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BackgroundEpilepsy management during pregnancy is crucial for both the mother and fetus. The use of antiseizure medications (ASMs) during pregnancy requires careful consideration due to their potential effects on maternal and fetal health.MethodsThis study analyzed trends in ASMs use among pregnant people in four Canadian provinces over 20 years (Manitoba, Saskatchewan, Alberta, and Quebec). Descriptive statistics were utilized to examine the characteristics of the population, with the frequency and patterns of ASM use estimated throughout each trimester. Linear regression models were developed to analyze yearly patterns of ASM utilization for the overall study population, as well as for people with and without epilepsy.ResultsAmong 1,317,141 pregnant individuals across four provinces, 0.7% had epilepsy. Of the total pregnancies, 1.7% (n = 22,783) were exposed to ASMs, comprising 4,392 from pregnant people with epilepsy (PPWE) and 18,391 from those without epilepsy (PPWOE). Results demonstrated varying trends in ASM usage between provinces, with an overall increase in usage among people without epilepsy in Manitoba, Saskatchewan, and Alberta. ASM use among PPWOE surged significantly in Manitoba (24.2–149.1 per 10,000 pregnant people), Saskatchewan (29.4–107.0 per 10,000), and Alberta (65.7–241.7 per 10,000) (p < 0.05). In Alberta, PPWE’s ASM exposure also rose, from 23.6 in 2008 to 43.0 per 10,000 pregnant people in 2021, while Quebec witnessed a decrease from 59.2 in 1998 to 45.5 per 10,000 pregnancies in 2015. Analysis of ASM use by trimester illustrated a substantial decline among PPWOE from 365 days pre-pregnancy to the third trimester in all provinces. ASM utilization by drug class showcased significant shifts, with second-generation ASMs experiencing a notable rise. Carbamazepine, once prominent, declined, making way for lamotrigine. Regional variations underscore diverse preferences, such as clonazepam’s sustained popularity in Manitoba and Quebec.ConclusionThe study identified increasing trends in ASM use, particularly the increased use of second-generation ASMs, and differences in prescription patterns for pregnant individuals with and without epilepsy. These findings reveal changing ASM use patterns, including increased second-generation ASM use and regional disparities, providing valuable insights into real-world prescription practices.

AimsPatients visiting the emergency department (ED) or hospitalized for heart failure (HF) are at increased risk for subsequent adverse outcomes, however effective risk stratification remains challenging. We utilized a machine-learning (ML)-based approach to identify HF patients at risk of adverse outcomes after an ED visit or hospitalization using a large regional administrative healthcare data system.Methods and resultsPatients visiting the ED or hospitalized with HF between 2002-2016 in Alberta, Canada were included. Outcomes of interest were 30-day and 1-year HF-related ED visits, HF hospital readmission or all-cause mortality. We applied a feature extraction method using deep feature synthesis from multiple sources of health data and compared performance of a gradient boosting algorithm (CatBoost) with logistic regression modelling. The area under receiver operating characteristic curve (AUC-ROC) was used to assess model performance. We included 50,630 patients with 93,552 HF ED visits/hospitalizations. At 30-day follow-up in the holdout validation cohort, the AUC-ROC for the combined endpoint of HF ED visit, HF hospital readmission or death for the Catboost and logistic regression models was 74.16 (73.18-75.11) versus 62.25 (61.25-63.18), respectively. At 1-year follow-up corresponding values were 76.80 (76.1-77.47) versus 69.52 (68.77-70.26), respectively. AUC-ROC values for the endpoint of all-cause death alone at 30-days and 1-year follow-up were 83.21 (81.83-84.41) versus 69.53 (67.98-71.18), and 85.73 (85.14-86.29) versus 69.40 (68.57-70.26), for the CatBoost and logistic regression models, respectively.ConclusionsML-based modelling with deep feature synthesis provided superior risk stratification for HF patients at 30-days and 1-year follow-up after an ED visit or hospitalization using data from a large administrative regional healthcare system.

Abstract Artificial intelligence-enabled electrocardiogram (ECG) algorithms are gaining prominence for the early detection of cardiovascular (CV) conditions, including those not traditionally associated with conventional ECG measures or expert interpretation. This study develops and validates such models for simultaneous prediction of 15 different common CV diagnoses at the population level. We conducted a retrospective study that included 1,605,268 ECGs of 244,077 adult patients presenting to 84 emergency departments or hospitals, who underwent at least one 12-lead ECG from February 2007 to April 2020 in Alberta, Canada, and considered 15 CV diagnoses, as identified by International Classification of Diseases, 10th revision (ICD-10) codes: atrial fibrillation (AF), supraventricular tachycardia (SVT), ventricular tachycardia (VT), cardiac arrest (CA), atrioventricular block (AVB), unstable angina (UA), ST-elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), pulmonary embolism (PE), hypertrophic cardiomyopathy (HCM), aortic stenosis (AS), mitral valve prolapse (MVP), mitral valve stenosis (MS), pulmonary hypertension (PHTN), and heart failure (HF). We employed ResNet-based deep learning (DL) using ECG tracings and extreme gradient boosting (XGB) using ECG measurements. When evaluated on the first ECGs per episode of 97,631 holdout patients, the DL models had an area under the receiver operating characteristic curve (AUROC) of 90% for 4 diagnoses (AVB, HCM, MS, STEMI). DL models outperformed XGB models with about 5% higher AUROC on average. Overall, ECG-based prediction models demonstrated good-to-excellent prediction performance in diagnosing common CV conditions.

Background: Healthcare resource use for atrial fibrillation (AF) is high, but it may not be equivalent across all patients. We examined whether sex differences exist for AF high-cost users (HCUs), who account for the top 10% of total acute care costs. Methods: All patients aged ≥ 20 years who presented to the emergency department (ED) or were hospitalized with AF were identified in Alberta, Canada, between 2011 and 2015. The cohort was categorized by sex into HCUs and non-HCUs. Healthcare utilization was defined as ED, hospital, and physician visits, and costs included those for hospitalization, ambulatory care, physician billing, and drugs. All costs were inflated to 2022 Canadian dollars (CAD$). Results: Among 48,030 AF patients, 45.1% were female. Of these, 31.8% were HCUs, and the proportions of female and male patients were equal (31.9% vs 31.7%). Female HCUs were older, more likely to have hypertension and heart failure, and had a higher stroke risk than male HCUs. Mean healthcare utilization did not differ among HCUs by sex, except for number of ED visits, which was higher in male patients (12.7% vs 9.2%, P < 0.0001). Overall, HCUs accounted for 65.8% of the total costs (CAD$3.4 billion). Almost half of total HCU costs were attributable to female HCUs (CAD$966.1 million). Significant differences were present in the distributions of HCU-related costs (male patients: 74.6% hospitalization, 9.5% ambulatory care, 12.4% physician billing, 3.5% drugs; female patients: 77.7% hospitalization, 7.4% ambulatory care, 11.5% physician billing, 3.5% drugs, P < 0.0001). Conclusions: Despite having a lower AF prevalence, female patients represent an equal proportion of HCUs, and account for almost half the total HCU costs. Interventions targeted at reducing the number of AF HCU are needed, particularly for female patients. Résumé: Contexte: L’utilisation des ressources en santé est élevée pour la fibrillation auriculaire (FA), mais elle n’est pas forcément équivalente pour tous les patients. Nous avons examiné s’il existait des différences entre les sexes pour ce qui est des cas très coûteux de FA, qui représentent les 10 % supérieurs des coûts totaux de soins de courte durée. Méthodologie: Tous les patients âgés de 20 ans et plus qui se sont présentés au service des urgences ou qui ont été hospitalisés pour une FA ont été répertoriés en Alberta, au Canada, entre 2011 et 2015. La cohorte a été divisée par sexe en fonction des utilisateurs très coûteux et des autres utilisateurs. L’utilisation des soins de santé était définie comme des consultations aux urgences, à l’hôpital ou chez le médecin, et les coûts comprenaient les hospitalisations, les soins ambulatoires, les honoraires des médecins et les médicaments. Tous les coûts ont été convertis en dollars canadiens ($ CA) de 2022. Résultats: Parmi les 48 030 patients atteints de FA, 45,1 % étaient des femmes et 31,8 % étaient des utilisateurs très coûteux, en proportions égales entre les femmes et les hommes (31,9 % vs 31,7 %). Parmi les utilisateurs très coûteux, les femmes étaient plus âgées, plus susceptibles de présenter de l’hypertension et une insuffisance cardiaque, et leur risque d’AVC était plus élevé comparativement aux hommes. L’utilisation moyenne des soins de santé n’affichait pas de différences chez les utilisateurs très coûteux selon le sexe, à l’exception des consultations aux urgences, qui étaient plus fréquentes chez les hommes (12,7 % vs 9,2 %, p < 0,0001). Dans l’ensemble, les utilisateurs très coûteux représentaient 65,8 % des coûts totaux, qui étaient de 3,4 milliards de dollars canadiens. Les femmes représentaient par ailleurs près de la moitié du total des utilisations très coûteuses (966,1 millions de dollars canadiens). Des différences significatives ont été observées quant à la répartition des coûts liés aux utilisateurs très coûteux (hommes : hospitalisations [74,6 %], soins ambulatoires [9,5 %], honoraires des médecins [12,4 %], médicaments [3,5 %]; femmes : hospitalisations [77,7 %], soins ambulatoires [7,4 %], honoraires des médecins [11,5 %], médicaments [3,5 %], p < 0,0001). Conclusions: Bien que la FA soit moins fréquente chez les femmes que chez les hommes, celles-ci représentent une proportion tout aussi importante des utilisations très coûteuses et comptent pour presque la moitié des coûts totaux attribuables aux utilisateurs très coûteux. Des interventions visant à réduire les utilisations très coûteuses pour la FA sont donc nécessaires, particulièrement chez les femmes.

