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Background: Sodium–glucose cotransporter-2 (SGLT2) inhibitors are cardioprotective agents in patients with type 2 diabetes mellitus and atherosclerotic cardiovascular disease (CVD). Since little is known about their uptake in atherosclerotic CVD, we examined SGLT2 inhibitor prescribing trends and identified potential disparities in prescribing patterns. Methods: We conducted an observational study using linked population-based health data in Ontario, Canada, from April 2016 to March 2020 of patients aged 65 years or older with concomitant type 2 diabetes and atherosclerotic CVD. To examine prevalent prescribing of SGLT2 inhibitors (canagliflozin, dapagliflozin and empagliflozin), we constructed 4 cross-sectional yearly cohorts from Apr. 1 to Mar. 31 (2016/17, 2017/18, 2018/19 and 2019/20). We estimated prevalent SGLT2 inhibitor prescribing by year and by subgroups, and identified factors associated with SGTL2 inhibitor prescribing using multivariable logistic regression. Results: There were 208 303 patients in our overall cohort (median age 74.0 yr [interquartile range 68.0–80.0 yr], 132 196 [63.5%] male). Although SGLT2 inhibitor prescribing increased over time, from 7.0% to 20.1%, statin prescribing was initially 10-fold higher and later threefold higher than SGLT2 inhibitor prescribing. In 2019/20, SGLT2 inhibitor prescribing was roughly 50% lower among those aged 75 years or older than among those younger than 75 years (12.9% v. 28.3%, p < 0.001) and in women than in men (15.3% v. 22.9%, p < 0.001). Age 75 years or older, female sex, history of heart failure and kidney disease, and low income were independent factors of lower SGLT2 inhibitor prescribing. Among physician specialists, visits to endocrinologists and family physicians were stronger factors of SGLT2 inhibitor prescribing than cardiologist visits. Interpretation: We found that 1 in 5 patients with diabetes and atherosclerotic CVD were prescribed SGLT2 inhibitors in 2019/20, whereas statins were prescribed for 4 of every 5 patients. Although SGLT2 inhibitor prescribing increased over the study period, disparities in adoption by age, sex, socioeconomic status, comorbidities and physician specialty remained. [ABSTRACT FROM AUTHOR]

Background: Renin‐angiotensin‐aldosterone system inhibitors (RAASIs) are recommended for most patients with coronary artery disease (CAD). However, there is debate across guidelines as to which patients with CAD benefit the most from these agents. This study investigated the association between RAASIs and cardiovascular outcomes and acute kidney injury in a contemporary cohort of patients with CAD. Methods: Patients ≥65 years of age with CAD alive on April 1, 2012 in Ontario, Canada were included. Outcomes included major adverse cardiovascular events (MACE: cardiovascular death, myocardial infarction (MI), unstable angina, stroke, or coronary revascularization), and acute kidney injury (AKI) hospitalizations at 4 years. Inverse probability of treatment‐weighted Cox proportional hazards regression models was used to compare the rates of each outcome in patients treated with and without RAASIs (angiotensin‐converting enzyme inhibitors or angiotensin II receptor blockers). Results: There were 165,058 patients with CAD identified (mean age 75 years, 65.5% male, 64.7% prescribed RAASIs). After inverse‐probability weighting, treatment with RAASIs was associated with a lower rate of MACE compared with treatment without RAASIs (17.6% vs 18.2%, hazard ratio [HR]: 0.96, 95% CI: 0.93–0.99, respectively). However, treatment with RAASIs was associated with a higher rate of AKI compared with treatment without RAASIs (1.7% vs 1.5%, HR: 1.14, 95% CI: 1.02–1.29, respectively). The reduction in MACE was greater in patients with prior MI (HR: 0.87, 95% CI: 0.82–0.92) compared with patients without prior MI (HR: 1.00, 95% CI: 0.97–1.04, interaction p < 0.01). The increase in AKI was lower in patients with prior MI (HR: 0.82, 95% CI: 0.66–1.00) compared with patients without prior MI (HR: 1.37, 95% CI: 1.19–1.57, interaction p < 0.01). Conclusions: This study supports the continued use of RAASIs in patients with CAD, although the benefit appears smaller in magnitude than observed in prior trials. High‐risk patients, particularly those with prior MI, appear to benefit the most from RAASIs. [ABSTRACT FROM AUTHOR]

Background: Although accurate risk prediction is essential in guiding treatment decisions in primary prevention of atherosclerotic cardiovascular disease, the accuracy of the Framingham Risk Score (recommended by a Canadian guideline) and the Pooled Cohort Equations (recommended by US guidelines) has not been assessed in a large contemporary Canadian population. Our primary objective was to assess the calibration and discrimination of the Framingham Risk Score and Pooled Cohort Equations in Ontario, Canada.Methods: We conducted an observational study involving Ontario residents aged 40 to 79 years, without a history of atherosclerotic cardiovascular disease, who underwent cholesterol testing and blood pressure measurement from Jan. 1, 2010, to Dec. 31, 2014. We compared predicted event rates generated by the Framingham Risk Score and the Pooled Cohort Equations with observed event rates at 5 years using linkages from validated administrative databases.Results: Our study cohort included 84 617 individuals (mean age 56.3 yr, 56.9% female). Over a maximum follow-up period of 5 years, we observed 2162 (2.6%) events according to the outcome definition of the Framingham Risk Score, and 1224 (1.4%) events according to the outcome definition of the Pooled Cohort Equations. The predicted event rate of 5.78% by the Framingham Risk Score and 3.51% by the Pooled Cohort Equations at 5 years overestimated observed event rates by 101% and 115%, respectively. The degree of overestimation differed by age and ethnicity. The C statistics for the Framingham Risk Score (0.74) and Pooled Cohort Equations (0.73) were similar.Interpretation: The Framingham Risk Score and Pooled Cohort Equations significantly overpredicted the actual risks of atherosclerotic cardiovascular disease events in a large population from Ontario. Our finding suggests the need for further refinement of cardiovascular disease risk prediction scores to suit the characteristics of a multiethnic Canadian population. [ABSTRACT FROM AUTHOR]

Background: Readmission rates after acute myocardial infarction (AMI) and heart failure (HF) hospitalizations have decreased in the United States since the implementation of the Hospital Readmissions Reduction Program.Objectives: This study was designed to examine the temporal trends of readmission and mortality after AMI and HF in Ontario, Canada, where reducing hospital readmissions has not had a policy incentive.Methods: The cohort was comprised of AMI or HF patients 65 years of age or older who had been hospitalized from 2006 to 2017. Primary outcomes were 30-day readmission and post-discharge mortality. Secondary outcomes included in-hospital mortality, 30-day mortality from admission, and in-hospital mortality or 30-day mortality post-discharge. Adjusted monthly trends for each outcome were examined over the study period.Results: Our cohorts included 152,808 AMI and 223,283 HF patients. Age- and sex-standardized AMI hospitalization rates in Ontario declined 32% from 2006 to 2017 while HF hospitalization rates declined slightly (9.1%). For AMI, risk-adjusted 30-day readmission rates declined from 17.4% in 2006 to 14.7% in 2017. All AMI risk-adjusted mortality rates also declined from 2006 to 2017 with 30-day post-discharge mortality from 5.1% to 4.4%. For HF, overall risk-adjusted 30-day readmission was largely unchanged from 2006 to 2014 at 21.9%, followed by a decline to 20.8% in 2017. Risk-adjusted 30-day post-discharge mortality declined from 7.1% in 2006 to 6.6% in 2017.Conclusions: The patterns of outcomes in Ontario are consistent with the United States for AMI, but diverge for HF. For AMI and HF, admissions, readmissions, and mortality rates declined over this period. The reasons for the country-specific patterns for HF need further exploration. [ABSTRACT FROM AUTHOR]

