovascular disease in patients with "definite" FH is 10- to 20-fold that of a normolipidemic individual and initiating treatment in youth or young adulthood can normalize life expectancy. Target levels for low-density lipoprotein cholesterol are proposed and are aligned with the Canadian Cardiovascular Society guidelines on dyslipidemia. Recommendation for the use of inhibitors of proprotein convertase kexin/subtilisin type 9 are made in patients who cannot achieve therapeutic low-density lipoprotein cholesterol targets on maximally tolerated statins and ezetimibe. The writing committee used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology in the preparation of the present document, which offers guidance for practical evaluation and management of patients with FH. This position statement also aims to raise awareness of FH nationally, and to mobilize patient support, promote knowledge translation, and availability of treatment and health care resources for this under-recognized, but important medical condition.

Background: Observational studies have shown better survival in patients undergoing coronary artery bypass grafting (CABG) with 2 arterial grafts compared with 1. However, whether a third arterial graft is associated with incremental benefit remains uncertain. We sought to analyze the outcomes of 3 versus 2 arterial grafts during CABG. As a secondary objective, we compared CABG with 2 or 3 arterial grafts (multiple arterial grafts [MAG]) with CABG using a single arterial graft (SAG). Methods: Retrospective cohort analyses of all patients undergoing primary isolated CABG in Ontario, Canada, from October 2008 to March 2016. Propensity score matching was performed between patients with 3 arterial grafts (3Art group) versus 2 (2Art group). The primary outcome was time to first event of a composite of death, myocardial infarction, stroke, and repeat revascularization (major adverse cardiac and cerebrovascular events). Additional analyses were performed to evaluate the association between MAG versus SAG and long-term outcomes using propensity score matching. Results: Fifty thousand, two hundred thirty patients underwent isolated CABG during our study period; 3044 (6.1%) and 8253 (16.4%) patients had 3 and 2 arterial grafts, respectively, resulting in 2789 propensity score matching pairs for the primary analyses. Mean and maximum follow-up was 4.2 and 8.5 years, respectively. Radial artery grafting was more common in the 3Art versus 2Art group (79.3% versus 65.6%, P P =0.26). Up to 8 years, there were no differences in major adverse cardiac and cerebrovascular events (3Art 27%, 95% confidence interval [CI], 24% to 30% versus 2Art 25%, 95% CI, 22% to 28%; hazard ratio [HR], 1.08, 95% CI, 0.94–1.25), death (HR, 1.08; 95% CI, 0.90–1.29), myocardial infarction (HR, 1.15; 95% CI, 0.87–1.51), stroke (HR, 1.39; 95% CI, 0.95–2.06), or repeat revascularization (HR, 1.04; 95% CI, 0.82–1.32). When evaluating MAG versus SAG, 8629 patient pairs were formed using propensity score matching. At 8 years, cumulative incidences of major adverse cardiac and cerebrovascular events (HR, 0.82, 95% CI, 0.77–0.88), survival (HR, 0.80; 95% CI, 0.73–0.88), repeat revascularization (HR, 0.79; 95% CI, 0.69–0.90), and myocardial infarction (HR, 0.83; 95% CI, 0.72–0.97) were superior in the MAG group. Conclusions: CABG with 3 arterial grafts was not associated with increased in-hospital death nor with better clinical outcomes at 8-year follow-up, compared with CABG with 2 arterial grafts. MAG was associated with superior outcomes compared with SAG.

Purpose: To determine the positive predictive values (PPV) of Ontario administrative data codes for the identification of open (OSR) and endovascular (EVAR) repairs of elective (eAAA) and ruptured (rAAA) abdominal aortic aneurysms. Methods: We randomly identified 319 eAAA and rAAA repairs at two Toronto hospitals between April 2003 and March 2015, using administrative health data in Ontario, Canada. International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) codes I71.3 and I71.4, were used to identify rAAA and eAAA patients, respectively. A blinded retrospective chart review was conducted and served as the gold standard comparator. Re-abstracted records were compared to Canadian Classification of Health Interventions (CCI) and Ontario Health Insurance Plan (OHIP) codes in the Canadian Institute for Health Information Discharge Abstract Database (CIHI-DAD) and OHIP databases. We calculated the PPV and 95% confidence intervals (95% CI) of individual and combined procedure and billing codes for elective and ruptured OSR and EVAR (eOSR, eEVAR, rOSR, and rEVAR). Results: Permutation of codes allowed identification of eOSR with 95% PPV (95% CI 88, 98), eEVAR with 96% PPV (95% CI 90, 99), rOSR with 87% PPV (95% CI 79, 93) and rEVAR with 91% PPV (95% CI 59, 100). Conclusions: Diagnostic, procedure and billing code combinations allow identification of eOSR, eEVAR, rOSR and rEVAR patients in Ontario administrative data with a high degree of certainty.