Background: Cardiomyopathy (CM) is a rare childhood disease associated with morbidity and mortality. Limited data exist on paediatric CM in Canada. Given the rare nature, single-centre studies are not sufficiently powered to address important questions. Therefore, administrative health data may serve as a resource for the study of childhood CM. The goal of this study was to validate the accuracy of International Classification of Diseases (ICD)-based algorithms to identify paediatric CM in health databases using a clinical registry as the gold standard. Methods: The clinical registry was compiled from outpatient and inpatient records at the Stollery Children’s Hospital (January 1, 2013, to December 31, 2021). Patients were categorized as having CM or screened without CM. Data were linked to administrative health databases using the patient’s Unique Lifetime Identifier. Algorithms based on the presence of ICD, 10th Revision, codes for CM were then evaluated, and cross-tabulations against the clinical registry were generated. Accuracy, positive predictive value, negative predictive value, sensitivity, and specificity were calculated. Results: The clinical registry had 90 patients with CM and 249 screened without CM. The algorithms ruled out CM (high negative predictive value) but had variability in the ability to diagnose CM positive predictive value. The algorithm that performed the best was based on a diagnosis of CM in a hospitalization or 2 ambulatory visits. Conclusions: A combination of inpatient and outpatient databases can be used, with acceptable accuracy, to identify paediatric patients with CM. This finding allows for the use of the identified algorithm for the comprehensive study of paediatric CM in Canada. Résumé: Contexte: La cardiomyopathie (CM) est une maladie rare de l’enfance associée à des taux élevés de morbidité et de mortalité et sur laquelle les données sont limitées en contexte canadien. En raison de la rareté de cette maladie, les études monocentriques ne peuvent atteindre la puissance statistique nécessaire pour répondre à certaines questions importantes. Les données administratives sur la santé peuvent donc constituer une ressource intéressante pour examiner la CM chez les enfants. La présente étude visait à valider l’exactitude d’algorithmes fondés sur la Classification internationale des maladies (CIM) pour repérer les cas de CM pédiatrique dans des bases de données sur la santé, en utilisant un registre clinique comme référence. Méthodologie: Un registre clinique a été élaboré à partir des dossiers de clinique interne et externe du Stollery Children’s Hospital (du 1er janvier 2013 au 31 décembre 2021). Les patients ont été classés en deux catégories : atteints de CM ou dépistés sans CM. Les données ont été liées aux bases de données administratives sur la santé en utilisant le numéro d’identification unique des patients (Unique Lifetime Identifier). Des algorithmes fondés sur les codes de la CIM-10 ont été évalués et des analyses croisées avec le registre clinique ont été réalisées. L’exactitude, la valeur prédictive positive (VPP), la valeur prédictive négative (VPN), la sensibilité et la spécificité des algorithmes ont été calculées. Résultats: Le registre clinique comprenait 90 patients atteints de CM et 249 patients dépistés sans CM. Les algorithmes permettaient d’exclure correctement la CM (VPN élevée), mais leur capacité à établir le diagnostic de CM variait (VPP). L’algorithme le plus performant était fondé sur l’attribution d’un code diagnostique de CM lors d’une hospitalisation ou de deux visites ambulatoires. Conclusions: La combinaison de bases de données sur les hospitalisations et sur les soins externes peut être utilisée pour identifier les enfants atteints de CM avec une exactitude acceptable. Cette observation corrobore l’utilisation de l’algorithme ciblé pour réaliser une étude exhaustive de la CM chez l’enfant au Canada.

Background We examined the association between hemoglobin A1c (HbA1c) and the development of cardiovascular disease (CVD) in men and women, without diabetes or CVD at baseline. Methods and Results This retrospective cohort study included adults aged 40 to

IntroductionSocial determinants of health (SDH) may influence children’s weight status. Our objective was to examine relationships between SDH and preschoolers’ weight status. MethodsThis retrospective cohort study included 169 465 children (aged 4–6 years) with anthropometric measurements taken at immunization visits from 2009 to 2017 in Edmonton and Calgary, Canada. Children were categorized by weight status based on WHO criteria. Maternal data were linked to child data. The Pampalon Material and Social Deprivation Indexes were used to assess deprivation. We used multinomial logistic regression to generate relative risk ratios (RRRs) to examine associations between ethnicity, maternal immigrant status, neighbourhood-level household income, urban/ rural residence and material and social deprivation with child weight status. ResultsChildren of Chinese ethnicity were less likely than those in the General Population to have overweight (RRR = 0.64, 95% CI: 0.61–0.69) and obesity (RRR = 0.51, 0.42–0.62). Children of South Asian ethnicity were more likely than those in the General Population to have underweight (RRR = 4.14, 3.54–4.84) and more likely to have obesity (RRR = 1.39, 1.22–1.60). Children with maternal immigrant status were less likely than those without maternal immigrant status to have underweight (RRR = 0.72, 0.63–0.82) and obesity (RRR = 0.71, 0.66–0.77). Children were less likely to have overweight (RRR = 0.95, 0.94–0.95) and obesity (RRR = 0.88, 0.86–0.90) for every CAD 10 000 increase in income. Relative to the least deprived quintile, children in the most materially deprived quintile were more likely to have underweight (RRR = 1.36, 1.13–1.62), overweight (RRR = 1.52, 1.46–1.58) and obesity (RRR = 2.83, 2.54–3.15). Relative to the least deprived quintile, children in the most socially deprived quintile were more likely to have overweight (RRR = 1.21, 1.17–1.26) and obesity (RRR = 1.40, 1.26–1.56). All results are significant to p $lt; 0.001. ConclusionOur findings suggest the need for interventions and policies to address SDH in preschoolers to optimize their weight and health.

IntroductionLes déterminants sociaux de la santé peuvent avoir une incidence sur le poids des enfants. Notre objectif était d’étudier les relations entre les déterminants sociaux de la santé et le poids des enfants d’âge préscolaire. MéthodologieCette étude de cohorte rétrospective portait sur 169 465 enfants (âgés de 4 à 6 ans) dont les mesures anthropométriques ont été prises lors de rendez-vous de vaccination de 2009 à 2017 à Edmonton et à Calgary (Canada). Les enfants ont été classés par statut pondéral sur la base des critères de l’Organisation mondiale de la santé (OMS). Les données sur les mères ont été jumelées aux données sur les enfants. Les indices de défavorisation matérielle et sociale de Pampalon ont été utilisés pour évaluer la défavorisation. Nous avons utilisé une régression logistique multinomiale pour générer des rapports de risque relatif (RRR) afin d’étudier les associations entre, d’une part, le groupe ethnique, le statut d’immigration de la mère, le revenu des ménages du quartier, la résidence en milieu urbain ou rural et la défavorisation matérielle et sociale et, d’autre part, le statut pondéral de l’enfant. RésultatsLes enfants d’origine chinoise risquaient moins que ceux de la population générale de faire de l’embonpoint (RRR = 0,64, IC à 95 % : 0,61 à 0,69) ou de l’obésité (RRR = 0,51, 0,42 à 0,62). Les enfants d’origine sud-asiatique risquaient plus que ceux de la population générale d’être en situation d’insuffisance pondérale (RRR = 4,14, 3,54 à 4,84) ou d’obésité (RRR = 1,39, 1,22 à 1,60). Les enfants de mère immigrante risquaient moins que les autres à être en situation d’insuffisance pondérale (RRR = 0,72, 0,63 à 0,82) ou d’obésité (RRR = 0,71, 0,66 à 0,77). La probabilité que les enfants fassent de l’embonpoint (RRR = 0,95, 0,94 à 0,95) ou de l’obésité (RRR = 0,88, 0,86 à 0,90) diminuait avec chaque passage à la tranche de revenu de 10 000 $ CA supérieure. Par rapport au quintile le moins défavorisé, les enfants du quintile le plus défavorisé sur le plan matériel risquaient plus de présenter une insuffisance pondérale (RRR = 1,36, 1,13 à 1,62), un surpoids (RRR = 1,52, 1,46 à 1,58) ou de l’obésité (RRR = 2,83, 2,54 à 3,15). Par rapport au quintile le moins défavorisé, les enfants du quintile le plus socialement défavorisé risquaient plus de présenter un surpoids (RRR = 1,21, 1,17 à 1,26) ou de l’obésité (RRR = 1,40, 1,26 à 1,56). Tous les résultats sont significatifs à p $lt; 0,001. ConclusionNos constatations indiquent qu’il est nécessaire de mettre en place des interventions et des politiques qui tiennent compte des déterminants sociaux de la santé chez les enfants d’âge préscolaire afin d’optimiser leur poids et leur santé.

Abstract The feasibility and value of linking electrocardiogram (ECG) data to longitudinal population-level administrative health data to facilitate the development of a learning healthcare system has not been fully explored. We developed ECG-based machine learning models to predict risk of mortality among patients presenting to an emergency department or hospital for any reason. Using the 12-lead ECG traces and measurements from 1,605,268 ECGs from 748,773 healthcare episodes of 244,077 patients (2007–2020) in Alberta, Canada, we developed and validated ResNet-based Deep Learning (DL) and gradient boosting-based XGBoost (XGB) models to predict 30-day, 1-year, and 5-year mortality. The models for 30-day, 1-year, and 5-year mortality were trained on 146,173, 141,072, and 111,020 patients and evaluated on 97,144, 89,379, and 55,650 patients, respectively. In the evaluation cohort, 7.6%, 17.3%, and 32.9% patients died by 30-days, 1-year, and 5-years, respectively. ResNet models based on ECG traces alone had good-to-excellent performance with area under receiver operating characteristic curve (AUROC) of 0.843 (95% CI: 0.838–0.848), 0.812 (0.808–0.816), and 0.798 (0.792–0.803) for 30-day, 1-year and 5-year prediction, respectively; and were superior to XGB models based on ECG measurements with AUROC of 0.782 (0.776–0.789), 0.784 (0.780–0.788), and 0.746 (0.740–0.751). This study demonstrates the validity of ECG-based DL mortality prediction models at the population-level that can be leveraged for prognostication at point of care.

Background: Guideline-directed medical therapy (GDMT) improves clinical outcomes in patients with heart failure with reduced ejection fraction (HFrEF). Despite its proven efficacy, GDMT is underutilized in clinical practice. The current study examines GDMT utilization after incident hospitalization for HF to promote medication initiation, and titration to target dosing within a reasonable time period. Methods: This observational study identified 66,372 patients with HFrEF who were aged ≥ 65 years and had an incident HF hospitalization, using administrative health data (2013-2018). GDMT (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor-neprilysin inhibitors, β-blockers (BB), and mineralocorticoid receptor antagonists ) received within the 6 months after hospitalization was evaluated by monitoring therapy combinations, optimal dosing (proportion receiving ≥ 50% of the target dose for these inhibitors and blockers, and any dose of MRA), and maximal and last dose assessed, and by use of a GDMT intensity score. Results: Among patients with HFrEF, 4768 (7.2%) were on no therapy, 17,184 (25.9%), were on monotherapy, 30,912 (46.6%) were on dual therapy, and 13,508 (20.4%) were on triple therapy. Only 8747 (13.2%) and 5484 (8.3%) achieved optimal GDMT based on the maximum dose and the last dispensed dose, respectively, within 6 months postdischarge. Finally, 38,869 (58.6%) achieved < 50% of the maximum intensity score, 23,006 (34.7%) achieved between 50% and 74% of the maximum intensity score, and 4497 (6.8%) achieved a score that was ≥ 75% of the maximum intensity score. Conclusions: Current pharmacologic management for patients with HFrEF does not align with the Canadian guidelines. Given this gap in care, innovative strategies to optimize care in patients with HFrEF are needed. Résumé: Introduction: Les traitements médicamenteux préconisés dans les lignes directrices (TMPLD) permettent d’améliorer les résultats cliniques des patients atteints d’insuffisance cardiaque à fraction d’éjection réduite (ICFER). En dépit des preuves de leur efficacité, les TMPLD sont sous-utilisés dans la pratique clinique. La présente étude porte sur l’utilisation des TMPLD après une hospitalisation incidente en raison d’une IC afin de favoriser l’amorce de la médication, et l’ajustement de la posologie en vue d’atteindre la dose cible dans un délai raisonnable. Méthodes: Cette étude observationnelle portait sur 66 372 patients atteints d’ICFER qui avaient ≥ 65 ans et une hospitalisation incidente en raison d’une IC, et reposait sur les données administratives sur la santé (2013-2018). Nous avons évalué les TMPLD (inhibiteurs de l’enzyme de conversion de l’angiotensine, bloqueurs des récepteurs de l’angiotensine, β-bloquants [BB] et antagonistes des récepteurs des minéralocorticoïdes [ARM]) reçus dans les six mois après l’hospitalisation par la surveillance des combinaisons de traitement, la posologie optimale (proportion recevant ≥ 50 % de la dose cible pour ces inhibiteurs et ces bloquants, et toute dose d’ARM), la dose maximale et la dernière dose évaluées, et par l’utilisation d’un score d’intensité des TMPLD. Résultats: Parmi les patients atteints d’ICFER, 4 768 (7,2 %) n’avaient reçu aucun traitement, 17 184 (25,9 %), avaient reçu une monothérapie, 30 912 (46,6 %) avaient reçu une bithérapie et 13 508 (20,4 %) avaient reçu une trithérapie. Seuls 8 747 (13,2 %) et 5 484 (8,3 %) avaient obtenu les TMPLD optimaux en fonction de la dose maximale et de la dernière dose administrée, et ce, respectivement, dans les six mois après la sortie de l’hôpital. Enfin, 38 869 (58,6 %) avaient obtenu < 50 % du score d’intensité maximale, 23 006 (34,7 %) avaient obtenu entre 50 % et 74 % du score d’intensité maximale, et 4 497 (6,8 %) avaient obtenu un score qui était ≥ 75 % du score d’intensité maximale. Conclusions: La prise en charge pharmacologique actuelle des patients atteints d’ICFER va à l’encontre des lignes directrices canadiennes. Compte tenu de cette lacune dans les soins, des stratégies novatrices pour optimiser les soins aux patients atteints d’ICFER sont nécessaires.