Factors that influence decision of non–vitamin K antagonist oral anticoagulants (NOACs) use among older atrial fibrillation (AF) patients in long-term care (LTC) facilities have not been well studied. The aim of this study was to assess whether increased frailty influenced physicians to prescribe NOACs over warfarin. We retrospectively reviewed the electronic medical record (EMR) and pharmacy data of 25 LTC facilities in Ontario, Canada, in May 2015. The diagnosis of AF was ascertained from EMR and confirmed by complete chart review of a random sample of the cohort. A score of ≥2 on the Changes in Health, End-stage disease, Signs, and Symptoms (CHESS) scale was used as a surrogate marker of frailty. Multivariable logistic regression model was used to assess whether a higher frailty score is associated with the use of NOACs in comparison to warfarin, independent of potential patient-level confounders. In total, 3378 active residents were assessed in 25 LTC facilities. All the residents were ≥65 years old. We identified 433 residents with AF; 273 (63%) AF residents were on anticoagulation therapy and included in the analysis. Residents were more often treated with NOACs (n = 159; 58%) in comparison to warfarin (n = 114; 42%). A CHESS score of ≥2 increased the odds of prescribing NOACs by 2.46 times [95% confidence interval (CI) 1.11, 5.49; P =.03] when adjusted for important patient-level factors. Patients with hypertension had a trend of increased NOAC prescriptions but did not reach statistical significance [odds ratio 2.1 (95% CI 0.91, 4.81), P =.08]. None of the patient-level factors were associated with NOAC prescriptions. In this real world cohort of AF patients in LTC who are prescribed an oral anticoagulation therapy, a higher CHESS score (≥2) is associated with increased use of NOACs in comparison to warfarin. [ABSTRACT FROM AUTHOR]

Background: In 2007, the American Heart Association recommended antibiotic prophylaxis for the prevention of infective endocarditis (IE) for only the highest-risk patients. Whether this change affected the use of antibiotic prophylaxis and the incidence of IE is unclear.Methods: IE-related hospitalizations were identified from 2002 to 2014 among all adults and those at high and moderate risk for IE, stratified by age. Prescriptions for antibiotic prophylaxis were obtained from the Ontario Drug Benefit database for adults ≥65 years of age. Outcomes were antibiotic prophylaxis prescription rates and incidence of IE-related hospitalization. Trends in patient and pathogen characteristics were analyzed. Time series analyses were performed with segmented regression and change-point analyses.Results: Prescriptions for antibiotic prophylaxis decreased substantially in the moderate-risk cohort after the guideline revision (mean quarterly prescriptions, 30 680 versus 17 954 [level change, -6,481; P=0.0004] per 1 million population) with a minimal, yet significant, decrease followed by a slow increase in the high-risk group. There were 7551 IE-related hospitalizations among 6884 adults ≥18 years of age. Among adults ≥65 years of age, the mean IE rate increased from 872 to 1385 and 229 to 283 per 1 million population at risk per quarter in the high- and moderate-risk groups, respectively. Change-point analyses indicated that this increase occurred in the second half of 2010 in adults ≥65 years of age, 3 years after the American Heart Association guideline revision. Staphylococcus aureus and streptococcal species accounted for 30.3% and 26.4% of all IE, with a decrease in streptococcal infections over time.Conclusions: Antibiotic prophylaxis decreased significantly in the moderate-risk group with minimal change in the high-risk group after the American Heart Association guideline revision in 2007. However, IE-related hospitalizations increased among both high- and moderate-risk patients 3 years after the revision. Our study provides support for the cessation of antibiotic prophylaxis in the moderate-risk population. [ABSTRACT FROM AUTHOR]

Background: The prognostic importance of high-density lipoprotein cholesterol (HDL-C) as a specific risk factor for cardiovascular (CV) disease has been challenged by recent clinical trials and genetic studies.Objectives: This study sought to reappraise the association of HDL-C level with CV and non-CV mortality using a "big data" approach.Methods: An observational cohort study was conducted using the CANHEART (Cardiovascular Health in Ambulatory Care Research Team) dataset, which was created by linking together 17 different individual-level data sources. People were included if they were between 40 and 105 years old on January 1, 2008, living in Ontario, Canada, without previous CV conditions or severe comorbidities, and had an outpatient fasting cholesterol measurement in the year prior to the inception date. The primary outcome was cause-specific mortality.Results: A total of 631,762 individuals were included. The mean age of our cohort was 57.2 years, 55.4% were women, and mean HDL-C level was 55.2 mg/dl. There were 17,952 deaths during a mean follow-up of 4.9 ± 0.4 years. The overall all-cause mortality rate was 8.1 per 1,000 person-years for men and 6.6 per 1,000 person-years for women. Individuals with lower HDL-C levels were more likely to have low incomes, unhealthy lifestyle, higher triglycerides levels, other cardiac risk factors, and medical comorbidities. Individuals with lower HDL-C levels were independently associated with higher risk of CV, cancer, and other mortality compared with individuals in the reference ranges of HDL-C levels. In addition, individuals with higher HDL levels (>70 mg/dl in men, >90 mg/dl in women) had increased hazard of non-CV mortality.Conclusions: Complex associations exist between HDL-C levels and sociodemographic, lifestyle, comorbidity factors, and mortality. HDL-C level is unlikely to represent a CV-specific risk factor given similarities in its associations with non-CV outcomes. [ABSTRACT FROM AUTHOR]

The article discusses the results of the Affordability and Real-World Antiplatelet Treatment Effectiveness After Myocardial Infarction Study (ARTEMIS), that was published within the issue. Topics covered include the ability of co-payment vouchers for PSY12 inhibitors to reduce major adverse cardiovascular events (MACE), adherence to dual antiplatelet therapy, and the increased use of ticagrelor.

IMPORTANCE: Prior studies have shown that physicians in New York State (New York) perform twice as many cardiac catheterizations per capita as those in Ontario for stable patients. However, the role of patient selection in these findings and their implications for detection of obstructive coronary artery disease (CAD) are largely unknown. OBJECTIVE: To evaluate the extent of obstructive CAD and to compare the probability of detecting obstructive CAD for patients undergoing cardiac catheterization. DESIGN, SETTING, AND PATIENTS: An observational study was conducted involving patients without a history of cardiac disease who underwent elective cardiac catheterization between October 1,2008, and September 30,2011. Obstructive CAD was defined as diameter stenosis of 50% or more in the left main coronary artery or stenosis of 70% or more in a major epicardial vessel. MAIN OUTCOMES AND MEASURES: Observed rates and predicted probabilities of obstructive CAD. Predicted probabilities were estimated using logistic regression models. RESULTS: A total of 18 114 patients from New York and 54 933 from Ontario were included. The observed rate of obstructive CAD was significantly lower in New York at 30.4% (95% CI, 29.7%-31.0%) than in Ontario at 44.8% (95% CI, 44.4%-45.3%; P < .001). The percentage of patients with left main or 3-vessel CAD was also significantly lower in New York than in Ontario (7.0% [95% CI, 6.6%-7.3%] vs 13.0% [95% CI, 12.8%-13.3%]; P < .001). In New York, a substantially higher percentage of patients with low predicted probability of obstructive CAD underwent cardiac catheterization; for example, only 19.3% (95% CI, 18.7%-19.9%) of patients undergoing cardiac catheterization in New York had a greater than 50% predicted probability of having obstructive CAD than those in Ontario at 41% (95% CI, 40.6%-41.4%; P < .001). At 30 days, crude mortality for patients undergoing cardiac catheterization was slightly higher in New York at 0.65% (90 of 13 824; 95% CI, 0.51%-0.78%) than in Ontario at 0.38% (153 of 40 794; 95% CI, 0.32%-0.43%; P < .001). CONCLUSIONS AND RELEVANCE: In Ontario compared with New York State, patients undergoing elective cardiac catheterization were significantly more likely to have obstructive CAD. This appears to be related to a higher percentage of patients in New York with low predicted probability of CAD undergoing cardiac catheterization. [ABSTRACT FROM AUTHOR]

