Sex Differences in In-Hospital Management and Outcomes of Patients With Acute Coronary Syndrome.

BACKGROUND: Coronary heart disease is a leading cause of mortality among women. Systematic evaluation of the quality of care and outcomes in women hospitalized for acute coronary syndrome (ACS), an acute manifestation of coronary heart disease, remains lacking in China. METHODS: The CCC-ACS project (Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome) is an ongoing nationwide registry of the American Heart Association and the Chinese Society of Cardiology. Using data from the CCC-ACS project, we evaluated sex differences in acute management, medical therapies for secondary prevention, and in-hospital mortality in 82 196 patients admitted for ACS at 192 hospitals in China from 2014 to 2018. RESULTS: Women with ACS were older than men (69.0 versus 61.1 years, P<0.001) and had more comorbidities. After multivariable adjustment, eligible women were less likely to receive evidence-based acute treatments for ACS than men, including early dual antiplatelet therapy, heparins during hospitalization, and reperfusion therapy for ST-segment-elevation myocardial infarction. With respect to strategies for secondary prevention, eligible women were less likely to receive dual antiplatelet therapy, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, statins at discharge, and smoking cessation and cardiac rehabilitation counseling during hospitalization. In-hospital mortality rate was higher in women than in men (2.60% versus 1.50%, P<0.001). The sex difference in in-hospital mortality was no longer observed in patients with ST-segment-elevation myocardial infarction (adjusted odds ratio, 1.18; 95% CI, 1.00 to 1.41; P=0.057) and non-ST-segment elevation ACS (adjusted odds ratio, 0.84; 95% CI, 0.66 to 1.06; P=0.147) after adjustment for clinical characteristics and acute treatments. CONCLUSIONS: Women hospitalized for ACS in China received acute treatments and strategies for secondary prevention less frequently than men. The observed sex differences in in-hospital mortality were mainly attributable to worse clinical profiles and fewer evidence-based acute treatments provided to women with ACS. Specially targeted quality improvement programs may be warranted to narrow sex-related disparities in quality of care and outcomes in patients with ACS. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02306616.

Cardiac rehabilitation for patients having cardiac surgery: a systematic review.

INTRODUCTION: Cardiac rehabilitation (CR) is recommended for all cardiac patients including patients after cardiac surgery. Since the effect of CR after cardiac surgery has not been well established yet, we conducted a systematic review on the effects of CR for patients after cardiac surgery compared to treatment as usual. EVIDENCE ACQUISITION: A systematic review of randomized clinical trials (RCTs), quasi-randomized and prospective observational studies in The Cochrane Library, PubMed/MEDLINE and EMBASE was undertaken until October 18th, 2017. Adults after any kind of cardiac surgery were included. Primary outcome was all-cause mortality, other outcomes were serious adverse events, health-related quality of life, work participation, functioning and costs/cost-effectiveness. Risk of bias was evaluated, and the quality of evidence was assessed by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria. EVIDENCE SYNTHESIS: Eighteen RCTs and 15 observational studies were included. Low risk of bias was only observed in one observational study. Meta-analysis of RCTs suggested no significant difference of CR compared to control on mortality (random-effects relative risk (RR) 0.93 (95% CI: 0.40-1.81), while observational studies suggested statistically significant beneficial effect associated with CR (random-effects RR=0.49, 95% CI: 0.35 - 0.68). CR did not significantly affect any of the other outcomes. Due to the limited data TSA could not be performed. CONCLUSIONS: The body of evidence does not allow us to reach any reliable conclusions about the effectiveness of CR following cardiac surgery. Future trials need to be conducted with low risks of bias and clearly defined outcomes.

Association of Neighborhood Socioeconomic Context With Participation in Cardiac Rehabilitation.