Alberta has rich clinical and health services data held under the custodianship of Alberta Health and Alberta Health Services (AHS), which is not only used for clinical and administrative purposes but also disease surveillance and epidemiological research. Alberta is the largest province in Canada with a single payer centralised health system, AHS, and a consolidated data and analytics team supporting researchers across the province. This paper describes Alberta's data custodians, data governance mechanisms, and streamlined processes followed for research data access. AHS has created a centralised data repository from multiple sources, including practitioner claims data, hospital discharge data, and medications dispensed, available for research use through the provincial Data and Research Services (DRS) team. The DRS team is integrated within AHS to support researchers across the province with their data extraction and linkage requests. Furthermore, streamlined processes have been established, including: 1) ethics approval from a research ethics board, 2) any necessary operational approvals from AHS, and 3) a tripartite legal agreement dictating terms and conditions for data use, disclosure, and retention. This allows researchers to gain timely access to data. To meet the evolving and ever-expanding big-data needs, the University of Calgary, in partnership with AHS, has built high-performance computing (HPC) infrastructure to facilitate storage and processing of large datasets. When releasing data to researchers, the analytics team ensures that Alberta's Health Information Act's guiding principles are followed. The principal investigator also ensures data retention and disposition are according to the plan specified in ethics and per the terms set out by funding agencies. Even though there are disparities and variations in the data protection laws across the different provinces in Canada, the streamlined processes for research data access in Alberta are highly efficient.

Background: Heart failure (HF) is a leading complication of nonvalvular atrial fibrillation (NVAF), and the presence of both conditions worsens prognosis. Sex-specific associations between NVAF and outcomes focus on stroke; less is known about HF. We evaluated sex differences in incident HF in NVAF. Methods: We identified adults age ≥ 65 years hospitalized for incident NVAF without prior HF from April 2010 to March 2018 in Canada. The primary outcome was incident HF hospitalization, with a secondary composite outcome of incident HF hospitalization or all-cause mortality at 1 year. Cox proportional hazard regression models were constructed for the association between sex and outcomes, adjusting for age, comorbidities, socioeconomic status, cardioversion, and medications. Results: Of 68,909 NVAF patients, 53.8% were women. Women had a higher rate of the primary outcome (30.0% vs 25.6%, P < 0.001) and the composite outcome (39.5% vs 36.6%, P < 0.001) than men. In multivariable analysis without adjusting for medications, there was an 8% increase risk of HF (95% confidence interval [CI] 1.05-1.11, P < 0.001) for women, which was attenuated when accounting for medication (hazard ratio [HR] 1.01, 95% CI 0.98-1.04). After full adjustment, women age ≥ 75 years were at higher risk of the primary outcome (HR 1.10, 95% CI 1.06-1.13, P < 0.001) and the composite outcome (HR 1.04, 95% CI 1.01-1.07, P < 0.001), compared with men, whereas there was a significantly lower risk for those age 65-75 years. Conclusions: In this nationwide study of incident NVAF without HF, women age ≥ 75 years were more likely to develop HF or die than men. Strategies to prevent HF in older women with NVAF are needed. Résumé: Contexte: L’insuffisance cardiaque (IC) est une complication majeure de la fibrillation auriculaire non valvulaire (FANV), et la présence des deux affections assombrit le pronostic. Les associations entre la FANV et ses complications en fonction du sexe ont surtout porté sur l’AVC; on en connaît moins sur l’IC. Nous avons évalué les différences entre les sexes pour l’IC fortuite dans la FANV. Méthodologie: Nous avons identifié des adultes de ≥ 65 ans, sans antécédents d’IC, hospitalisés pour une FANV fortuite entre avril 2010 et mars 2018 au Canada. L’hospitalisation à la suite d’une IC fortuite constituait le critère d’évaluation principal, le critère d’évaluation secondaire composé comprenait les hospitalisations pour un épisode d’IC fortuite ou le décès toutes causes confondues à un an. Des modèles de régression à risques proportionnels de Cox ont servi à évaluer l’association entre le sexe et les résultats, après correction en fonction de l’âge, des comorbidités, de la situation socio-économique, de la cardioversion et de la médication. Résultats: Le groupe étudié comptait 68 909 patients atteints de FANV dont 53,8 % étaient des femmes. Les femmes étaient plus nombreuses à répondre au critère d’évaluation principal (30,0 % vs 25,6 %, p < 0,001) et au critère d’évaluation composé (39,5 % vs 36,6 %, p

Abstract 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

Summary: Background: Echocardiography (echo) based machine learning (ML) models may be useful in identifying patients at high-risk of all-cause mortality. Methods: We developed ML models (ResNet deep learning using echo videos and CatBoost gradient boosting using echo measurements) to predict 1-year, 3-year, and 5-year mortality. Models were trained on the Mackay dataset, Taiwan (6083 echos, 3626 patients) and validated in the Alberta HEART dataset, Canada (997 echos, 595 patients). We examined the performance of the models overall, and in subgroups (healthy controls, at risk of heart failure (HF), HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF)). We compared the models' performance to the MAGGIC risk score, and examined the correlation between the models’ predicted probability of death and baseline quality of life as measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ). Findings: Mortality rates at 1-, 3- and 5-years were 14.9%, 28.6%, and 42.5% in the Mackay cohort, and 3.0%, 10.3%, and 18.7%, in the Alberta HEART cohort. The ResNet and CatBoost models achieved area under the receiver-operating curve (AUROC) between 85% and 92% in internal validation. In external validation, the AUROCs for the ResNet (82%, 82%, and 78%) were significantly better than CatBoost (78%, 73%, and 75%), for 1-, 3- and 5-year mortality prediction respectively, with better or comparable performance to the MAGGIC score. ResNet models predicted higher probability of death in the HFpEF and HFrEF (30%–50%) subgroups than in controls and at risk patients (5%–20%). The predicted probabilities of death correlated with KCCQ scores (all p

Background: Data are limited data on the prevalence of cardiovascular disease (CVD) and multimorbidity in contemporary cohorts of high-cost users (HCUs) in Canada.We examined the following: (i) the prevalence of CVD, with a comparison of total healthcare costs among HCUs with vs without CVD; (ii) the contribution of other comorbidities to costs among HCUs with CVD; and (iii) the trajectory of healthcare costs in the years before and after becoming an HCU. Methods: The study included adult Alberta patients in the Canadian Institutes of Health Research/Canadian Institute for Health Information Dynamic Cohort of Complex, High System Users from 2011-2012 through 2014-2015. We examined total healthcare costs, including hospital, ambulatory care, physician services, and drugs. Results: Among 88,536 HCUs, 23.4% had no CVD, 28.9% were hospitalized with a primary diagnosis of CVD, and 47.7% were hospitalized with a secondary diagnosis of CVD. Total healthcare costs were $2.0 billion (20.4% non-hospital costs), $2.8 billion (24.1% non-hospital costs), and $4.9 billion (19.8% non-hospital costs), respectively, in the 3 groups. Many HCUs with CVD were frail (74.2%) and many had diabetes (33.8%) or chronic obstructive pulmonary disease (27.9%), which contributed to higher costs and mortality. Healthcare expenditures in HCUs with CVD were several times higher than per capita health expenditures in the years prior to, and following, their inclusion in the dynamic HCU cohort. Conclusions: CVD is very common in HCUs of healthcare. HCUs with CVD have high rates of frailty and multimorbidity. Further research is needed to identify and intervene earlier, in order to flatten the cost curve in these complex patients. Résumé: Introduction: Les données sur la prévalence des maladies cardiovasculaires (MCV) et de la multimorbidité au sein des cohortes contemporaines de grands utilisateurs (GU) du Canada sont limitées. Nous avons examiné ce qui suit : (i) la prévalence des MCV en comparant les coûts totaux des soins de santé entre les GU atteints de MCV et les GU non atteints de MCV; (ii) la contribution des autres comorbidités aux coûts liés aux GU atteints de MCV; (iii) la trajectoire des coûts des soins de santé dans les années avant et après avoir été considérés comme un GU. Méthodes: L’étude portait sur des patients adultes de l’Alberta de la Cohorte dynamique de grands utilisateurs du système de santé aux besoins complexes de 2011-2012 à 2014-2015 des Instituts de recherche en santé du Canada et de l’Institut canadien d’information sur la santé. Nous avons examiné les coûts totaux des soins de santé, notamment les coûts hospitaliers, les coûts des soins ambulatoires, des services médicaux et des médicaments. Résultats: Parmi les 88 536 GU, 23,4 % n’avaient pas de MCV, 28,9 % étaient hospitalisés et avaient un diagnostic principal de MCV, et 47,7 % étaient hospitalisés et avaient un diagnostic secondaire de MCV. Les coûts totaux des soins de santé des 3 groupes étaient respectivement de 2,0 G$ (20,4 % de coûts non hospitaliers), 2,8 G$ (24,1 % de coûts non hospitaliers) et 4,9 G$ (19,8 % de coûts non hospitaliers). Plusieurs GU atteints de MCV étaient fragiles (74,2 %) et beaucoup avaient le diabète (33,8 %) ou une maladie pulmonaire obstructive chronique (27,9 %), qui contribuaient à des coûts et à une mortalité plus élevés. Les dépenses de santé par personne liées aux GU atteints de MCV étaient beaucoup plus élevées que les dépenses de santé par personne dans les années qui précédaient ou suivaient leur inclusion dans la cohorte dynamique de GU atteints de MCV. Conclusions: Les GU de soins de santé sont très fréquemment atteints de MCV. Les GU atteints de MCV présentent des taux de fragilité et de multimorbidité élevés. D’autres recherches sont nécessaires pour cerner et intervenir plus tôt afin d’aplatir la courbe des coûts chez ces patients aux besoins complexes.