Objectives: The study assessed the appropriateness of coronary revascularization in Ontario, Canada, and examined its association with longer-term outcomes. Background: Although appropriate use criteria for coronary revascularization have been developed to improve the rational use of cardiac invasive procedures, it is unknown whether greater adherence to appropriateness guidelines is associated with improved clinical outcomes in stable coronary artery disease. Methods: A population-based cohort of stable patients undergoing cardiac catheterization was assembled from April 1, 2006, to March 31, 2007. The appropriateness for coronary revascularization at the time of coronary angiography was retrospectively adjudicated using the appropriate use criteria. Clinical outcomes between coronary revascularization and medical treatment without revascularization, stratified by appropriateness categories, were compared. Results: In 1,625 patients with stable coronary artery disease, percutaneous coronary intervention or coronary artery bypass grafting was only performed in 69% who had an appropriate indication for coronary revascularization. Coronary revascularization was associated with a lower adjusted hazard of death or acute coronary syndrome (hazard ratio [HR]: 0.61; 95% confidence interval [CI]: 0.42 to 0.88) at 3 years compared with medical therapy in appropriate patients. The rate of coronary revascularization was 54% in the uncertain category and 45% in the inappropriate category. No significant difference in death or acute coronary syndrome between coronary revascularization and no revascularization in the uncertain category (HR: 0.57; 95% CI: 0.28 to 1.16) and the inappropriate category (HR: 0.99; 95% CI: 0.48 to 2.02) was observed. Conclusions: Using the appropriateness use criteria, we identified substantial underutilization and overutilization of coronary revascularization in contemporary clinical practice. Underutilization of coronary revascularization is associated with significantly increased risks of adverse outcomes in patients with appropriate indications. [Copyright &y& Elsevier]

Background: The ratio of percutaneous coronary interventions to coronary artery bypass graft surgeries (PCI:CABG ratio) varies considerably across hospitals. We conducted a comprehensive study to identify clinical and nonclinical factors associated with variations in the ratio across 17 cardiac centres in the province of Ontario. Methods: In this retrospective cohort study, we selected a population-based sample of 8972 patients who underwent an index cardiac catheterization between April 2006 and March 2007 at any of 17 hospitals that perform invasive cardiac procedures in the province. We classified the hospitals into four groups by PCI:CABG ratio (low [< 2.0], low-medium [2.0-2.7], medium- high [2.8-3.2] and high [> 3.2]). We explored the relative contribution of patient, physician and hospital factors to variations in the likelihood of patients receiving PCI or CABG surgery within 90 days after the index catheterization. Results: The mean PCI:CABG ratio was 2.7 overall. We observed a threefold variation in the ratios across the four hospital ratio groups, from a mean of 1.6 in the lowest ratio group to a mean of 4.6 in the highest ratio group. Patients with single-vessel disease usually received PCI (88.4%-99.0%) and those with left main artery disease usually underwent CABG (80.8%- 94.2%), regardless of the hospital's procedure ratio. Variation in the management of patients with non- emergent multivessel disease accounted for most of the variation in the ratios across hospitals. The mode of revascularization largely reflected the recommendation of the physician performing the diagnostic catheterization and was also influenced by the revascularization "culture" at the treating hospital. Interpretation: The physician performing the diagnostic catheterization and the treating hospital were strong independent predictors of the mode of revascularization. Opportunities exist to improve transparency and consistency around the decision-making process for coronary revascularization, most notably among patients with non- emergent multivessel disease. [ABSTRACT FROM AUTHOR]

Objectives: Our main objective was to evaluate the longer-term safety and efficacy of drug-eluting stents (DES) in off-label indications as compared with bare-metal stents (BMS). Background: DES are frequently implanted in patients with off-label indications. However, the longer-term safety and effectiveness of DES among patients with off-label indications are not well understood. Methods: Propensity score matching analysis was performed in a population-based cohort that included 6,944 off-label and 9,126 on-label patients who received percutaneous coronary interventions (PCIs) in Ontario, Canada, between December 1, 2003, and March 31, 2006. Off-label indications were defined on the basis of clinical and procedural characteristics. Results: For patients with off-label indications, rates of repeat target vessel revascularization at 3 years were significantly lower among patients treated with DES compared with those treated with BMS (11.6% vs. 15.3%, p < 0.001). Myocardial infarction rates were not significantly different between patients treated with DES and BMS (p = 0.52). Mortality rates were significantly lower among off-label patients treated with DES compared with BMS at 3 years of follow-up (6.9% vs. 10.5%, p < 0.001). For patients with on-label indications, the use of DES was associated with significantly lower rates of target vessel revascularization, but composite rates of myocardial infarction or death were not significantly different from BMS. Conclusions: For patients with off-label indications, DES implantation was associated with lower target vessel revascularization without an associated increase in longer-term risk of myocardial infarction or death compared with BMS. [Copyright &y& Elsevier]

Background: Contrast-induced nephropathy is the leading cause of in-hospital acute renal failure. This side effect of contrast agents leads to increased morbidity, mortality, and health costs. Ensuring adequate hydration prior to contrast exposure is highly effective at preventing this complication, although the optimal hydration strategy to prevent contrast-induced nephropathy still remains an unresolved issue. Former meta-analyses and several recent studies have shown conflicting results regarding the protective effect of sodium bicarbonate. The objective of this study was to assess the effectiveness of normal saline versus sodium bicarbonate for prevention of contrast-induced nephropathy. Methods: The study searched MEDLINE, EMBASE, Cochrane databases, International Pharmaceutical Abstracts database, ISI Web of Science (until 15 December 2008), and conference proceedings for randomized controlled trials that compared normal saline with sodium bicarbonate-based hydration regimen regarding contrast-induced nephropathy. Random-effects models were used to calculate summary odds ratios. Results: A total of 17 trials including 2,633 subjects were pooled. Pre-procedural hydration with sodium bicarbonate was associated with a significant decrease in the rate of contrast-induced nephropathy (odds ratios 0.52; 95% confidence interval 0.34-0.80, P = 0.003). Number needed to treat to prevent one case of contrast-induced nephropathy was 16 (95% confidence interval 10-34). No significant differences in the rates of post-procedure hemodialysis (P = 0.20) or death (P = 0.53) was observed. Conclusion: Sodium bicarbonate-based hydration was found to be superior to normal saline in prevention of contrast-induced nephropathy in this updated meta-analysis. [ABSTRACT FROM AUTHOR]