BACKGROUND: Cardiac rehabilitation (CR) is underutilized in the United States, with fewer than 20% of eligible patients participating in CR programs. Individual socioeconomic status is associated with CR utilization, but data regarding neighborhood characteristics and CR are sparse. We investigated the association of neighborhood socioeconomic context with CR participation in the SCCS (Southern Community Cohort Study). METHODS AND RESULTS: The SCCS is a prospective cohort study of 84 569 adults in the southeastern United States from 2002 to 2009, 52 117 of whom have Medicare or Medicaid claims. Using these data, we identified participants with hospitalizations for myocardial infarction, percutaneous coronary intervention, or coronary artery bypass surgery and ascertained their CR utilization. Neighborhood socioeconomic context was assessed using a neighborhood deprivation index derived from 11 census-tract level variables. We analyzed the association of CR utilization with neighborhood deprivation after adjusting for individual socioeconomic status. A total of 4096 SCCS participants (55% female, 57% black) with claims data were eligible for CR. CR utilization was low, with 340 subjects (8%) participating in CR programs. Study participants residing in the most deprived communities (highest quintile of neighborhood deprivation) were less than half as likely to initiate CR (odds ratio 0.42, 95% confidence interval, 0.27-0.66, P<0.001) as those in the lowest quintile. CR participation was inversely associated with all-cause mortality (hazard ratio 0.77, 95% confidence interval, 0.60-0.996, P<0.05). CONCLUSIONS: Lower neighborhood socioeconomic context was associated with decreased CR participation independent of individual socioeconomic status. These data invite research on interventions to increase CR access in deprived communities.

[Cost effectiveness of a theoretical cardiac rehabilitation program after myocardial infarction]. / Costo efectividad de un programa de rehabilitación cardiovascular modelo para personas post infarto agudo al miocardio en el Servicio de Salud Metropolitano Norte.

BACKGROUND: Secondary prevention programs are an essential part of comprehensive care of patients with cardiovascular disease (CVD), and its effectiveness in reducing morbidity or mortality has been proved. AIM: To determine the cost-effectiveness of a theoretical comprehensive cardiac rehabilitation (CCR) outpatient program after Myocardial Infarction, to be implemented in a Chilean Public Health System. MATERIAL AND METHODS: We designed a theoretical protocol of a CCR program based on recommendations of international guidelines, but adapted to local needs. A cost analysis was developed. Life years due to premature death were estimated with and without participation in CCR. The gained life-years and cost-effectiveness of the program were thus calculated. RESULTS: The annual cost of cardiac rehabilitation center is $ 64,407,065 Chilean pesos (CLP). The Incremental Cost Effectiveness Ratio (ICER) considering a reduction of late mortality of 25%, is $ 475,209.7 CLP per year of life gained. Since this figure is lower than one unit of per capita gross domestic product, the intervention is considered very cost-effective. CONCLUSIONS: A comprehensive cardiac rehabilitation program after myocardial infarction is very cost-effective in the context of its implementation in a public health service.

Costo efectividad de un programa de rehabilitación cardiovascular modelo para personas post infarto agudo al miocardio en el Servicio de Salud Metropolitano Norte / Cost effectiveness of a theoretical cardiac rehabilitation program after myocardial infarction

Background: Secondary prevention programs are an essential part of comprehensive care of patients with cardiovascular disease (CVD), and its effectiveness in reducing morbidity or mortality has been proved. Aim: To determine the cost-effectiveness of a theoretical comprehensive cardiac rehabilitation (CCR) outpatient program after Myocardial Infarction, to be implemented in a Chilean Public Health System. Material and Methods: We designed a theoretical protocol of a CCR program based on recommendations of international guidelines, but adapted to local needs. A cost analysis was developed. Life years due to premature death were estimated with and without participation in CCR. The gained life-years and cost-effectiveness of the program were thus calculated. Results: The annual cost of cardiac rehabilitation center is $ 64,407,065 Chilean pesos (CLP). The Incremental Cost Effectiveness Ratio (ICER) considering a reduction of late mortality of 25%, is $ 475,209.7 CLP per year of life gained. Since this figure is lower than one unit of per capita gross domestic product, the intervention is considered very cost-effective. Conclusions: A comprehensive cardiac rehabilitation program after myocardial infarction is very cost-effective in the context of its implementation in a public health service.