Background: Previous studies on lone/unexplained atrial fibrillation and atrial flutter (AF) did not exclude patients with contemporary secondary AF triggers. We characterized unexplained AF using a strict definition, and compared it to secondary AF. Methods: In this population-based study, unexplained AF was defined by the lack of any identifiable triggering medical/surgical diagnosis. Comparisons by AF type (unexplained vs secondary), age-of-onset (≤ / > 65 years), and sex were undertaken. Data were acquired by linking 6 population databases maintained by the Alberta Ministry of Health over a 9-year period (April 2006 to March 2015). The primary composite outcome of stroke, transient ischemic attack, thromboembolism, and/or death was assessed. Results: There were 33,150 incident AF diagnoses identified, including 1145 patients (3.5%) with unexplained AF, 931 (81.2%) of whom were aged ≤ 65 years (2.8% of diagnoses, and 79% male). Patients with unexplained AF less often received rate/rhythm-control drugs (P 65 ans) et par sexe ont été effectuées. Les données ont été acquises en reliant six bases de données de population maintenues par le ministère de la Santé de l’Alberta sur une période de neuf ans (avril 2006 à mars 2015). Le paramètre d’évaluation principal comprenant l’accident vasculaire cérébral (AVC), l’accident ischémique transitoire, la thromboembolie et/ou le décès a été évalué. Résultats: Au total, 33 150 diagnostics de FA ont été recensés, dont 1 145 patients (3,5 %) présentant une FA inexpliquée, parmi lesquels 931 (81,2 %) étaient âgés de ≤ 65 ans (2,8 % des diagnostics, et 79 % d’hommes). Les patients atteints de FA inexpliquée ont moins souvent reçu de médicaments pour contrôler la fréquence ou le rythme cardiaque (p < 0,0001), mais ils ont plus souvent subi une cardioversion électrique (p < 0,0001) par rapport aux patients atteints de FA secondaire. Les hommes étaient plus jeunes au moment du diagnostic d’une FA inexpliquée (45 [intervalle interquartile : 34 à 59] vs 58 [intervalle interquartile : 40 à 69] ans; p < 0,001). Après un ajustement pour l’âge au moment du diagnostic, il n’y avait pas de différence entre les sexes quant au paramètre d’évaluation principal. La survie sans événement chez les patients jeunes ayant présenté une FA inexpliquée (âge ≤ 65 ans) était de 99,4 % à un an, et de 98,3 % à trois ans. À trois ans, une ou plusieurs hospitalisations/consultations à l’urgence pour des raisons non cardiovasculaires et pour une FA sont survenues chez 56,6 % et 23,8 % de ces patients, respectivement. Conclusions: En utilisant une définition contemporaine stricte de la FA inexpliquée, cette étude montre que cette affection est rare, majoritairement masculine, et qu’elle est associée à une excellente survie sans événement. Cependant, le taux élevé d’utilisation de soins actifs dans les hôpitaux après le diagnostic est préoccupant.

Summary: Background: National guidelines recommend that all adults over the age of 40 years undergo screening for diabetes at least once every 3-years. We examined the adherence to these guidelines among males and females after accounting for age, urban/rural residence, and material deprivation. We also examined the incidence of prediabetes and diabetes in adherent and non-adherent individuals. Methods: Our study is based on a retrospective population-level inception cohort of adults aged 40–79 years without pre-existing diabetes or cardiovascular disease on April 1, 2013. Adherence during a 3-year screening period (2013–2016) and prediabetes and diabetes during a 4-year follow-up period were examined. Multivariate logistic regression was used to examine the adjusted association between sex and adherence. Findings: Among 1,380,697 individuals (49·2% male, 50·8% female) adherence rates were 69·9% in males and 79·8% in females. Sex-differences in adherence were largest in younger individuals (58·0% and 72·6% and in males and females aged 40–44 years, respectively) and consistent across rural/urban residence and material deprivation. Females were more adherent (adjusted odds ratio 1·92; 95% confidence interval 1·89 to 1·95) than males. Prediabetes and diabetes rates among individuals who adhered to screening guidelines were 15·7% and 2·6% among males and 13·4% and 1·5% among females. During the follow-up period, an additional 3·2% and 1·9% of adherent males and females had diabetes. Incidence rates of prediabetes and diabetes during the follow-up period among individuals who did not adhere to screening guidelines were 8·8% and 2·1% among males and 7·3% and 1·3% among females. Interpretation: Adherence to diabetes screening guidelines is sub-optimal, especially among young males. Despite lower rates of adherence to screening, males have higher rates of prediabetes and diabetes compared to females. There is a need for education campaigns to improve diabetes screening rates in young adults, especially males. Funding: This study was funded by the Canadian Institutes of Health Research Sex and Gender Science Chair (Recipient: Kaul).

Background Socioeconomic status (SES) impacts clinical outcomes associated with severe congenital heart disease (sCHD). We examined the impact of SES and remoteness of residence (RoR) on congenital heart disease (CHD) outcomes in Canada, a jurisdiction with universal health insurance. Methods and Results All infants born in Canada (excluding Quebec) from 2008 to 2018 and hospitalized with CHD requiring intervention in the first year were identified. Neighborhood level SES income quintiles were calculated, and RoR was categorized as residing 300 km from the closest of 7 cardiac surgical programs. In‐hospital mortality at 300 km, respectively. Although SES and RoR had no impact on sCHD mortality, infants with mCHD living >300 km had a higher risk of mortality relative to those living

Background: Whether advances in identification and management of atrial fibrillation and atrial flutter (collectively, AF) have led to improved outcomes is unclear. We sought to study trends in clinical outcomes selected as quality indicators for nonvalvular AF in Canada. Methods: We identified hospitalized patients with a first diagnosis of nonvalvular AF between April 2006 and March 2015, in all of Canada except Quebec. We assessed trends in 1-year incidence of stroke/systemic embolism (SSE), major bleeding, and initial heart failure (HF) hospitalization. Results: The cohort included 466,476 patients. The median age was 77 years (interquartile range, 68-84 years), 46% were female, and 68% had a Congestive Heart Failure, Hypertension, Age (≥75 years), Diabetes, Stroke/Transient Ischemic Attack, Vascular Disease, Age (65-74 years), Sex (Female) (CHA2DS2-VASc) score > 3. Within 1 year of discharge, 3.5% were hospitalized for stroke or SSE, 1.6% for major bleeding, and 8.6% for new HF. Over the study period, the crude rate of SSE declined from 3.6% to 3.3% (P = 0.002), whereas the rates of hospitalization for new HF and for major bleeding did not significantly change. After adjustment for CHA2DS2-VASc score, the yearly rates of incident SSE (risk ratio, 0.99; 95% confidence interval [CI], 0.98-0.99; P = 0.002) and HF (risk ratio, 0.99; 95% CI, 0.99-1.00; P = 0.001) declined ≤ 1% absolute, whereas major bleeding remained unchanged (risk ratio, 1.00; 95% CI, 0.99-1.00; P = 0.28). Conclusions: Among hospitalized patients with nonvalvular AF in Canada, the rate of SSE and new HF decreased modestly over a 10-year period, with no significant change in major bleeding. Efforts to study process-based quality indicators, with increased focus on HF prevention, are needed. Résumé: Contexte: On ne sait pas si les avancées en matière de détection et de prise en charge de la fibrillation auriculaire et du flutter auriculaire (collectivement appelés « FA » ci-après) ont permis d’améliorer les résultats pour les patients. Nous avons donc étudié les tendances à l’égard de résultats cliniques particuliers pris comme indicateurs de qualité relatifs à la FA non valvulaire au Canada. Méthodologie: Nous avons recensé les patients hospitalisés au Canada (sauf au Québec) entre avril 2006 et mars 2015 en raison d’une FA non valvulaire nouvellement diagnostiquée. Nous avons évalué les tendances quant à la survenue d’un accident vasculaire cérébral ou d’une embolie systémique (AVC/ES), d’une hémorragie majeure et d’une première hospitalisation pour insuffisance cardiaque. Résultats: La cohorte comprenait 466 476 patients, dont l’âge médian était de 77 ans (intervalle interquartile : 68 à 84 ans); 46 % des patients étaient des femmes, et 68 % avaient un score CHA2DS2-VASc (Congestive Heart Failure [insuffisance cardiaque congestive], hypertension, âge [≥ 75 ans], diabète, Stroke/Transient Ischemic Attack [AVC/accident ischémique transitoire] – maladie vasculaire, âge [65-74 ans], sexe [femmes]) supérieur à 3. Dans l’année suivant la sortie de l’hôpital, 3,5 % des patients ont été hospitalisés en raison d’un AVC ou d’un AVC/ES, 1,6 %, en raison d’une hémorragie majeure et 8,6 %, en raison d’une nouvelle insuffisance cardiaque. Au cours de la période étudiée, le taux brut d’AVC/ES est passé de 3,6 % à 3,3 % (p = 0,002), tandis que les taux d’hospitalisation en raison d’une nouvelle insuffisance cardiaque ou d’une hémorragie majeure n’ont pas changé de manière significative. Après correction pour tenir compte du score CHA2DS2-VASc, les taux annuels de survenue d’un AVC/ES (rapport des risques de 0,99; intervalle de confiance [IC] à 95 % : de 0,98 à 0,99; p = 0,002) et d’une insuffisance cardiaque (rapport des risques de 0,99; IC à 95 % : de 0,99 à 1,00; p = 0,001) ont diminué de ≤ 1 % en valeur absolue, tandis que le taux de survenue d’une hémorragie majeure n’a pas changé (rapport des risques : 1,00; IC à 95 % : de 0,99 à 1,00; p = 0,28). Conclusions: Parmi les patients hospitalisés au Canada en raison d’une FA non valvulaire, les taux d’AVC/ES et de nouvelle insuffisance cardiaque ont affiché une réduction modeste sur une période de 10 ans, tandis que le taux d’hémorragie majeure n’a pas changé de manière significative. D’autres études évaluant les indicateurs de qualité fondés sur les procédés, notamment en matière de prévention de l’insuffisance cardiaque, s’imposent.