Abstract: Objectives : To determine if elevations of adhesion molecules in acute coronary syndrome (ACS) are useful for risk stratification. Design and methods : A cell adhesion array (Randox Ltd.) and NT-proBNP were measured in 216 ACS patients. Results : Kaplan–Meier and Cox models indicate early elevations of NT-proBNP but not the adhesion molecules are predictive of future death/myocardial infarction. Discussion : Elevations of adhesion molecules early after pain onset in ACS are not useful for long-term risk stratification. [Copyright &y& Elsevier]

Objectives: We evaluated whether appropriateness and baseline risk of cardiac catheterization varied according to regional intensity of invasive therapy after acute myocardial infarction (AMI), and whether AMI mortality varied according to invasive intensity regions. Background: Marked regional variations exist in cardiac invasive procedure use after AMI within the U.S. Methods: We performed an analysis of 44,639 Medicare fee-for-service beneficiaries hospitalized with AMI between 1998 and 2001. Invasive procedure intensity was determined based on overall cardiac catheterization rates for Medicare enrollees. Cardiac catheterization appropriateness was determined by the American College of Cardiology/American Heart Association classification and baseline risk was estimated using the GRACE (Global Registry of Acute Coronary Events) risk score. The primary outcomes of the study were cardiac catheterization use within 60 days and 3-year mortality after hospital admission. Results: Higher invasive intensity regions were more likely to perform cardiac catheterizations on class I patients (appropriate) (RR 1.38, 95% confidence interval [CI] 1.27 to 1.48), class II patients (equivocal) (RR 1.42, 95% CI 1.31 to 1.53), and class III patients (inappropriate) (RR 1.29, 95% 0.97 to 1.67) compared with low-intensity regions after adjusting for patient and physician characteristics. The overall cardiac catheterization use was 5.2% lower for each increase in GRACE risk decile, and this relationship was observed similarly in all regions. Risk-standardized mortality rates of AMI patients at 3 years were not substantially different between regions. Conclusions: Although higher-risk patients and those with more appropriate indications may have the most to benefit from an invasive strategy after AMI, we found that higher-invasive regions do not differentiate procedure selection based on the patients’ appropriateness or their baseline risks. [Copyright &y& Elsevier]

Abstract: Background: For patients presenting with acute coronary syndrome (ACS) to the emergency department, early identification of those that are at high risk for subsequent myocardial necrosis or adverse outcomes would allow earlier or more aggressive treatment. We determined if a panel of biomarkers can be used to identify high risk patients. Methods: A cohort (84 females/132 males) from our 1996 ACS study population that had EDTA specimens stored (−70 °C) was selected and the earliest available specimen was analyzed for 11 biomarkers (IL-6, IL-8, MCP-1, VEGF, L-selectin, P-selectin, E-selectin, ICAM-1, VCAM-1, NT-proBNP, cTnT). These data were linked to the existing cTnI and health outcome databases for this population. ROC curve analysis for myocardial necrosis (i.e., peak cTnI >0.04 μg/l) identified 3 candidate biomarkers. These 3 biomarkers were applied together to generate a panel test (2 of the 3 biomarkers increased for a positive result) and assessed for its ability to identify patients at risk for myocardial necrosis and the combined endpoint of death, myocardial infarction (MI) and heart failure (HF). Results: The panel test (IL-6, NT-proBNP, E-selectin) alone detected 60% (95% CI: 49–69; false positive rate: 26%) of subjects that would be classified with myocardial necrosis. Kaplan–Meier and Cox proportional analyses indicated that patients positive by the biomarker panel (including those with cTnI ≤0.04 μg/l) had significantly worse outcomes (death/MI/HF) as compared to those negative by both cTnI and the panel test. Conclusion: A biomarker panel analyzed early after pain onset can identify individuals at risk for both myocardial necrosis and the combined endpoint of death/MI/HF. Additional prospective studies are required to assess this panel for both early MI detection and to further refine which health outcomes (death, MI, HF) are associated with positive panel results. [Copyright &y& Elsevier]

Background Health care expenditure per person is significantly higher in the United States compared with Canada, but whether there are differences in quality of care of many conditions is unknown. We compared the process of care and outcomes of patients with heart failure, the most common cause of hospitalization for individuals 65 years and older in both countries. Methods We compared processes of care and 30-day and 1-year risk-standardized mortality rates among 28 521 US Medicare beneficiaries and 8180 similarly aged patients in Ontario, Canada, hospitalized with heart failure from 1998 to 2001. Results More US patients underwent left ventricular ejection fraction assessment during hospitalization compared with Canadian patients (61.2% vs 41.7%, P<.001). At discharge, patients in the United States were prescribed β-blockers more frequently (28.7% vs 25.4%, P<.001) but angiotensin-converting enzyme inhibitors less frequently (54.3% vs 63.4%, P<.001). Among ideal candidates, prescription of β-blockers (32.5% vs 29.7%, P = .08) or angiotensin-converting enzyme inhibitors (78.3% vs 77.6%, P = .68) was not significantly different between the 2 countries. The US patients had lower risk characteristics on admission and lower crude mortality rates at 30 days and 1 year. Thirty-day risk-standardized mortality was significantly lower for the US patients (8.9% vs 10.7%, P<.001), but 1-year risk-standardized mortality was no longer significantly different (32.2% vs 32.3%, P = .98). Conclusion Patients with heart failure who are hospitalized in the United States had lower short-term mortality at 30 days, but 1-year mortality rates were not significantly different between the United States and Canada. [ABSTRACT FROM AUTHOR]

Background International medical graduates (IMGs) make up a substantial proportion of the physician workforce and play an important role in the care of patients with acute myocardial infarction (AMI). There are concerns that IMGs may provide inferior medical care compared with locally trained medical graduates, but that has not been established. Methods We performed a retrospective cohort study of linked administrative databases containing health care claims of physicians’ service payments, hospital discharge abstracts, and patients’ vital status. We included 127 275 AMI patients admitted between April 1, 1992, and March 31, 2000, to acute care hospitals in Ontario. We then compared the risk-adjusted mortality rates and adjusted use of secondary prevention medications and cardiac invasive procedures in patients treated by IMGs vs Canadian medical graduates. Results Of the 127 275 admitted AMI patients, 28 061 (22.0%) were treated by IMGs and 99 214 (78.0%) by Canadian medical graduates. The risk-adjusted mortality rates of IMG- and Canadian medical graduate–treated patients were not significantly different at 30 days (13.3% vs 13.4%, P = .57) and at 1 year (21.8% vs 21.9%, P = .63). Furthermore, AMI patients treated by both groups had similar adjusted likelihood of receiving secondary prevention medications at 90 days and cardiac invasive procedures at 1 year. Conclusions The use of secondary prevention medications and cardiac procedures and the mortality of AMI patients were similar, regardless of the origin of medical education of the admitting physician. This information places the care provided by IMGs into perspective and supports the ability of well-selected IMGs in caring for AMI patients. [ABSTRACT FROM AUTHOR]