Background Heterozygous familial hypercholesterolemia (FH) is a common genetic disease predisposing affected individuals to a high risk of cardiovascular disease. Yet, considerable uncertainty exists regarding its impact on psychosocial wellbeing. Objectives We performed a systematic review and meta-analysis of the association between FH and symptoms of anxiety and depression, and health-related quality of life (HRQL). Methods We searched MEDLINE, EMBASE, Global Health, the Cochrane Library, PsycINFO, and PubMed for peer-reviewed literature published in English between January 1, 1990 and January 1, 2018. Quantitative and qualitative studies were eligible if they included patients with confirmed FH and evaluated its association with symptoms of anxiety or depression, or HRQL. We performed a narrative synthesis of studies, including thematic analysis of qualitative studies, and where data permitted, random-effects meta-analysis reporting standardized mean differences (SMD) and 95% confidence intervals. Results We found 10 eligible studies measuring HRQL, depression and anxiety. Random-effects meta-analysis of 4 (n = 4293) and 5 studies (n = 5098), respectively, showed that patients with FH had slightly lower symptoms of anxiety (SMD: −0.29 [95% CI: −0.53, −0.04]) and mental HRQL (SMD: −0.10 [95% −0.20, −0.00]) relative to general population controls. No significant differences existed in depressive symptoms (SMD: 0.04 [95% CI: −0.12, 0.19]) or physical HRQL scores (SMD: 0.02 [95% CI: −0.09, 0.12]). Conclusions Our systematic review suggests that patients with FH may report small but measurable differences in anxiety symptoms and mental HRQL.

Although the burden of aortic stenosis (AS) on our health care system is expected to rise, little is known regarding its epidemiology at the population level. Our primary objective was to evaluate trends in AS hospitalization, treatment and outcomes.We performed a population-based observational study including 37,970 patients newly hospitalized with AS from 2004 and 2013 in Ontario, Canada. We calculated age- and sex-standardized rate of AS hospitalization through direct standardization. The independent association between year of the hospitalization, and 30-day and 1-year mortality rate was evaluated using logistic regression models to account for temporal changes in patient characteristics.The overall age- and sex-standardized AS hospitalization rate increased slightly from 36 per 100,000 in 2004 to 39 per 100,000 in 2013. A substantial increase was seen in patients ≥85years, where hospitalization rates increased 29% from 400 to 516 per 100,000 from 2004 to 2013 (P.001). In this study period, 36.2% of patients received aortic valve interventions within 30days of hospitalization. Among treated patients, an improving mortality trend was observed in which the adjusted odds ratio (OR) was significantly lower in 2013 as compared to 2004 (OR 0.55 for 30-day mortality, 0.74 for 1-year morality). In contrast, no significant temporal change in mortality was seen among patients without aortic valve intervention.AS hospitalizations in the elderly increased significantly beyond that was expected from population growth. Many AS patients did not receive aortic valve intervention after hospitalization. Mortality among the treated patients improved significantly over time.

Background: This is the first national indigenous cohort study in which a common, in-depth protocol with a common set of objectives has been adopted by several indigenous communities across Canada. Objectives: The overarching objective of the Canadian Alliance for Healthy Hearts and Minds (CAHHM) cohort is to investigate how the community-level environment is associated with individual health behaviors and the presence and progression of chronic disease risk factors and chronic diseases such as cardiovascular disease (CVD) and cancer. Methods: CAHHM aims to recruit approximately 2,000 First Nations indigenous individuals from up to nine communities across Canada and have participants complete questionnaires, blood collection, physical measurements, cognitive assessments, and magnetic resonance imaging (MRI). Results: Through individual- and community-level data collection, we will develop an understanding of the specific role of the socioenvironmental, biological, and contextual factors have on the development of chronic disease risk factors and chronic diseases. Conclusions: Information collected in the indigenous cohort will be used to assist communities to develop local management strategies for chronic disease, and can be used collectively to understand the contextual, environmental, socioeconomic, and biological determinants of differences in health status in harmony with First Nations beliefs and reality.