Background: Although ST-elevation myocardial infarction (STEMI) management has evolved substantially over the past decade, its effect on bleeding and transfusion rates are largely unknown in a contemporary population. Methods: Our study cohort included patients 20 years of age or older who were hospitalized for STEMI between 2007 and 2016 across all Canadian provinces, except Quebec. Unadjusted rates of bleeding and of transfusion during STEMI episodes were calculated overall and for each province according to fiscal year. Patients were stratified into 4 groups according to their bleeding/transfusion. Characteristics, treatment, and outcomes were compared between groups. Multivariate logistic regression modelling was used to assess the association between bleeding and transfusion on in-hospital mortality. Results: Using 108,832 STEMI episodes, rates of in-hospital bleeding and transfusion declined between 2007 and 2016 from 3.9% to 2.8% (P < 0.0001) and 4.7% to 3.8% (P < 0.0001), respectively. However, variation in bleeding and transfusion rates were observed across Canadian provinces. Patients with bleeding or transfusion, were older, female, and had more comorbidities. Compared with patients who did not bleed or receive a transfusion, individuals who bled, were transfused, or bled and were transfused, had higher in-hospital mortality (18.6%, 30.3%, and 30.4%, respectively [P < 0.0001]). The association remained after adjustment: bleeding (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.8-2.4), transfusion (OR, 4.4; 95% CI, 3.9-4.9), and bleeding and transfusion (OR, 3.8; 95% CI, 3.2-4.6). Conclusions: The proportion of Canadian STEMI patients who experienced in-hospital bleeding and transfusion has decreased over the past 9 years. However, patients with bleed or transfusion remain at higher risk of adverse outcomes. Résumé: Introduction: Bien que la prise en charge de l’infarctus du myocarde avec élévation du segment ST (STEMI) ait considérablement ait considérablement évoluée au cours de la dernière décennie, on ignore en grande partie ses répercussions sur les taux d’hémorragies et de transfusions dans la population contemporaine. Méthodes: Notre étude de cohorte regroupait des patients de 20 ans ou plus qui avaient été hospitalisés en raison d’un STEMI entre 2007 et 2016 dans toutes les provinces canadiennes, excepté le Québec. Nous avons calculé globalement et pour chacune des provinces les taux non ajustés d’hémorragies et de transfusions durant les épisodes de STEMI en fonction de l’année financière. Nous avons réparti les patients en quatre groupes en fonction de leurs hémorragies/transfusions. Nous avons comparé les caractéristiques, le traitement et les issues entre les groupes. Nous avons utilisé la modélisation par régression logistique multivariée pour évaluer l’association entre les hémorragies et les transfusions par rapport à la mortalité à l’hôpital. Résultats: À partir des 108 832 épisodes de STEMI, les taux d'hémorragies et de transfusions à l’hôpital ont baissé entre 2007 et 2016 de 3,9 % à 2,8 % (P < 0,0001) et de 4,7 % à 3,8 % (P < 0,0001), respectivement. Toutefois, nous avons observé la variation des taux d’hémorragies et de transfusions dans toutes les provinces canadiennes. Les patients qui avaient des hémorragies ou des transfusions, étaient plus âgés, de sexe féminin, et avaient plus de comorbidités. Comparativement aux patients qui n’avaient pas d’hémorragie ou qui ne recevaient pas de transfusion, les individus qui avaient une hémorragie, subissaient une transfusion, ou avaient une hémorragie et subissaient une transfusion étaient exposés à une mortalité à l’hôpital plus élevée (18,6 %, 30,3 % et 30,4 %, respectivement [P < 0,0001]). L’association a subsisté après l’ajustement : hémorragie (ratio d’incidence approché [RIA], 2,0; intervalle de confiance [IC] à 95 %, 1,8-2,4), transfusion (RIA, 4,4; IC à 95 %, 3,9-4,9), et hémorragie et transfusion (RIA, 3,8; IC à 95 %, 3,2-4,6). Conclusions: La proportion de patients canadiens atteints de STEMI qui subissaient des hémorragies ou des transfusions à l’hôpital a diminué au cours des 9 dernières années. Toutefois, les patients qui avaient une hémorragie ou une transfusion demeuraient exposés à un risque plus élevé d’issues défavorables.

Abstract Background Pregnancy offers a unique opportunity to identify women at higher future risk of type 2 diabetes mellitus (DM). In pregnancy, a woman has greater engagement with the healthcare system, and certain conditions are more apt to manifest, such as gestational DM (GDM) that are important markers for future DM risk. This study protocol describes the development and validation of a risk prediction model (RPM) for estimating a woman’s 5-year risk of developing type 2 DM after pregnancy. Methods Data will be obtained from existing Ontario population-based administrative datasets. The derivation cohort will consist of all women who gave birth in Ontario, Canada between April 2006 and March 2014. Pre-specified predictors will include socio-demographic factors (age at delivery, ethnicity), maternal clinical factors (e.g., body mass index), pregnancy-related events (gestational DM, hypertensive disorders of pregnancy), and newborn factors (birthweight percentile). Incident type 2 DM will be identified by linkage to the Ontario Diabetes Database. Weibull accelerated failure time models will be developed to predict 5-year risk of type 2 DM. Measures of predictive accuracy (Nagelkerke’s R 2), discrimination (C-statistics), and calibration plots will be generated. Internal validation will be conducted using a bootstrapping approach in 500 samples with replacement, and an optimism-corrected C-statistic will be calculated. External validation of the RPM will be conducted by applying the model in a large population-based pregnancy cohort in Alberta, and estimating the above measures of model performance. The model will be re-calibrated by adjusting baseline hazards and coefficients where appropriate. Discussion The derived RPM may help identify women at high risk of developing DM in a 5-year period after pregnancy, thus facilitate lifestyle changes for women at higher risk, as well as more frequent screening for type 2 DM after pregnancy.

Background Oral anticoagulation (OAC) therapy prevents morbidity and mortality in nonvalvular atrial fibrillation; whether location of diagnosis influences OAC uptake or adherence is unknown. Methods and Results Retrospective cohort study (2008–2019), identifying adults with incident nonvalvular atrial fibrillation across health care settings (emergency department, hospital, outpatient) at high risk of stroke. OAC uptake and adherence via proportion of days covered for direct OACs and time in therapeutic range for warfarin were measured. Proportion of days covered was categorized as low (0–39%), intermediate (40–79%), and high (80–100%). Warfarin control was defined as time in therapeutic range ≥65%. All‐cause mortality was examined at a 3‐year landmark. Among 75 389 patients with nonvalvular atrial fibrillation (47.0% women, mean 77.4 years), 19.7% were diagnosed in the emergency department, 59.1% in the hospital, and 21.2% in the outpatient setting. Ninety‐day OAC uptake was 51.6% in the emergency department, 50.9% in the hospital, and 67.9% in the outpatient setting (P

Abstract Study Objective Patients with syncope are frequently admitted to the hospital, but whether this improves outcome is unknown. We tested whether hospitalization reduced mortality in patients who presented to emergency departments (EDs) with syncope. Methods We conducted a propensity analysis of the outcomes of patients ≥18 years old presenting to EDs with a primary diagnosis of syncope in April 2004–March 2013. The model used 1:1 nearest‐neighbor matching to predicted admission using age, sex, urban residence, household income, and 14 significant comorbidities from 4 administrative databases of the province of Alberta. The primary outcome was death. Results There were 57,417 ED patients with a primary diagnosis of syncope; 8864 were admitted, and 48,553 were discharged in

Background: Syncope is a common presentation to the emergency department (ED), yet little is known regarding patient mode of arrival. Methods: We identified patients ≥20 years old who presented to the ED with a primary diagnosis of syncope in Alberta and Ontario, Canada, between 2010 and 2016. Outcomes included 30-day in-hospital mortality, ED revisits, and rehospitalizations according to mode of arrival and discharge status. The estimated cost for ambulance use was calculated based on the provincial rates (Alberta CAD$385 and Ontario $240). Results: A total of 271,601 syncope presentations to the ED were identified and 60.7% arrived by ambulance. A total of 76.3% (n = 125,793) of ambulance users and 87.0% of self-presenters (n = 92,845) were discharged from the ED. Regardless of mode of arrival, discharged patients were younger with fewer comorbidities. Compared with ambulance users admitted, those discharged had lower in-hospital mortality (0.2% vs 3.5%, P < 0.001), ED revisits (4.4% vs 10.4%, P < 0.001), and rehospitalizations (3.6% vs 10.7%, P < 0.001). Discharged self-presenters also had significantly lower outcomes (P < 0.001, for each outcome) compared with admitted self-presenters. The estimated cost for ambulance use among patients discharged from the ED was $33,137,735. Conclusion: A majority of syncope patients arrived to the ED by ambulance, and over 3 quarters were directly discharged home. Although discharged patients had a favourable short-term prognosis, they incurred high transportation costs. Strategies aimed at preventing unnecessary ambulance use are needed. Résumé: Contexte: La syncope est une manifestation courante chez les patients qui se présentent au service des urgences; pourtant, on en sait peu sur la façon dont ces patients arrivent à l’hôpital. Méthodologie: Nous avons examiné les dossiers de patients âgés de 20 ans ou plus qui se sont présentés au service des urgences d’hôpitaux de l’Alberta et de l’Ontario, au Canada, et qui ont reçu un diagnostic de syncope entre 2010 et 2016. Les issues évaluées comprenaient la mortalité hospitalière à 30 jours, les nouvelles visites au service des urgences et les réadmissions à l’hôpital en fonction du mode d’arrivée et du statut au moment de la sortie de l’hôpital. Le coût estimatif des services d’ambulance a été calculé à partir des tarifs provinciaux (385 $ en Alberta et 240 $ en Ontario). Résultats: En tout, 271 601 cas de syncope ont été recensés dans les services des urgences; dans 60,7 % des cas, le patient est arrivé en ambulance. Au total, 76,3 % (n = 125 793) des patients arrivés en ambulance et 87,0 % des patients qui se sont présentés d’eux-mêmes (n = 92 845) ont reçu leur congé du service des urgences. Quel que soit leur mode d’arrivée, les patients qui ont reçu leur congé étaient plus jeunes et présentaient moins d’affections concomitantes. Chez les patients arrivés en ambulance, ceux qui ont reçu leur congé ont affiché des résultats inférieurs à ceux qui ont été admis à l’hôpital quant à la mortalité hospitalière (0,2 % vs 3,5 %, p < 0,001), aux nouvelles visites au service des urgences (4,4 % vs 10,4 %, p < 0,001) et aux réadmissions à l’hôpital (3,6 % vs 10,7 %, p < 0,001). Dans le cas des patients qui se sont présentés d’eux-mêmes, l’incidence des issues évaluées était aussi plus faible chez ceux qui ont reçu leur congé (p < 0,001 pour chaque issue) que chez ceux qui ont été admis à l’hôpital. Le coût estimatif du recours aux services d’ambulance par les patients qui ont reçu leur congé du service des urgences se chiffrait à 33 137 735 $. Conclusion: La majorité des patients subissant une syncope sont arrivés au service des urgences en ambulance, et plus des trois quarts ont reçu directement leur congé à la maison. Bien que le pronostic à court terme des patients ayant reçu leur congé du service des urgences ait été favorable, ces patients ont dû payer des frais de transport élevés. Des stratégies visant à prévenir le recours inutile aux services d’ambulance s’imposent.