Background β-Blockers substantially improve survival in patients with chronic heart failure (HF) with left ventricular systolic dysfunction, but concerns about cardiovascular adverse effects may deter physicians from prescribing this therapy. We performed an overview of randomized β-blocker trials in patients with HF to quantify the risks of these adverse effects. Methods Heart failure trials of β-blockers were identified by electronic searches of the MEDLINE database from 1966 to 2002. The random-effects model was used to combine results from individual trials and calculate estimates of risks associated with therapy. Results β-Blocker therapy was associated with significant absolute annual increases in risks of hypotension (11 per 1000; 95% confidence interval [CI], 0-22), dizziness (57 per 1000; 95% CI, 11-104), and bradycardia (38 per 1000; 95% CI, 21-54). There was no significant absolute risk of fatigue associated with therapy (3 per 1000; 95% CI, -2 to 9). β-Blocker therapy was associated with a reduction in all-cause withdrawal of medication (14 per 1000; 95% CI, -2 to 29) as well as significant reductions in all-cause mortality (34 per 1000; 95% CI, 20-49), HF hospitalizations (40 per 1000; 95% CI, 22-58), and worsening HF (52 per 1000; 95% CI, 10-94). Conclusions Although β-blocker therapy was associated with hypotension, dizziness, and bradycardia, the absolute increases in risk were small, and overall fewer patients were withdrawn from β-blocker therapy than from placebo. This information should alleviate concerns about prescribing this life-saving therapy to patients with HF. [ABSTRACT FROM AUTHOR]

Context The benefits of cardiovascular therapies such as statins for secondary prevention have been well documented, although they may not be optimally used in patients most likely to benefit. Ideally, aggressiveness in the use of these beneficial therapies should correlate with baseline cardiovascular risk. Objective To examine the association between physicians' treatment aggressiveness and baseline cardiovascular risk. Design, Setting, and Patients Retrospective cohort study incorporating the use of multiple linked health care administrative databases covering more than 1.4 million elderly residents of Ontario. We included 396 077 patients aged 66 years or older who had a history of cardiovascular disease or diabetes while undergoing medical treatment and who were alive on April 1, 1998. Baseline cardiovascular risk was derived using a risk-adjustment index in which we modeled probability of death after 3 years of follow-up. Main Outcome Measure Likelihood of statin use, stratified by baseline cardiovascular risk, after adjusting for age, sex, socioeconomic status, and rural or urban residence. Results Only 75 617 patients (19.1%) in this secondary prevention cohort were prescribed statins. In patients 66 to 74 years old, the adjusted probabilities of statin prescription were 37.7%, 26.7%, and 23.4% in the categories of low, intermediate, and high baseline risk, respectively. The likelihood of statin prescription was 6.4% lower (adjusted odds ratio, 0.94; 95% confidence interval, 0.93-0.95) for each year of increase in age and each 1% increase in predicted 3-year mortality risk. The influence of age also interacted synergistically with baseline risk on the prescription of statins (P<.001). Conclusions We found that prescription of statins diminished progressively as baseline cardiovascular risk and future probability of death increased. Since the benefits of a therapy are dependent on the baseline risk, the maximum benefits of statins may not be fully realized... [ABSTRACT FROM AUTHOR]

Context: β-Blocker therapy remains substantially underused in cardiac patients despite its proven mortality benefits. Reluctance to prescribe these agents may derive from concerns about their association with symptoms of depression, fatigue, and sexual dysfunction. Objective: To determine the association of β-blockers with depressive symptoms, fatigue, and sexual dysfunction by performing a quantitative review of randomized trials that tested β-blockers in myocardial infarction, heart failure, and hypertension. Data Sources: Randomized trials of β-blockers used in the treatment of myocardial infarction, heart failure, or hypertension were identified by searching the MEDLINE database for English-language articles (1966-2001). In addition, we searched the reference lists of previously published trials and reviews of β-blockers for additional studies. Study Selection: Criteria for inclusion of trials in the review were: random allocation of study treatments, placebo control, noncrossover design, enrollment of at least 100 patients, and a minimum of 6 months of follow-up. The initial search produced 475 articles, 42 of which met these criteria. Fifteen of these trials reported on depressive symptoms, fatigue, or sexual dysfunction and were selected for inclusion. Data Extraction: For each trial, 1 author abstracted the frequency of adverse events in the β-blocker and placebo groups and the numbers of patients randomized to the treatment groups. Two other authors verified the counts of events, and all authors adjudicated any discrepancies. Two different types of information on adverse events were abstracted: patient-reported symptoms and withdrawal of therapy due to a specified symptom. We categorized the tested β-blockers by generation (early vs late) and lipid solubility (high vs low to moderate). Data Synthesis: The 15 trials involved more than 35 000 subjects. β-Blocker therapy was not associated with a significant... [ABSTRACT FROM AUTHOR]

Background: Hip fractures are costly and common in older adults, but there is limited understanding of how treatment patterns and outcomes might differ between countries. Methods: We performed a retrospective serial cross‐sectional cohort study of adults aged ≥66 years hospitalized with hip fracture between 2011 and 2018 in the US, Canada, England, the Netherlands, Taiwan, and Israel using population‐representative administrative data. We examined mortality, hip fracture treatment approaches (total hip arthroplasty [THA], hemiarthroplasty [HA], internal fixation [IF], and nonoperative), and health system performance measures, including hospital length of stay (LOS), 30‐day readmission rates, and time‐to‐surgery. Results: The total number of hip fracture admissions between 2011 and 2018 ranged from 23,941 in Israel to 1,219,696 in the US. In 2018, 30‐day mortality varied from 3% (16% at 1 year) in Taiwan to 10% (27%) in the Netherlands. With regards to processes of care, the proportion of hip fractures treated with HA (range 23%–45%) and THA (0.2%–10%) differed widely across countries. For example, in 2018, THA was used to treat approximately 9% of patients in England and Israel but less than 1% in Taiwan. Overall, IF was the most common surgery performed in all countries (40%–60% of patients). IF was used in approximately 60% of patients in the US and Israel, but only 40% in England. In 2018, rates of nonoperative management ranged from 5% of patients in Taiwan to nearly 10% in England. Mean hospital LOS in 2018 ranged from 6.4 days (US) to 18.7 days (England). The 30‐day readmission rate in 2018 ranged from 8% (in Canada and the Netherlands) to nearly 18% in England. The mean days to surgery in 2018 ranged from 0.5 days (Israel) to 1.6 days (Canada). Conclusions: We observed substantial between‐country variation in mortality, surgical approaches, and health system performance measures. These findings underscore the need for further research to inform evidence‐based surgical approaches. [ABSTRACT FROM AUTHOR]