Background Increased mortality is well described in patients with atrial fibrillation (AF), primarily related to death from cardiovascular causes. One may hypothesize that cardiology care may be associated with a reduction in cardiovascular deaths in patients with AF, thereby improving their overall survival. The aim of this study was to assess the association between cardiologist care and clinical outcomes, including all-cause mortality, in patients with new-onset AF. Methods This was a retrospective population-level, propensity score–matched cohort study of patients aged 20-80 years with new-onset AF presenting to an emergency department in Ontario, Canada between 2010 and 2012. Patients who saw a cardiologist within 1 year of the initial diagnosis were matched to patients who did not see a cardiologist. Linked administrative databases were used for cohort construction and allow for 1-year follow-up to assess for the clinical end points of death, hospitalization for AF, stroke syndromes, bleeding, and heart failure. Results Cardiologist care was associated with a lower 1-year rate of death (5.3% vs 7.7%; hazard ratio, 0.68; 95% confidence interval, 0.55-0.84), despite an increased rate of hospitalizations for AF (17.9% vs 8.2%), stroke syndromes (1.7% vs 0.5%), bleeding (3.1% vs 2.0%), and heart failure (3.2% vs 1.4%). Conclusions Cardiologist care was associated with a reduction in death in patients with new-onset AF. Further study to obtain a greater understanding of the processes of care associated with the observed survival improvement is warranted.

Aim To use a novel methodology to assess the incidence and specific causes of Out-of-Hospital Cardiac Arrest (OHCA) within a young urban cohort. Methods All EMS attended OHCA patients in a large urban area, between 2009 and 2012, aged 2–45 years, treated or untreated, who died or survived, and that were designated as “no obvious cause” etiology by trained data abstractors were included. Using multisource (medical and coroner) records, an expert panel adjudicated the causes of the OHCAs as: confirmed cardiac causes, confirmed non- cardiac causes, and other causes. Results Of a total of 1993 cases EMS designated as “no obvious cause”, only 29.9% (595/1993) were due to confirmed cardiac causes; the rest were due to other causes (non-cardiac etiologies): confirmed drug overdose (n = 624), trauma (n = 108), cancer (n = 69), complex chronic care (n = 65) and non-cardiac acute illness – mostly vascular, infectious, and metabolic (n = 376). The annual incidence rate of “no obvious cause” OHCAs after initial field classification was 12.97/100,000 pt. years (95% CI 12.40, 13.50), compared to 3.87/100,000 pt. years (95% CI 3.56, 4.18) for the confirmed cardiac OHCAs after adjudication. The predominant underlying etiologies of confirmed cardiac OHCAs were coronary heart disease and structural heart disease. Conclusions In young adults with OHCA, confirmed cardiac causes were responsible in a minority of cases, and they differed in presentation from those with confirmed non- cardiac causes. Establishing rigorous case ascertainment strategies with linkage to multiple data sources will facilitate a more reliable evaluation of the causes of these events.

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

Aims Improvement in resuscitation efforts has translated to an increasing number of survivors after out-of-hospital cardiac arrest (OHCA). Our objectives were to assess the long-term outcomes and predictors of mortality for patients who survived OHCA. Methods We conducted a population-based cohort study linking the Toronto RescuNET cardiac arrest database with administrative databases in Ontario, Canada. We included patients with non-traumatic OHCA from December 1, 2005 to December 31, 2014. The primary outcomes were mortality at 1 year and 3 years. Cox proportional hazard models were constructed to evaluate the predictors of mortality. Results Among the 28,611 OHCA patients who received treatment at the scene of arrest, 1591 patients survived to hospital discharge. During hospitalization, 36% received coronary revascularizations and 27% received an implantable cardioverter defibrillator. At one year after discharge, 12.6% of patients had died and 37.3% were readmitted. At 3 years, mortality rate was 20% and all-cause readmission rate was 54.1%. Older age and a history of cancer were associated with higher risk of 3-year mortality. Shockable rhythm at presentation (hazard ratio [HR] 0.62, 95% CI 0.45–0.85), use of coronary revascularization (HR 0.37, 95% CI 0.28–0.51) or implantable cardioverter defibrillator (HR 0.28, 95% CI 0.20–0.41) was associated with substantially lower 3-year mortality. Prior cardiac conditions and other arrest characteristics were not associated with long-term mortality. Conclusions Survivors of OHCA face significant morbidity and mortality after hospital discharge. Clinical trials are needed to evaluate the potential benefits of invasive cardiac procedures in OHCA survivors.