Background: Single-center studies have shown the high costs associated with the hospital evaluation of syncope. National cost estimates for syncope-related hospitalizations are sparse, and none exist in Canada. Methods: The Canadian Institute for Health Information Discharge Abstract Database was used to identify acute care hospitalizations with a primary diagnosis of syncope between fiscal years (FY) 2004 and 2015 in all provinces and territories (except Quebec). We used multiple linear regression to calculate the trends in prevalence of hospital admissions and generalized linear regression to estimate the costs of a hospitalization. The syncope hospitalization rate and the cost per hospitalization in Quebec were assumed to be the average of the rest of the country. The future hospitalization cost burden of syncope was projected to 2030. Results: There were 128,263 hospitalizations for a primary diagnosis of syncope over the 10-year study period, resulting in a total cost of $619.9 million (Canadian). An estimate of 41,044 syncope hospitalizations occurred in Quebec, costing $198.7 million. The total hospitalization cost of syncope in Canada was estimated at $818.5 million. The annual costs of syncope hospitalizations increased from $66.6 to $68.5 million between FY2004 and FY2015, respectively, and are projected to increase to $87.1 million in 2030. Conclusion: Hospitalization costs for syncope in Canada are high and rising. Research is needed to identify opportunities to deliver more efficient and cost-effective care. Résumé: Contexte: Des études monocentriques ont mis en lumière les coûts élevés associés à l’évaluation hospitalière d’une syncope. Les estimations nationales du coût des hospitalisations liées aux syncopes sont rares, et il n’en existe aucune au Canada. Méthodologie: La base de données sur les congés des patients de l’Institut canadien d’information sur la santé a été utilisée pour recenser les hospitalisations de courte durée liées à un diagnostic primaire de syncope entre les années financières (AF) 2004 et 2015 dans toutes les provinces et territoires (sauf le Québec). Nous avons eu recours, d’une part, à la régression linéaire multiple pour calculer les tendances de la prévalence d’admissions à l’hôpital et, d’autre part, à la régression linéaire généralisée pour estimer les coûts d’une hospitalisation. Le taux d’hospitalisations liées à une syncope et le coût par hospitalisation au Québec ont été établis hypothétiquement à la moyenne du reste du pays. Le futur fardeau du coût des hospitalisations liées à une syncope a été projeté jusqu’en 2030. Résultats: Nous avons recensé 128 263 hospitalisations liées à un diagnostic primaire de syncope au cours de la période de 10 ans à l’étude, ce qui se traduit par un coût total de 619,9 M$ (canadiens). Selon une estimation, 41 044 hospitalisations liées à une syncope seraient survenues au Québec, au coût de 198,7 M$. Le coût total des hospitalisations liées à une syncope au Canada a été estimé à 818,5 M$. Les coûts annuels des hospitalisations liées à une syncope ont augmenté, passant de 66,6 à 68,5 M$ entre les AF 2004 et 2015, respectivement, et ils devraient encore augmenter pour atteindre 87,1 M$ en 2030. Conclusion: Les coûts des hospitalisations liées à une syncope au Canada sont élevés et en hausse. D’autres travaux de recherche devront être effectués pour cerner les possibilités de prestations de soins plus efficaces et rentables.

Summary: Background: SARS-Cov-2 infection rates are high among residents of long-term care (LTC) homes. We used machine learning to identify resident and community characteristics predictive of SARS-Cov-2 infection. Methods: We linked 26 population-based health and administrative databases to identify the population of all LTC residents tested for SARS-Cov-2 infection in Ontario, Canada. Using ensemble-based algorithms, we examined 484 factors, including individual-level demographics, healthcare use, comorbidities, functional status, and laboratory results; and community-level characteristics to identify factors predictive of infection. Analyses were performed separately for January to April (early wave 1) and May to August (late wave 1). Findings: Among 80,784 LTC residents, 64,757 (80.2%) were tested for SARS-Cov-2 (median age 86 (78–91) years, 30.6% male), of whom 10.2% of 33,519 and 5.2% of 31,238 tested positive in early and late wave 1, respectively. In the late phase (when restriction of visitors, closure of communal spaces, and universal masking in LTC were routine), regional-level characteristics comprised 33 of the top 50 factors associated with testing positive, while laboratory values and comorbidities were also predictive. The c-index of the final model was 0.934, and sensitivity was 0.887. In the highest versus lowest risk quartiles, the odds ratio for infection was 114.3 (95% CI 38.6–557.3). LTC-related geographic variations existed in the distribution of observed infection rates and the proportion of residents at highest risk. Interpretation: Machine learning informed evaluation of predicted and observed risks of SARS-CoV-2 infection at the resident and LTC levels, and may inform initiatives to improve care quality in this setting. Funding: Funded by a Canadian Institutes of Health Research, COVID-19 Rapid Research Funding Opportunity grant (# VR4 172736) and a Peter Munk Cardiac Centre Innovation Grant. Dr. D. Lee is the Ted Rogers Chair in Heart Function Outcomes, University Health Network, University of Toronto. Dr. Austin is supported by a Mid-Career investigator award from the Heart and Stroke Foundation. Dr. McAlister is supported by an Alberta Health Services Chair in Cardiovascular Outcomes Research. Dr. Kaul is the CIHR Sex and Gender Science Chair and the Heart & Stroke Chair in Cardiovascular Research. Dr. Rochon holds the RTO/ERO Chair in Geriatric Medicine from the University of Toronto. Dr. B. Wang holds a CIFAR AI chair at the Vector Institute.

IntroductionPreviously developed cesarean section (CS) and emergency CS prediction tools use antenatal and intrapartum risk factors. We aimed to develop a predictive model for the risk of emergency CS before the onset of labour utilizing antenatal obstetric and non-obstetric factors.MethodsWe completed a secondary analysis of data collected from the CHILD Cohort Study. The analysis was limited to term (≥37 weeks), singleton pregnant women with cephalic presentation. The sample was divided into a training and validation dataset. The emergency CS prediction model was developed in the training dataset and the performance accuracy was assessed by the area under the receiver operating characteristic curve(AUC) of the receiver operating characteristic analysis (ROC). Our final model was subsequently evaluated in the validation dataset.ResultsThe participant sample consisted of 2,836 pregnant women. Mean age of participants was 32 years, mean BMI of 25.4 kg/m2 and 39% were nulliparous. 14% had emergency CS delivery. Each year of increasing maternal age increased the odds of emergency CS by 6% (adjusted Odds Ratio (aOR 1.06,1.02-1.08). Likewise, there was a 4% increase odds of emergency CS for each unit increase in BMI (aOR 1.04,1.02-1.06). In contrast, increase in maternal height has a negative association with emergency CS. The final emergency CS delivery predictive model included six variables (hypertensive disorders of pregnancy, antenatal depression, previous vaginal delivery, age, height, BMI). The AUC for our final prediction model was 0.74 (0.72-0.77) in the training set with a similar AUC in the validation dataset (0.77; 0.71-0.82).ConclusionThe developed and validated emergency CS delivery prediction model can be used in counselling prospective parents around their CS risk and healthcare resource planning. Further validation of the tool is suggested.

BackgroundGiven that pregnant women taking medications are excluded from clinical trials, real-world evidence is essential. We aimed to build a Canadian Mother-Child Cohort Active Surveillance Initiative (CAMCCO) and compare frequency of prematurity, low-birth-weight (LBW), major malformations, multiplicity, and gestational medication use across four provinces.MethodsCAMCCO is a collaborative research infrastructure that uses real-world data from large provincial health care databases in Canada; developed with standardized methods to similarly construct population-based pregnancy/child cohorts with longitudinal follow-up by linking administrative/hospital/birth databases. CAMCCO also includes a common repository to i) share algorithms and case definitions based on diagnostic and procedural codes for research/training purpose, and ii) download aggregate data relevant to primary care providers, researchers, and decision makers. For this study, data from Quebec (1998-2015), Manitoba (1995-2019), Saskatchewan (1996-2020), and Alberta (2005-2018) are compared (Chi-square tests, p-values), and trends are calculated using Cochran-Armitage trend tests.ResultsAlmost two-thirds (61%) of women took medications during pregnancy, mostly antibiotics (26%), asthma drugs (8%), and antidepressants (4%). Differences in the prevalence of prematurity (5.9-6.8%), LBW (4.0-5.2%), and multiplicity (1.0-2.5%) were statistically significant between provinces (pInterpretationMedications are often used among Canadian pregnancies but adverse pregnancy outcomes vary across provinces. Digitized health data may help researchers and care providers understand the risk-benefit ratios related to gestational medication use, as well as province-specific trends.

Background Small observational studies have suggested that statin users have a lower risk of dying with COVID‐19. We tested this hypothesis in a large, population‐based cohort of adults in 2 of Canada’s most populous provinces: Ontario and Alberta. Methods and Results We examined reverse transcriptase–polymerase chain reaction swab positivity rates for SARS‐CoV‐2 in adults using statins compared with nonusers. In patients with SARS‐CoV‐2 infection, we compared 30‐day risk of all‐cause emergency department visit, hospitalization, intensive care unit admission, or death in statin users versus nonusers, adjusting for baseline differences in demographics, clinical comorbidities, and prior health care use, as well as propensity for statin use. Between January and June 2020, 2.4% of 226 142 tested individuals aged 18 to 65 years, 2.7% of 88 387 people aged 66 to 75 years, and 4.1% of 154 950 people older than 75 years had a positive reverse transcriptase–polymerase chain reaction swab for SARS‐CoV‐2. Compared with 353 878 nonusers, the 115 871 statin users were more likely to test positive for SARS‐CoV‐2 (3.6% versus 2.8%, P

South Asians (SAs), originating from the Indian subcontinent (India, Pakistan, Sri Lanka, Bangladesh, Nepal, and Bhutan), represent one quarter of the global population and are the largest visible minority in Canada. SAs experience the highest rates of coronary artery disease in Canada. Although conventional cardiovascular risk factors remain predictive in SA, the excess risk is not fully explained by these risk factors alone. Abdominal obesity, metabolic syndrome, and insulin resistance likely contribute a greater risk in SAs than in other populations. The South Asian Heart Alliance has been recently formed to investigate and recommend the best strategies for the prevention of cardiometabolic disease in SAs in Canada. This topic review represents a comprehensive overview of the magnitude of cardiovascular disease in SAs in Canada, with a review of conventional and novel risk markers in the SA population. Both primary and secondary prevention strategies are suggested and when possible, adapted specifically for the SA population. The need for SAs and their healthcare professionals to be more aware of the problem and potential solutions, along with the need for population-specific research, is highlighted. Résumé: Les Asiatiques du sud originaires du sous-continent indien (Inde, Pakistan, Sri Lanka, Bangladesh, Népal et Bhoutan) représentent le quart de la population mondiale et constituent la plus importante minorité visible au Canada. C’est aussi au sein de cette population qu’on observe les taux de coronaropathie les plus élevés au Canada. Bien que les facteurs de risque cardiovasculaire classiques conservent leur valeur prédictive chez les Asiatiques du sud, ils n’expliquent pas à eux seuls le risque excédentaire observé. L’obésité abdominale, le syndrome métabolique et l’insulinorésistance constituent vraisemblablement des facteurs de risque plus importants chez les Asiatiques du sud que dans les autres populations. La South Asian Heart Alliance a récemment été mise sur pied afin d’explorer les stratégies exemplaires pour la prévention des maladies cardiométaboliques chez les Asiatiques du sud au Canada et de formuler des recommandations à cet égard. Cette revue thématique présente un aperçu de l’importance des maladies cardiovasculaires au sein de la population des Asiatiques du sud du Canada, ainsi qu’un résumé des marqueurs de risque classiques et nouveaux dans cette population. Les auteurs proposent des stratégies de prévention primaire et secondaire adaptées, dans la mesure du possible, à la population des Asiatiques du sud. Ils font également ressortir l’importance de sensibiliser davantage les Asiatiques du sud et les professionnels de la santé aux risques et aux solutions possibles, ainsi que la nécessité de mener des recherches axées sur cette population particulière.