Estimating a patient's risk for cardiovascular disease (CVD) is cumbersome. Someone has to locate information about the patient's medical history, physical measurements, and laboratory test results and then enter it into a risk calculator, which might be embedded in the electronic health record but is not seamlessly integrated into clinical workflow. In contrast, most clinicians routinely receive an estimated glomerular filtration rate (eGFR) on every report of a patient's serum creatinine results. This article describes an attempt to make estimates of a patient's risk for CVD as readily available as estimates of the patient's eGFR. Visual Abstract. Development and Validation of the CANHEART Population-Based Laboratory Prediction Models for Atherosclerotic Cardiovascular Disease: Estimating a patient's risk for cardiovascular disease (CVD) is cumbersome. Someone has to locate information about the patient's medical history, physical measurements, and laboratory test results and then enter it into a risk calculator, which might be embedded in the electronic health record but is not seamlessly integrated into clinical workflow. In contrast, most clinicians routinely receive an estimated glomerular filtration rate (eGFR) on every report of a patient's serum creatinine results. This article describes an attempt to make estimates of a patient's risk for CVD as readily available as estimates of the patient's eGFR. Background: Prediction of atherosclerotic cardiovascular disease (ASCVD) in primary prevention assessments exclusively with laboratory results may facilitate automated risk reporting and improve uptake of preventive therapies. Objective: To develop and validate sex-specific prediction models for ASCVD using age and routine laboratory tests and compare their performance with that of the pooled cohort equations (PCEs). Design: Derivation and validation of the CANHEART (Cardiovascular Health in Ambulatory Care Research Team) Lab Models. Setting: Population-based cohort study in Ontario, Canada. Participants: A derivation and internal validation cohort of adults aged 40 to 75 years without cardiovascular disease from April 2009 to December 2015; an external validation cohort of primary care patients from January 2010 to December 2014. Measurements: Age and laboratory predictors measured in the outpatient setting included serum total cholesterol, high-density lipoprotein cholesterol, triglycerides, hemoglobin, mean corpuscular volume, platelets, leukocytes, estimated glomerular filtration rate, and glucose. The ASCVD outcomes were defined as myocardial infarction, stroke, and death from ischemic heart or cerebrovascular disease within 5 years. Results: Sex-specific models were developed and internally validated in 2 160 497 women and 1 833 147 men. They were well calibrated, with relative differences less than 1% between mean predicted and observed risk for both sexes. The c-statistic was 0.77 in women and 0.71 in men. External validation in 31 697 primary care patients showed a relative difference less than 14% and an absolute difference less than 0.3 percentage points in mean predicted and observed risks for both sexes. The c-statistics for the laboratory models were 0.72 for both sexes and were not statistically significantly different from those for the PCEs in women (change in c-statistic, −0.01 [95% CI, −0.03 to 0.01]) or men (change in c-statistic, −0.01 [CI, −0.04 to 0.02]). Limitation: Medication use was not available at the population level. Conclusion: The CANHEART Lab Models predict ASCVD with similar accuracy to more complex models, such as the PCEs. Primary Funding Source: Canadian Institutes of Health Research. [ABSTRACT FROM AUTHOR]

Background: The ability to rule out or in a major adverse cardiac event (MACE) in patients with suspected acute coronary syndrome at emergency department (ED) presentation would be beneficial to patient care and the health care system. The clinical chemistry score (CCS) was evaluated in this context. Methods: This diagnostic accuracy study evaluated 2 different ED cohorts with suspected acute coronary syndrome. For patients in cohort 1, who presented to the ED of 3 hospitals in Hamilton, Ontario, between May and August 2013, retrospective measurements were taken using the Ortho Clinical Diagnostics high-sensitivity cardiac troponin I (hs-cTnI) assay; for patients in cohort 2, who presented to the ED of the same 3 hospitals in Hamilton between November 2012 and February 2013, an ED cardiac presentation blood test panel was performed with the Abbott Diagnostics hs-cTnI assay. The sensitivity and specificity of the CCS (cut-offs of ≥ 1 and 5) and hs-cTnI alone (published cut-offs) were compared for MACE (composite of death, myocardial infarction, unstable angina, revascularization) at 30 days for both cohorts and at 90 days for cohort 2. Results: The incidence of MACE at 30 days was higher in cohort 1 (n = 1058) (19.4%, 95% confidence interval [CI] 16.8%–22.2%) than in cohort 2 (n = 5974) (14.6%, 95% CI 13.6%–15.6%). In cohort 1, a CCS of 1 or above yielded a sensitivity of 99.5% (95% CI 97.3%–99.9%). The sensitivity with an Ortho hs-cTnI cut-off of 1 ng/L or above was 91.2% (95% CI 86.5%–95.7%). The specificity of a CCS of 5 (97.8%, 95% CI 96.5%–98.7%) was higher than when the overall 99th-percentile cut-off for the Ortho hs-cTnI assay (> 11 ng/L; 90.1%, 95% CI 87.9%–92.0%) was used. A similar pattern was observed in cohort 2 at 30 days and persisted at 90 days with the Abbott hs-cTnI assay. Interpretation: The CCS derived with 2 different hs-cTnI assays and ED populations yielded higher sensitivity and specificity estimates for MACE than hs-cTnI alone. An intervention study is needed to evaluate the impact of the CCS at both the patient and hospital levels. Trial registration: ClinicalTrials.gov, no. NCT01994577 [ABSTRACT FROM AUTHOR]

Background: Previous work showed lower cardiac intervention rates for patients with acute myocardial infarction (AMI) in Ontario than in the United States. We assessed whether Ontario's efforts to improve access to rapid percutaneous coronary intervention (PCI) for AMI were associated with improved timeliness of care and whether this closed the gap between the 2 jurisdictions. Methods: In this retrospective cohort study, we followed adults aged 66–99 years in the US and Ontario for 30 days after admission for incident AMI between 2003 and 2013 using health administrative data from both countries. We calculated the proportion of patients who received cardiac catheterization, PCI and coronary artery bypass grafting on the day of and within 30 days of admission overall and according to AMI type (ST-segment elevation AMI [STEMI] v. non-STEMI) and risk group (low, medium or high predicted risk of 30-d mortality). Results: We followed 414 216 patients in the US and 112 484 in Ontario. The large disparities in cardiac intervention rates observed in 2003 mostly disappeared over time. By 2013, the proportion of patients who received same-day PCI was only slightly higher in the US than in Ontario (22.3% v. 19.2%), whereas the converse was true for 30-day PCI (44.0% v. 41.3%). In 2013, patients with STEMI in the US and Ontario received PCI at nearly identical rates on the day of admission (66.3% v. 63.8%); however, more patients at high risk with STEMI in the US than in Ontario received PCI, both on the day of admission (55.5% v. 44.7%) and by 30 days (60.5% v. 55.0%). Interpretation: Despite differences in resources and organization of delivery systems, by 2013, timely receipt of PCI by Ontario patients with AMI lagged only slightly behind that by US patients. A higher supply of PCI centres in the US may have facilitated earlier intervention among patients at high risk with STEMI. [ABSTRACT FROM AUTHOR]

Background: Socioeconomic status is an important but understudied determinant of preoperative health status and postoperative outcomes. Previous work has focused on the impact of socioeconomic status on mortality, hospital stay, or complications. However, individuals with low socioeconomic status are also likely to have fewer supports to facilitate them remaining at home after hospital discharge. Thus, such patients may be less likely to return home over the short and intermediate term after major surgery. The newly validated outcome, days alive and out of hospital, may be highly suited to evaluating the impact of socioeconomic status on this postdischarge period. The study aimed to determine the association of socioeconomic status with short and intermediate term postoperative recovery as measured by days alive and out of hospital.Methods: The authors evaluated data from 724,459 adult patients who had one of 13 elective major noncardiac surgical procedures between 2006 and 2017. Socioeconomic status was measured by median neighborhood household income (categorized into quintiles). Primary outcome was days alive and out of hospital at 30 days, while secondary outcomes included days alive and out of hospital at 90 and 180 days, and 30-day mortality.Results: Compared to the highest income quintile, individuals in the lowest quintile had higher unadjusted risks of postoperative complications (6,049 of 121,099 [5%] vs. 6,216 of 160,495 [3.9%]) and 30-day mortality (731 of 121,099 [0.6%] vs. 701 of 160,495 [0.4%]) and longer mean postoperative length of stay (4.9 vs. 4.4 days). From lowest to highest income quintile, the mean adjusted days alive and out of hospital at 30 days after surgery varied between 24.5 to 24.9 days.Conclusions: Low socioeconomic status is associated with fewer days alive and out of hospital after surgery. Further research is needed to examine the underlying mechanisms and develop posthospital interventions to improve postoperative recovery in patients with fewer socioeconomic resources. [ABSTRACT FROM AUTHOR]