Comparative cardiovascular risk factor care across North America is unknown. We aimed to determine current performance in Canada and the United States (US).A systematic review was conducted of Medline and EMBASE (to June 1, 2014). Eligible studies reported on screening, awareness, treatment, or control rates for hypertension, dyslipidemia, diabetes, and smoking. Categorical performance 'ratings' on the basis of the most successful US health plans were used to classify rates as suboptimal (50%), below target (50%-70%), above target (70%-90%), or optimal (90%).A total of 127 studies reporting on 10,510,324 individuals across North America were included. Hypertension awareness (84.3%) and treatment (82.0%) rates in Canada and the US (82.7% and 75.6%, respectively) were above target, whereas control in both nations was below target (68.1% vs 51.8%, respectively). Canadian awareness, treatment, and control rates for dyslipidemia (42.7%, 40.9%, and 41.5%, respectively) were suboptimal, and American indicators were generally below target (61.5%, 43.0%, and 63.6%, respectively). Canada and the US showed diabetes awareness (88.2% vs 86.8%) and treatment rates (82.3% vs 82.5%) above target. However, glucose control was suboptimal in Canada (35.3%), and below target in the US (58.8%). There was a modest decline in absolute smoking prevalence rates in Canada from 1999 to 2013 (25.2% to 14.6%). Screening for tobacco use (72.2%) and counselling rates (73.8%) in the US were above target.Substantial variation exists in cardiovascular risk factor care across North America. Standardized reporting, dissemination of practice guidelines, and setting explicit goal-directed targets for performance might facilitate improvement.

This study sought to determine factors associated with cardiac electrophysiologist assessment and atrial fibrillation (AF) ablation in patients with new-onset AF.Factors driving variation in the use of AF ablation have not been well described.All individuals with new-onset AF in Ontario, Canada, between January 1, 2010, and December 31, 2012, were identified. Survival analysis accounting for the competing risk of death was used to evaluate the association between clinical and nonclinical factors and receipt of an electrophysiologist assessment. Factors associated with AF ablation were then determined in the subgroup of patients who received an electrophysiologist assessment.A total of 22,032 patients with new-onset AF were identified, 8,161 (37%) of whom received an electrophysiology assessment. Prior cardiologist care was associated with electrophysiologist assessment (hazard ratio [HR]: 1.57; p 0.0001). Rural residence was associated with a decreased incidence of electrophysiology assessment (HR: 0.80; p 0.0001). A total of 424 (5.2%) patients receiving an electrophysiologist assessment had an AF ablation. Recurrent AF emergency department (ED) visits between the index ED visit and the initial electrophysiologist assessment (HR for ≥2 ED visits: 4.22; p 0.0001) and rural residence (HR: 1.50; p = 0.002) were both associated with AF ablation. Cardiovascular comorbidities were associated with a decreased incidence of AF ablation.Rural patients with AF have a lower incidence of electrophysiologist assessment but paradoxically a higher incidence of AF ablation compared with their urban counterparts. Clinical factors such as recurrent ED visits for AF and cardiovascular comorbidities are the most important factors associated with of AF ablation.