Abstract Background Pulmonary edema is a cardinal feature of heart failure but no quantitative tests are available in clinical practice. The goals of this study were to develop a simple cardiovascular magnetic resonance (CMR) approach for lung water quantification, to correlate CMR derived lung water with intra-cardiac pressures and to determine its prognostic significance. Methods Lung water density (LWD, %) was measured using a widely available single-shot fast spin-echo acquisition in two study cohorts. Validation Cohort: LWD was compared to left ventricular end-diastolic pressure or pulmonary capillary wedge pressure in 19 patients with heart failure undergoing cardiac catheterization. Prospective Cohort: LWD was measured in 256 subjects, including 121 with heart failure, 82 at-risk for heart failure and 53 healthy controls. Clinical outcomes were evaluated up to 1 year. Results Within the validation cohort, CMR LWD correlated to invasively measured left-sided filling pressures (R = 0.8, p 20.8% (mean + 2 standard deviations of healthy controls) was an independent predictor of death, hospitalization or emergency department visit within 1 year, hazard ratio 2.4 (1.1–5.1, p = 0.03). Conclusions In patients with heart failure, increased CMR-derived lung water is associated with increased intra-cardiac filling pressures, and predicts 1 year outcomes. LWD could be incorporated in standard CMR scans.

Background: Patients undergoing percutaneous coronary intervention (PCI) are increasingly older and have a higher comorbidity burden. This study evaluated trends in 30-day, 1-year, and 2-year total and cause-specific mortality using a large, contemporary cohort of patients who underwent PCI in Alberta, Canada. Methods: We used the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) registry to identify patients aged ≥ 20 years who underwent PCI between 2005 and 2013. All patients were followed until death or being censored by August 2016. Cause of death was from the Vital Statistics database and classified as cardiac or noncardiac. Multivariable logistic regression was used to calculate predicted mortality at 30 days, 1 year, and 2 years post-PCI. Results: Of the 35,602 patients who underwent PCI, 5284 (14.8%) had died. Mean (standard deviation) follow-up was 74.9 (35.1) months. Over the study period, patients were older and more likely to undergo PCI for an acute coronary syndrome indication. Thirty-day (2005: 1.3%; 2013: 3.2%; P < 0.001), 1-year (2005: 2.7%; 2013: 5.7%; P < 0.001), and 2-year (2005: 4.5%; 2013: 7.5%; P < 0.001) predicted mortality after PCI increased over the study period. Cardiac cause of death dominated in the short-term, but the proportion of noncardiac deaths increased as time from PCI to death increased (30 days = 11.5%, 1 year = 31.5%, 2 years = 39.6%; P < 0.001). Conclusions: In this population-based study, we found all-cause mortality at 30 days, 1 year, and 2 years after PCI increased over time. Cardiac causes of death dominate in the short-term after PCI; however, noncardiac cause becomes a major driver of mortality in the long-term. Résumé: Contexte: Les patients devant subir une intervention coronarienne percutanée (ICP) sont de plus en plus âgés et subissent un fardeau accru de comorbidités. La présente étude a évalué les tendances de la mortalité totale et due à une cause particulière à 30 jours, 1 an et 2 ans, au sein d’une vaste cohorte contemporaine de patients ayant subi une ICP en Alberta, au Canada. Méthodologie: Nous avons utilisé le registre APPROACH (Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease) pour recenser les patients âgés de 20 ans ou plus qui avaient subi une ICP entre 2005 et 2013. Tous les patients ont fait l’objet d’un suivi jusqu’au décès ou à la censure des données en août 2016. La cause du décès était issue de la Base de données sur l’état civil et classée comme étant d’origine cardiaque ou non cardiaque. On a eu recours à un modèle de régression logistique multivarié pour calculer la mortalité prédite 30 jours, 1 an et 2 ans après l’ICP. Résultats: Sur les 35 602 patients ayant subi une ICP, 5 284 (14,8 %) étaient décédés. La durée moyenne de suivi (écart type) était de 74,9 (35,1) mois. Au cours de la période de l’étude, les patients étaient plus âgés et plus susceptibles de subir une ICP pour une indication de syndrome coronarien aigu. On observe une augmentation de la mortalité prédite après l’ICP au cours de la période de l’étude selon les taux suivants : à trente jours (2005 : 1,3 %; 2013 : 3,2 %; p < 0,001), à 1 an (2005 : 2,7 %; 2013 : 5,7 %; p < 0,001) et à 2 ans (2005 : 4,5 %; 2013 : 7,5 %; p < 0,001). Les causes cardiaques de décès dominaient à court terme, mais la proportion de décès d’origine non cardiaque augmentait avec le temps au fur et à mesure de l’allongement de l’intervalle entre la date de l’ICP et le décès (30 jours = 11,5 %, 1 an = 31,5 %, 2 ans = 39,6 %; p < 0,001). Conclusions: Dans cette étude de population, nous avons trouvé que la mortalité toutes causes confondues à 30 jours, 1 an et 2 ans après une ICP augmente au fil du temps. Les causes cardiaques de décès dominent peu de temps après l’ICP, tandis que les causes non cardiaques jouent un rôle déterminant dans la mortalité à long terme.

Background: Ambulance use is a costly mode of transportation to the emergency department (ED). Syncope is a frequent presentation to the ED; however, no data exist regarding the proportion of hospitalized patients with syncope arriving by ambulance and their outcomes compared with self-presenters. Methods: The Canadian Institute for Health Information database was used to identify patients aged > 20 years hospitalized with a primary diagnosis of syncope (International Classification of Diseases 10th Revision code R55) in Canada, except Quebec, between April 2004 and March 2016. Logistic regression models (odds ratio and 95% confidence interval) were used to identify demographics, clinical factors, and province associated with ambulance use and whether ambulance use was associated with in-hospital mortality. Results: Among 108,967 syncope hospitalizations, 64% of patients arrived by ambulance, and use increased from 58.8% to 66.1% over 12 years (P for trend < 0.01). Significant variations existed in ambulance use across provinces (P < 0.01). Predictors associated with higher odds of ambulance use were increasing age, male sex, urban residence, residing in areas with lower annual household income, and higher comorbidity burden. In multivariable-adjusted analysis, ambulance use was associated with a 1.7-fold higher odds of in-hospital mortality. Conclusions: Approximately two-thirds of patients hospitalized for syncope presented by ambulance, and use has increased over time. Hospitalized patients in syncope who are transported by ambulance have a worse prognosis. Further research on emergency medical services’ risk stratification of patients who are transported by ambulance may help to identify a low-risk population who may obviate the need for transport. Résumé: Contexte: L'ambulance est un moyen de transport coûteux pour se rendre à l'urgence. La syncope est un symptôme fréquent chez les patients se présentant à l'urgence; toutefois, on ignore quelle est la proportion des patients hospitalisés pour une syncope qui sont arrivés en ambulance et quelle est l'issue de leur séjour à l'hôpital par rapport à ceux qui sont arrivés à l'urgence par leurs propres moyens. Méthodologie: Nous avons utilisé la base de données de l'Institut canadien d'information sur la santé pour recenser les patients âgés de plus de 20 ans hospitalisés avec un diagnostic primaire de syncope (Classification internationale des maladies, 10e révision, code R55) au Canada, à l'exception du Québec, entre avril 2004 et mars 2016. Des modèles de régression logistique (rapport de cotes et intervalle de confiance à 95 %) ont été utilisés pour déterminer quelles caractéristiques démographiques, quels facteurs cliniques et quelles provinces sont associés au recours à l'ambulance et s'il existe une association entre ce moyen de transport et la mortalité en cours d'hospitalisation. Résultats: Sur 108 967 hospitalisations pour une syncope, 64 % des patients étaient arrivés en ambulance, et le recours à ce moyen de transport a augmenté de 58,8 % à 66,1 % sur une période de 12 ans (p pour la tendance < 0,01). Des variations importantes concernant le recours à l'ambulance ont été observées d'une province à l'autre (p < 0,01). Les facteurs prédictifs associés à une probabilité plus élevée d'utilisation de l'ambulance étaient l'augmentation de l'âge, le sexe masculin, la résidence en zone urbaine, la résidence dans une région où le revenu annuel moyen des ménages est plus bas, ainsi qu'un fardeau de comorbidité plus lourd. Une analyse après ajustement multivarié a mis en évidence une multiplication par 1,7 de la probabilité de décès à l'hôpital associée au recours à l'ambulance. Conclusions: Environ deux tiers des patients hospitalisés pour une syncope sont arrivés à l'hôpital en ambulance, et le recours à ce moyen de transport a augmenté au fil du temps. Le pronostic est plus défavorable chez les patients hospitalisés en état de syncope qui ont été transportés en ambulance. Des recherches plus poussées sur la stratification des risques liés aux services médicaux d'urgence pour les patients transportés en ambulance pourraient aider à repérer les individus à faible risque n'ayant pas besoin d’un tel transport.

Background: Although appropriate noninvasive cardiac tests (NICTs) after an acute coronary syndrome (ACS) provide useful prognostic information, inappropriate use leads to inefficient expenditure of existing healthcare resources. By using the Alberta Contemporary Acute Coronary Syndrome Patient Invasive Treatment Strategies (COAPT) Registry, we evaluated the use and costs of NICTs among patients discharged within 1 year after ACS. Methods: All patients discharged from the hospital with a primary diagnosis of ACS in Alberta between 2004/2005 and 2015/2016 were included. Frequency of NICTs (stress tests [± imaging] and nonstress imaging tests) was determined from linked provincial databases. Costs were obtained from the Alberta Health Care Insurance Plan Medical Procedure List. Results: Of 55,516 patients with ACS, 30,760 had at least 1 NICT (55.4%), with 13,505 (24.3%) having > 1 NICT performed within 1 year. Temporal trends of NICT increased over time (stress tests: P trend < 0.001; nonstress imaging tests: P trend < 0.001). NICT most commonly occurred within the first 4 months after hospital discharge (stress tests at 2 months; nonstress imaging tests at 3-4 months). In 2015/2016, the total estimated costs of NICT were $1.35M, a 22.4% increase from 2004/2005 (1.10M) (P < 0.001), whereas a decrease in incidence of ACS over the same time period was noted (P = 0.008). Conclusions: Rates of NICT 1 year after ACS are high and increasing over time. Estimated costs of NICT appear to be escalating out of proportion to the ACS growth. Further investigation is warranted because it is speculative whether the increase in NICT and costs results in clinical benefit after ACS. Résumé: Contexte: Bien que les différents examens cardiaques non effractifs (ECNE) effectués après un syndrome coronarien aigu (SCA) fournissent des renseignements utiles au pronostic, leur emploi dans des situations inappropriées entraîne un gaspillage des ressources en santé. À l’aide du registre COAPT (Contemporary Acute Coronary Syndrome Patient Invasive Treatment Strategies) de l’Alberta, nous avons évalué l’emploi des ECNE et les coûts qui y sont associés chez les patients qui ont reçu leur congé de l’hôpital dans l’année suivant un SCA. Méthodologie: Tous les patients qui ont reçu leur congé de l’hôpital après un diagnostic primaire de SCA en Alberta entre 2004-2005 et 2015-2016 ont été inclus. La fréquence des ECNE (épreuves d’effort [avec ou sans examen d’imagerie] et examens d’imagerie au repos) a été déterminée à partir des bases de données provinciales couplées. Les coûts ont été établis à partir de la liste des actes médicaux du régime d’assurance-maladie de l’Alberta. Résultats: Des 55 516 patients ayant présenté un SCA, 30 760 ont subi au moins un ECNE (55,4 %) dans l’année qui a suivi l’événement; 13 505 (24,3 %) d’entre eux ont subi plus d’un ECNE. Les tendances temporelles en matière d’ECNE affichent une hausse (épreuves d’effort : p tendance < 0,001; examens d’imagerie au repos : p tendance < 0,001). Les ECNE ont généralement été effectués au cours des 4 premiers mois après la sortie de l’hôpital (épreuves d’effort, dans les 2 mois; examens d’imagerie au repos, dans les 3 à 4 mois). Le coût total des ECNE effectués en 2015-2016 a été évalué à 1,35 M$, soit une hausse de 22,4 % par rapport à 2004-2005 (1,10 M$) (p < 0,001), tandis que l’incidence des SCA a diminué au cours de la même période (p = 0,008). Conclusions: Les taux d’ECNE effectués dans l’année suivant un SCA sont élevés et augmentent au fil du temps. Le coût estimatif de ces ECNE semble s’accroître de façon disproportionnée par rapport à la croissance des SCA. Une enquête plus approfondie s’impose; à l’heure actuelle, on ne peut que spéculer quant aux bienfaits cliniques qui découlent de l’augmentation des ECNE effectués après un SCA et des coûts qu’ils engendrent.

