Risk of major adverse cardiovascular events after SARS-CoV-2 infection in British Columbia: a population-based study.

BACKGROUND: COVID-19 is associated with increased risk of post-acute cardiovascular outcomes. Population-based evidence for long periods of observation is still limited. METHODS: This population-based cohort study was conducted using data (2020-2001) from the British Columbia COVID-19 Cohort. The exposure of interest was SARS-CoV-2 infection, identified through reverse transcription-polymerase chain reaction (RT-PCR) assay. Individuals who tested positive (exposed) on RT-PCR were matched to negative controls (unexposed), on sex, age, and RT-PCR collection date, in a 1:4 ratio. Outcomes of interest were incident major adverse cardiovascular events and acute myocardial infarction, identified more than 30 days after RT-PCR collection date. The association between SARS-CoV-2 infection and cardiovascular risk was assessed through multivariable survival models. Population attributable fractions were computed from Cox models. RESULTS: WE INCLUDED 649,320 INDIVIDUALS: : 129,864 exposed and 519,456 unexposed. The median duration of follow-up was 260 days; 1,786 events (0·34%) took place among the unexposed, and 702 (0·54%) in the exposed. The risk of major adverse cardiovascular events was higher in the exposed (adjusted HR [aHR]:1·34; 95%CI:1·22-1·46), with greater risk observed in those who were hospitalized (aHR:3·81; 95%CI:3·12-4·65) or required ICU admission (aHR:6·25; 95%CI:4·59-8·52) compared to the unexposed group. The fraction of cardiovascular events attributable to SARS-CoV-2 was 7·04% (95%CI:4·67-9·41%). Comparable results were observed for acute myocardial infarction. CONCLUSIONS: SARS-CoV-2 infection was associated with higher cardiovascular risk with graded increase across the acute COVID-19 severity, contributing to 7% of incident major adverse cardiovascular events. These findings suggest that long-term monitoring of cardiovascular risk is required in COVID-19 survivors.

Long-term complications, reoperations and survival following cardioverter-defibrillator implant.

OBJECTIVE: Implantable cardioverter-defibrillators (ICDs) reduce risk of death in select populations, but are also associated with harms. We aimed to characterise long-term complications and reoperation rate. METHODS: We assessed the rate, cumulative incidence and predictors of long-term reoperation and survival using a prospective, multicentre registry serving British Columbia in Canada, a universal single payer healthcare system with 4.5 million residents. 3410 patients (mean 63.3 years, 81.7% male) with new primary (n=1854) or secondary prevention (n=1556) ICD implant from 2003 to 2012 were followed for a median of 34 months (single chamber n=1069, dual chamber n=1905, biventricular n=436). Independent predictors of adverse outcomes were defined using Cox regression models. RESULTS: The overall reoperation rate was 12.0% per patient-year, and less for single vs dual vs biventricular ICDs (9.1% vs 12.5% vs 17.8% per patient-year, respectively). The Kaplan-Meier complication estimates (excluding generator end of life) at 1, 3 and 5 years were respectively: single chamber 10.2%, 16.2% and 21.6%; dual 11.7%, 19.1% and 27.4% and biventricular 15.9%, 22.2% and 24.7%. Cardiac resynchronisation therapy had the highest rate of early lead complications, but lower long-term need for upgrade. Device complexity, age and atrial fibrillation were key determinants of complications. Overall mortality at 1, 3 and 5 years was 5.4%, 17.4% and 32.7%, respectively. In younger patients, observed 5-year survival approached the expected survival in the general population (relative survival ratio=0.96 (0.90-0.98)). With increasing age, observed survival steadily declined relative to expected. CONCLUSIONS: In a prospective registry capturing all procedures, complication and reoperation rates following de novo ICD implantation were high. Shared decision making must carefully consider these factors.

Recent UK trends in the unequal burden of coronary heart disease.

INTRODUCTION: The burden of coronary heart disease (CHD) in the UK is substantial. However, recent trends and associated socioeconomic inequalities are not well studied. We aim to identify and analyse these trends stratified by age, gender and socioeconomic quintiles. METHODS: We quantified the CHD burden and analysed trends from 1999 to 2007 in all adults aged over 25 years resident in England. Data sources included deaths (from ONS), health surveys, and hospital admissions (from Hospital Episode Statistics), all using ICD9 and ICD10 coding. Socioeconomic inequalities were calculated in both absolute and relative terms. RESULTS: In 2007, the CHD burden comprised approximately 205 000 hospital admissions (acute and elective), including approximately 110 000 admissions with acute coronary syndrome. There were approximately 1.5 million CHD patients with chronic disease living in the community. Approximately 67 500 of these were admitted during 2007 for revascularisation. There were approximately 173 000 CHD patients living with heart failure, of whom some 14% required hospital admission during 2007. Between 1999 and 2007, age-specific hospital admission rates generally decreased by 20%-35%. Community prevalence decreased by 10%-20%. Strong socioeconomic gradients were apparent in all patient groups, persisting or worsening between 1999 and 2007. CONCLUSIONS: The burden of CHD is immense, costly and unequal. Hospital admissions attract more attention than the far more numerous patients living with chronic disease in the community. Population-based rates for hospital admissions and CHD prevalence have been declining by 3%-4% per annum. However, marked socioeconomic gradients have persisted or worsened-there is no room for complacency.

Heart failure and chronic obstructive pulmonary disease: diagnostic pitfalls and epidemiology.

Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are global epidemics incurring significant morbidity and mortality. The combination presents many diagnostic challenges. Clinical symptoms and signs frequently overlap. Evaluation of cardiac and pulmonary function is often problematic and occasionally misleading. Echocardiography and pulmonary function tests should be performed in every patient. Careful interpretation is required to avoid misdiagnosis and inappropriate treatment. Airflow obstruction, in particular, must be demonstrated when clinically euvolaemic. Very high and very low concentrations of natriuretic peptides have high positive and negative predictive values for diagnosing HF in those with both conditions. Intermediate values are less informative. Both conditions are systemic disorders with overlapping pathophysiological processes. In patients with HF, COPD is consistently an independent predictor of death and hospitalization. However, the impact on ischaemic and arrhythmic events is unknown. Greater collaboration is required between cardiologists and pulmonologists to better identify and manage concurrent HF and COPD. The resulting symptomatic and prognostic benefits outweigh those attainable by treating either condition alone.