The proliferation of cardiac diagnostic tests over the past few decades has received substantial attention from policymakers. However, contemporary population-based temporal trends of the utilization of noninvasive cardiac diagnostic tests for coronary artery disease are not known. Our objective was to examine the temporal trends in the utilization of coronary computed tomography angiography (CCTA), myocardial perfusion imaging (MPI), exercise stress testing (GXT), and stress echocardiography between 2008 and 2014. We performed a population-based repeated cross-sectional study of the adult population of Ontario between January 1, 2008 and December 31, 2014. Annual utilization rates of noninvasive cardiac diagnostic tests were computed. For each cardiac testing modality, a negative binomial regression model was used to assess temporal changes in test utilization. GXT and MPI collectively accounted for 88% of all cardiac noninvasive diagnostic tests throughout our study period. Age- and sex-standardized rates of GXT declined from 26.7/1000 adult population to 21.6/1000 adult population (mean annual reduction of 3.4%; P0.001). MPI rates declined from 21.1/1000 adult population to 19.5/1000 adult population (mean annual reduction of 1.3%; P0.001). Although utilization rates for both CCTA and stress echocardiography increased over time, the combined rate of all available tests decreased from 50.8/1000 adult population to 49.1/1000 adult population (mean annual reduction of 1.1%; P0.001). In conclusion, utilization rates for the most prevalent noninvasive cardiac diagnostic tests-GXT and MPI-declined over our study period. Furthermore, the overall test utilization rate also declined over time. We believe our findings are encouraging from a health policy perspective. Nonetheless, rising utilization rates for CCTA and stress echocardiography will need to be monitored in the future.

Individuals’ risk for cardiovascular disease is shaped by lifestyle factors such as participation in physical activity. Some studies have suggested that rates of physical activity may be higher in walkable neighborhoods that are more supportive of engaging in physical activity in daily life. However, walkable neighborhoods may also contain increased levels of traffic-related air pollution (TRAP). Traffic-related air pollution, often measured through a surrogate marker (e.g. NO2), has been associated cardiovascular disease risk and risk factors [1–4]. The higher levels of TRAP in walkable neighborhoods may in turn increase the likelihood of developing conditions like hypertension and diabetes. Our recent work assessed how walkability and TRAP jointly affect the odds of diabetes and hypertension in a sample of community-dwelling adults from Southern Ontario, Canada [5]. This article contains additional data on the probability and odds of hypertension and diabetes according to their walkability and TRAP exposures. Data on cardiovascular risk factors were collected using health administrative databases and environmental exposures were assessed using national land use regression models predicting ground level concentrations of NO2 and validated walkability indices. The included data were generated using logistic regression accounting for exposures, covariates, and neighborhood clustering. These data may be used as primary data in future health risk assessments and systematic reviews, or to aid in the design of studies examining interactions between built environment and TRAP exposures (e.g. sample size calculations). Keywords: Walkability, Traffic-related air pollution, NO2, Diabetes, Hypertension, Cardiovascular risk factors, Health administrative data

Background Individuals living in unwalkable neighborhoods appear to be less physically active and more likely to develop obesity, diabetes mellitus, and hypertension. It is unclear whether neighborhood walkability is a risk factor for future cardiovascular disease. Methods and Results We studied residents living in major urban centers in Ontario, Canada on January 1, 2008, using linked electronic medical record and administrative health data from the CANHEART (Cardiovascular Health in Ambulatory Care Research Team) cohort. Walkability was assessed using a validated index based on population and residential density, street connectivity, and the number of walkable destinations in each neighborhood, divided into quintiles (Q). The primary outcome was a predicted 10‐year cardiovascular disease risk of ≥7.5% (recommended threshold for statin use) assessed by the American College of Cardiology/American Heart Association Pooled Cohort Equation. Adjusted associations were estimated using logistic regression models. Secondary outcomes included measured systolic blood pressure, total and high‐density lipoprotein cholesterol levels, prior diabetes mellitus diagnosis, and current smoking status. In total, 44 448 individuals were included in our analyses. Fully adjusted analyses found a nonlinear relationship between walkability and predicted 10‐year cardiovascular disease risk (least [Q1] versus most [Q5] walkable neighborhood: odds ratio =1.09, 95% CI : 0.98, 1.22), with the greatest difference between Q3 and Q5 (odds ratio=1.33, 95% CI : 1.23, 1.45). Dose–response associations were observed for systolic blood pressure, high‐density lipoprotein cholesterol, and diabetes mellitus risk, while an inverse association was observed with smoking status. Conclusions In our setting, adults living in less walkable neighborhoods had a higher predicted 10‐year cardiovascular disease risk than those living in highly walkable areas.

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