Estimates of the risk of recurrent cardiovascular events (residual risk) among patients with acute coronary syndromes have largely been based on clinical trial populations. Our objective was to estimate the residual risk associated with common comorbidities in a large, unselected, population-based cohort of acute coronary syndrome patients. 31,056 ACS patients (49.5%-non-ST segment elevation myocardial infarction [NSTEMI], 34.0%-ST segment elevation myocardial infarction [STEMI] and 16.5%-unstable angina [UA]) hospitalised in Alberta between April 2010 and March 2016 were included. The primary composite outcome was major adverse cardiovascular events (MACE) including: death, stroke or recurrent myocardial infarction. The secondary outcome was death from any cause. Cox-proportional hazard models were used to identify the impact of ACS type and commonly observed comorbidities (heart failure, hypertension, peripheral vascular disease, renal disease, cerebrovascular disease and diabetes). At 3.0 +/- 3.7 years, rates of MACE were highest in the NSTEMI population followed by STEMI and UA (3.58, 2.41 and 1.68 per 10,000 person years respectively). Mortality was also highest in the NSTEMI population followed by STEMI and UA (2.23, 1.38 and 0.95 per 10,000 person years respectively). Increased burden of comorbidities was associated with an increased risk of MACE, most prominently seen with heart failure (adjusted HR 1.83; 95% CI 1.73-1.93), renal disease (adjusted HR 1.52; 95% CI 1.40-1.65) and diabetes (adjusted HR 1.51; 95% CI 1.44-1.59). The cumulative presence of each of examined comorbidities was associated with an incremental increase in the rate of MACE ranging from 1.7 to 9.98 per 10,000 person years. Rates of secondary prevention medications at discharge were high including: statin (89.5%), angiotensin converting enzyme inhibitor/angiotensin receptor blocker (84.1%) and beta-blockers (85.9%). Residual cardiovascular risk following an acute coronary syndrome remains high despite advances in secondary prevention. A higher burden of comorbidities is associated with increased residual risk that may benefit from aggressive or novel therapies.

Background Improving health‐related quality of life is an important goal in the management of patients with heart failure (HF). Defining health‐related quality of life changes over time in patients with HF with preserved (HFpEF) or reduced ejection fraction and showing their association with other important clinical events could support the use of health‐related quality of life as a measure of quantifying HF care. Methods and Results In the Alberta HEART (Heart Failure Aetiology and Analysis Team) cohort (n=621), patients were categorized into 4 subgroups: healthy controls (n=98), at risk (n=163), HFpEF (n=191), and HF with reduced ejection fraction (n=169). The change of the Kansas City Cardiomyopathy Questionnaire (KCCQ), EuroQOL 5 dimensions, and Functional Assessment of Cancer Therapy—Anemia over 12 months, and its association with a composite of death or rehospitalization within 3 years were assessed. At baseline, the KCCQ overall summary score was 73 (interquartile range, 53–86) in HFpEF and 78 (interquartile range, 56–90) in HF with reduced ejection fraction (P=0.22). Overall, 30.5% of patients with HF experienced ≥5‐point improvements and 32.4% had ≥5‐point worsening in KCCQ overall summary score at 12 months, which did not differ between HFpEF and HF with reduced ejection fraction (P=0.23). Clinical events were higher in patients with HF who had a decline in KCCQ over 12 months as compared with those with stable KCCQ scores (70.2% versus 52.0%, P=0.012). The results were similar for the Functional Assessment of Cancer Therapy—Anemia and EuroQOL 5 dimensions. Conclusions In patients with HF, the KCCQ quantified clinically meaningful changes over time, which were associated with important clinical outcomes in patients with HFpEF. Given the observed variability and prognostication in different patient trajectories, health‐related quality of life measures could be valuable for quantifying the quality of care in healthcare systems.

Background We examined temporal trends, timing, and frequency, as well as adverse neonatal and maternal outcomes occurring in the first year postpartum among women experiencing syncope during pregnancy. Methods and Results This was a retrospective study of pregnancies between January 1, 2005, and December 31, 2014, in the province of Alberta, Canada. Of 481 930 pregnancies, 4667 had an episode of syncope. Poisson regression analysis found a 5% increase/year (rate ratio, 1.05; 95% CI, 1.04–1.06) in the age‐adjusted incidence of syncope. Overall, 1506 (32.3%) of the syncope episodes first occurred in the first trimester, 2058 (44.1%) in the second trimester, and 1103 (23.6%) in the third trimester; and 8% (n=377) of pregnancies had >1 episode of syncope. Compared with women without syncope, women who experienced syncope were younger (age

Background Little is known about the prognostic implications of frailty, a state of susceptibility to stressors and poor recovery to homeostasis in older people, after myocardial infarction (MI). Methods and Results We studied 3944 MI patients aged ≥65 years treated at 41 Australian hospitals from 2009 to 2016 in the CONCORDANCE (Australian Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events) registry. Frailty index (FI) was determined using the health deficit accumulation method. All‐cause and cardiac‐specific mortality at 6 months were compared between frail (FI >0.25) and nonfrail (FI ≤0.25) patients. Among 1275 patients with ST‐segment–elevation MI (STEMI), 192 (15%) were frail, and among 2669 non‐STEMI (NSTEMI) patients, 902 (34%) were frail. Compared with nonfrail counterparts, frail STEMI patients received 30% less reperfusion therapy and 22% less revascularization during index hospitalization; frail NSTEMI patients received 30% less diagnostic angiography and 39% less revascularization. Unadjusted 6‐month all‐cause mortality (STEMI: 13% versus 3%; NSTEMI: 13% versus 4%) and cardiac‐specific mortality (STEMI: 6% versus 1.4%, NSTEMI: 3.2% versus 1.2%) were higher among frail patients. After adjustment for known prognosticators, FI was significantly associated with higher 6‐month all‐cause (STEMI: odds ratio: 1.74 per 0.1 FI [95% confidence interval, 1.37–2.22], P

BackgroundUp to one fifth of readmissions after a heart failure hospitalization occur at a different hospital. This negatively impacts information continuity, but whether site of readmission impacts subsequent outcomes is unclear. Methods and ResultsRetrospective cohort study of all patients discharged with a primary diagnosis of heart failure in Canada between April 2004 and December 2013. We compared patients readmitted within 30 days to the original hospital versus a different hospital. Of the 217 039 heart failure patients (mean age, 76.8 years, 50.1% male), 39 368 (18.1%) were readmitted within 30 days—32 771 (83.2%) to the original hospital and 6597 (16.8%) to a different hospital (increasing over time from 15.6% in 2004 to 18.5% by 2013; P for trend=0.001). Patients readmitted to different hospitals were younger and were more likely to be male, have a rural residence, a more‐recent discharge year, an index hospitalization at a teaching hospital, and to be brought in by ambulance at the time of the readmission. Readmissions to the original hospital were substantially shorter (mean, 10.4 days [95% CI, 10.3–10.6] versus 11.6 days [95% CI, 11.3–12.0]; adjusted means, 11.0 versus 12.0; P

Adverse associations between air pollution and myocardial infarction (MI) are widely reported in medical literature. However, inconsistency and sensitivity of the findings are still big concerns. An exploratory investigation was undertaken to examine associations between air pollutants and risk of acute MI (AMI) hospitalization in Alberta, Canada. A time stratified case-crossover design was used to assess the transient effect of five air pollutants (carbon monoxide (CO), nitrogen dioxide (NO2), nitric oxide (NO), ozone (O3) and particulate matter with an aerodynamic diameter ≤2.5 (PM2.5)) on the risk of AMI hospitalization over the period 1999-2009. Subgroups were predefined to see if any susceptible group of individuals existed. A three-step procedure, including univariate analysis, multivariate analysis, and bootstrap model averaging, was used. The multivariate analysis was used in an effort to address adjustment uncertainty; whereas the bootstrap technique was used as a way to account for regression model uncertainty. There were 25,894 AMI hospital admissions during the 11-year period. Estimating health effects that are properly adjusted for all possible confounding factors and accounting for model uncertainty are important for making interpretations of air pollution-health effect associations. The most robust findings included: (1) only 1-day lag NO2 concentrations (6-, 12- or 24-hour average), but not those of CO, NO, O3 or PM2.5, were associated with an elevated risk of AMI hospitalization; (2) evidence was suggested for an effect of elevated risk of hospitalization for NSTEMI (Non-ST Segment Elevation Myocardial Infarction), but not for STEMI (ST segment elevation myocardial infarction); and (3) susceptible subgroups included elders (age ≥65) and elders with hypertension. As this was only an exploratory study there is a need to replicate these findings with other methodologies and datasets.

Background and purposeWe studied whether anticoagulant use and outcomes differed between rural versus urban Canadian non-valvular atrial fibrillation (NVAF) patients prior to the introduction of direct oral anticoagulant drugs.MethodsRetrospective cohort study of 25,284 adult Albertans with NVAF between April 1, 1999 and December 31, 2008.ResultsCompared to urban patients, rural patients were older (p = 0.0009) and had more comorbidities but lower bleeding risk at baseline. In the first year after NVAF diagnosis, urban patients were less likely to be hospitalized (aOR 0.82, 95%CI 0.77-0.89) or have an emergency department visit for any reason (aOR 0.61, 95%CI 0.56-0.66) but warfarin dispensation rates (72.2% vs 71.8% at 365 days, p = 0.98) and clinical outcomes were similar: 7.8% died in both groups, 3.2% rural vs. 2.8% urban had a stroke or systemic embolism (SSE) (aOR 0.92, 95%CI 0.77-1.11), and 6.6% vs. 5.7% (aOR 0.93, 95%CI 0.81-1.06) had a bleed. Baseline SSE risk did not impact warfarin dispensation (73.0% in those with high vs. 72.8% in those with low CHADS2 score, p = 0.85) but patients at higher baseline bleeding risk were less likely to be using warfarin (69.2% high vs. 73.6% low HASBLED score, pConclusionWarfarin use and clinical event rates did not differ between rural and urban NVAF patients in a universal access publically-funded healthcare system.