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

Background: There is a paucity of information about treatment and mortality trends after acute myocardial infarction (AMI) for cancer survivors (CS).Methods: In this population-based study, the authors compared temporal trends of treatments and outcomes (mortality, nonfatal cardiovascular outcomes), among CS and patients without cancer (the noncancer patient [NCP] group) with AMI in Ontario (Canada) using inverse probability treatment weight (IPTW)-adjusted modeling.Results: Of 270,089 patients with AMI (22,907 CS, 247,182 NCP, 1995-2013; median follow-up, 10.1 and 11.0 years, respectively), the use of invasive coronary strategies and pharmacotherapies increased and mortality declined for CS and NCP (all Ptrend  < .001). At 30 days after AMI, there was no difference between CS and NCP in the receipt of coronary angiography (incidence risk ratio [IRR], 0.98; 95% confidence interval [CI], 0.96-1.01; P = .23), percutaneous coronary intervention (IRR, 0.98; 95% CI, 0.94-1.02; P = .29), or bypass (IRR, 0.93; 95% CI, 0.85-1.02; P = .11). At 90 days after AMI, there was no difference in the receipt of β-blockers, clopidogrel, or nitrates; but CS were less often prescribed angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers and statins. CS had higher all-cause mortality at 30 days (adjusted hazard ratio [HR] 1.12; 95% CI, 1.07-1.17; P < .001), at 1 year (1.16; 95% CI, 1.12-1.20; P < .001), and long term (HR, 1.21; 95% CI, 1.17-1.25; P < .001) and had a greater risk of heart failure (HR, 1.08; 95% CI, 1.03-1.14; P = .001), but not myocardial re-infarction (HR, 0.98; 95% CI, 0.95-1.01; P = .22) or stroke (HR, 1.06; 95% CI, 0.97-1.16; P = .18).Conclusions: Among CS and NCP with AMI in Ontario, similar improvements in mortality and receipt of treatments were observed between 1995 and 2013. However, compared with NCP, CS had a higher risk of mortality and heart failure. Cancer 2018;124:1269-78. © 2017 American Cancer Society. [ABSTRACT FROM AUTHOR]

Key Points: Question: How do treatment patterns and outcomes for older patients presenting with acute myocardial infarction differ for low- vs high-income individuals across 6 countries. Findings: In this study of 289 376 patients aged 66 years or older hospitalized with ST-segment elevation myocardial infarction (STEMI) and 843 046 hospitalized with non-STEMI across 6 health systems, adjusted 30-day and 1-year mortality rates were higher for low-income patients, whereas rates of cardiac catheterization and percutaneous coronary interventions were lower. High-income patients also had shorter length of stay and lower rates of readmissions. Meaning: These results suggest that income-based disparities were present even in countries with universal health insurance and robust social safety net systems. Importance: Differences in the organization and financing of health systems may produce more or less equitable outcomes for advantaged vs disadvantaged populations. We compared treatments and outcomes of older high- and low-income patients across 6 countries. Objective: To determine whether treatment patterns and outcomes for patients presenting with acute myocardial infarction differ for low- vs high-income individuals across 6 countries. Design, Setting, and Participants: Serial cross-sectional cohort study of all adults aged 66 years or older hospitalized with acute myocardial infarction from 2013 through 2018 in the US, Canada, England, the Netherlands, Taiwan, and Israel using population-representative administrative data. Exposures: Being in the top and bottom quintile of income within and across countries. Main Outcomes and Measures: Thirty-day and 1-year mortality; secondary outcomes included rates of cardiac catheterization and revascularization, length of stay, and readmission rates. Results: We studied 289 376 patients hospitalized with ST-segment elevation myocardial infarction (STEMI) and 843 046 hospitalized with non-STEMI (NSTEMI). Adjusted 30-day mortality generally was 1 to 3 percentage points lower for high-income patients. For instance, 30-day mortality among patients admitted with STEMI in the Netherlands was 10.2% for those with high income vs 13.1% for those with low income (difference, −2.8 percentage points [95% CI, −4.1 to −1.5]). One-year mortality differences for STEMI were even larger than 30-day mortality, with the highest difference in Israel (16.2% vs 25.3%; difference, −9.1 percentage points [95% CI, −16.7 to –1.6]). In all countries, rates of cardiac catheterization and percutaneous coronary intervention were higher among high- vs low-income populations, with absolute differences ranging from 1 to 6 percentage points (eg, 73.6% vs 67.4%; difference, 6.1 percentage points [95% CI, 1.2 to 11.0] for percutaneous intervention in England for STEMI). Rates of coronary artery bypass graft surgery for patients with STEMI in low- vs high-income strata were similar but for NSTEMI were generally 1 to 2 percentage points higher among high-income patients (eg, 12.5% vs 11.0% in the US; difference, 1.5 percentage points [95% CI, 1.3 to 1.8 ]). Thirty-day readmission rates generally also were 1 to 3 percentage points lower and hospital length of stay generally was 0.2 to 0.5 days shorter for high-income patients. Conclusions and Relevance: High-income individuals had substantially better survival and were more likely to receive lifesaving revascularization and had shorter hospital lengths of stay and fewer readmissions across almost all countries. Our results suggest that income-based disparities were present even in countries with universal health insurance and robust social safety net systems. This serial cross-sectional cohort study compares whether treatment patterns and outcomes for patients presenting with acute myocardial infarction differ for low- vs high-income individuals across 6 countries. [ABSTRACT FROM AUTHOR]

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

Background: High-quality ambulatory care can reduce cardiovascular disease risk, but important gaps exist in the provision of cardiovascular preventive care. We sought to develop a set of key performance indicators that can be used to measure and improve cardiovascular care in the primary care setting. Methods: As part of the Cardiovascular Health in Ambulatory Care Research Team initiative, we established a 14-member multidisciplinary expert panel to develop a set of indicators for measuring primary prevention performance in ambulatory cardiovascular care. We used a 2-stage modified Delphi panel process to rate potential indicators, which were identified from the literature and national cardiovascular organizations. The top-rated indicators were pilot tested to determine their measurement feasibility with the use of data routinely collected in the Canadian health care system. Results: A set of 28 indicators of primary prevention performance were identified, which were grouped into 5 domains: risk factor prevalence, screening, management, intermediate outcomes and long-term outcomes. The indicators reflect the major cardiovascular risk factors including smoking, obesity, hypertension, diabetes, dyslipidemia and atrial fibrillation. All indicators were determined to be amenable to measurement with the use of population-based administrative (physician claims, hospital admission, laboratory, medication), survey or electronic medical record databases. Interpretation: The Cardiovascular Health in Ambulatory Care Research Team indicators of primary prevention performance provide a framework for the measurement of cardiovascular primary prevention efforts in Canada. The indicators may be used by clinicians, researchers and policy-makers interested in measuring and improving the prevention of cardiovascular disease in ambulatory care settings. [ABSTRACT FROM AUTHOR]

Presents the results of a prospective, population-based study conducted at a single hospital in New York State on coronary artery disease. Background on coronary artery calcification; Use of electron-beam computerized tomography scanning in the study; Overview of the study.

Presents a letter to the editor in reply to reader comment about the authors' article on using statins in elderly patients.

Comments on a study which investigated the nocebo effect and the side effects of placebo. Argument on the association between β-blockers and substantial risks for the side effects of placebo; Response to the comments.

A letter to the editor is presented in response to an article on exercise capacity and mortality in the March 14, 2002 issue.

Background: The Framingham Risk Score (FRS) and Pooled Cohort Equations (PCEs) overestimate risk in many contemporary cohorts.Objectives: This study sought to determine if recalibration of these scores using contemporary population-level data improves risk stratification for statin therapy.Methods: Five-year FRS and PCEs were recalibrated using a cohort of Ontario residents alive January 1, 2011, who were 30 to 79 years of age without cardiovascular disease. Scores were externally validated in a primary care cohort of routinely collected electronic medical record data from January 1, 2010, to December 31, 2014. The relative difference in mean predicted and observed risk, number of statins avoided, and number needed to treat with statins to reduce a cardiovascular event at 5 years were reported.Results: The FRS was recalibrated in 6,938,971 Ontario residents (51.6% women, mean age 48 years) and validated in 71,450 individuals (56.1% women, mean age 52 years). Recalibration reduced overestimation from 109% to 49% for women and 131% to 32% for men. The recalibrated FRS was estimated to reduce statin prescriptions in up to 26 per 1,000 low-risk women and 80 per 1,000 low-risk men, as well as reduce the number needed to treat from 61 to 47 in women and from 53 to 41 in men. In contrast, after recalibration of the PCEs, risk remained overestimated by 217% in women and 128% in men.Conclusions: Recalibration is a feasible solution to improve risk prediction but is dependent on the model being used. Recalibration of the FRS but not the PCEs reduced overestimation and may improve utilization of statins. [ABSTRACT FROM AUTHOR]

Background: The late cardiac effect of adjuvant trastuzumab and its potential interaction with anthracycline have not been well-studied on a population level. Methods: In this retrospective population-based cohort study, female breast cancer patients in Ontario, diagnosed between 2003 and 2009, were identified by the Ontario Cancer Registry and linked to administrative databases to ascertain demographics, cardiac risk factors, comorbidities, and use of adjuvant trastuzumab and other chemotherapy. Patients with pre-existing heart failure (HF) were excluded. The main endpoint was new diagnosis of HF. Analyses included Kaplan-Meier (KM) survival analysis, multivariable piecewise Cox regression, and competing risk and propensity score analyses. All statistical tests were two-sided. Results: Nineteen thousand seventy-four women with breast cancer treated with adjuvant chemotherapy were identified, of whom 3371 (17.7%) also received adjuvant trastuzumab. Anthracycline use was 84.9% overall. After a median follow-up of 5.9 years, patients treated with trastuzumab and chemotherapy were more likely to develop HF than patients on chemotherapy alone (5-year cumulative incidences of 5.2% vs 2.5%; log-rank P < .001). After adjusting for confounders, adjuvant trastuzumab remained independently associated with incident HF in the first 1.5 years (HR = 5.77, 95% CI = 4.38 to 7.62, P < .001), but not thereafter (HR = 0.87, 95% CI = 0.57 to 1.33, P = .53). Anthracycline use did not increase the risk of HF with trastuzumab synergistically, neither within (P interaction = .92) nor beyond 1.5 years (P interaction = .23). Conclusion: Adjuvant trastuzumab was associated with increased risk of new incidence of HF in breast cancer survivors during the period of adjuvant treatment but not thereafter. Routine intensive monitoring may not be necessary after completing adjuvant therapy. [ABSTRACT FROM AUTHOR]

We aimed to determine whether early public health interventions in 2020 mitigated the association of sociodemographic and clinical risk factors with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We conducted a population-based cohort study of all adults in Ontario, Canada who underwent testing for SARS-CoV-2 through December 31, 2020. The outcome was laboratory-confirmed SARS-CoV-2 infection, determined by reverse transcription polymerase chain reaction testing. Adjusted odds ratios (ORs) were determined for sociodemographic and clinical risk factors before and after the first-wave peak of the pandemic to assess for changes in effect sizes. Among 3,167,753 community-dwelling individuals, 142,814 (4.5%) tested positive. The association between age and SARS-CoV-2 infection risk varied over time (P-interaction < 0.0001). Prior to the first-wave peak, SARS-CoV-2 infection increased with age whereas this association reversed thereafter. Risk factors that persisted included male sex, residing in lower income neighborhoods, residing in more racially/ethnically diverse communities, immigration to Canada, hypertension, and diabetes. While there was a reduction in infection rates after mid-April 2020, there was less impact in regions with higher racial/ethnic diversity. Immediately following the initial peak, individuals living in the most racially/ethnically diverse communities with 2, 3, or ≥ 4 risk factors had ORs of 1.89, 3.07, and 4.73-fold higher for SARS-CoV-2 infection compared to lower risk individuals in their community (all P < 0.0001). In the latter half of 2020, this disparity persisted with corresponding ORs of 1.66, 2.48, and 3.70-fold higher, respectively. In the least racially/ethnically diverse communities, there was little/no gradient in infection rates across risk strata. Further efforts are necessary to reduce the risk of SARS-CoV-2 infection among the highest risk individuals residing in the most racially/ethnically diverse communities. [ABSTRACT FROM AUTHOR]

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

Anticoagulation may improve outcomes in patients with COVID-19 when started early in the course of illness. This was a population-based cohort study using linked administrative datasets of outpatients aged ≥65 years old testing positive for SARS-CoV-2 between January 1 and December 31, 2020 in Ontario, Canada. The key exposure was anticoagulation with warfarin or direct oral anticoagulants before COVID-19 diagnosis. We calculated propensity scores and used matching weights (MWs) to reduce baseline differences between anticoagulated and non-anticoagulated patients. The primary outcome was a composite of death or hospitalization within 60 days of a positive SARS-CoV-2 test. We used the Kaplan-Meier method and cumulative incidence functions to estimate risk of the primary and component outcomes at 60 days. We studied 23,159 outpatients (mean age 78.5 years; 13,474 [58.2%] female), among whom 3200 (13.8%) deaths and 3183 (13.7%) hospitalizations occurred within 60 days of the SARS-CoV-2 test. After application of MWs, the 60-day risk of death or hospitalization was 29.2% (95% CI 27.4%–31.2%) for anticoagulated individuals and 32.1% (95% CI 30.7%–33.5%) without anticoagulation (absolute risk difference [ARD], −2.9%; p = 0.005). Anticoagulation was also associated with a lower risk of death: 18.6% (95% CI 17.0%–20.2%) with anticoagulation and 20.9% (95% CI 19.7%–22.2%) in non-anticoagulated patients (ARD -2.3%; p = 0.005). Among outpatients aged ≥65 years, oral anticoagulation at the time of a positive SARS-CoV-2 test was associated with a lower risk of a composite of death or hospitalization within 60 days. • This was a population-based cohort study of older patients diagnosed with COVID-19. • Anticoagulation at time of COVID-19 diagnosis was associated with improved outcomes. • Early anticoagulation in high-risk outpatients merits study in a randomized controlled trial. [ABSTRACT FROM AUTHOR]