Inappropriate use of clinical practices in Canada: a systematic review.

BACKGROUND: Inappropriate health care leads to negative patient experiences, poor health outcomes and inefficient use of resources. We aimed to conduct a systematic review of inappropriately used clinical practices in Canada. METHODS: We searched multiple bibliometric databases and grey literature to identify inappropriately used clinical practices in Canada between 2007 and 2021. Two team members independently screened citations, extracted data and assessed methodological quality. Findings were synthesized in 2 categories: diagnostics and therapeutics. We reported ranges of proportions of inappropriate use for all practices. Medians and interquartile ranges (IQRs), based on the percentage of patients not receiving recommended practices (underuse) or receiving practices not recommended (overuse), were calculated. All statistics are at the study summary level. RESULTS: We included 174 studies, representing 228 clinical practices and 28 900 762 patients. The median proportion of inappropriate care, as assessed in the studies, was 30.0% (IQR 12.0%-56.6%). Underuse (median 43.9%, IQR 23.8%-66.3%) was more frequent than overuse (median 13.6%, IQR 3.2%-30.7%). The most frequently investigated diagnostics were glycated hemoglobin (underused, range 18.0%-85.7%, n = 9) and thyroid-stimulating hormone (overused, range 3.0%-35.1%, n = 5). The most frequently investigated therapeutics were statin medications (underused, range 18.5%-71.0%, n = 6) and potentially inappropriate medications (overused, range 13.5%-97.3%, n = 9). INTERPRETATION: We have provided a summary of inappropriately used clinical practices in Canadian health care systems. Our findings can be used to support health care professionals and quality agencies to improve patient care and safety in Canada.

Enhanced capture of healthcare-related harms and injuries in the 11th revision of the International Classification of Diseases (ICD-11).

The World Health Organization (WHO) plans to submit the 11th revision of the International Classification of Diseases (ICD) to the World Health Assembly in 2018. The WHO is working toward a revised classification system that has an enhanced ability to capture health concepts in a manner that reflects current scientific evidence and that is compatible with contemporary information systems. In this paper, we present recommendations made to the WHO by the ICD revision's Quality and Safety Topic Advisory Group (Q&S TAG) for a new conceptual approach to capturing healthcare-related harms and injuries in ICD-coded data. The Q&S TAG has grouped causes of healthcare-related harm and injuries into four categories that relate to the source of the event: (a) medications and substances, (b) procedures, (c) devices and (d) other aspects of care. Under the proposed multiple coding approach, one of these sources of harm must be coded as part of a cluster of three codes to depict, respectively, a healthcare activity as a 'source' of harm, a 'mode or mechanism' of harm and a consequence of the event summarized by these codes (i.e. injury or harm). Use of this framework depends on the implementation of a new and potentially powerful code-clustering mechanism in ICD-11. This new framework for coding healthcare-related harm has great potential to improve the clinical detail of adverse event descriptions, and the overall quality of coded health data.

Review article: simulation: a means to address and improve patient safety.

PURPOSE: The purpose of this article is to review the role of technical and nontechnical skills in routine and crisis situations. We discuss the role of different simulation modalities in addressing these skills and competencies to enhance patient safety. PRINCIPAL FINDINGS: Human and system errors are a recognized cause of significant morbidity and mortality. Technical skills encompass the medical and procedural knowledge required for patient care, while nontechnical skills are behaviour-based and include task management, situation awareness, teamwork, decision-making, and leadership. Both sets of skills are required to improve patient safety. Healthcare simulation can provide an opportunity to practice technical and nontechnical skills in a patient-safe environment. More specifically, these skills are most required in dynamic and crisis situations, which may best be practiced in a simulated patient setting. CONCLUSION: Healthcare simulation is a valuable tool to improve patient safety. Simulation-based education can focus on the necessary technical and nontechnical skills to enhance patient safety. Simulation-based research can serve as a means to identify gaps in current practice, test different solutions, and show improved practice patterns by studying performance in a setting that does not compromise patient safety.

ICD-11 for quality and safety: overview of the WHO Quality and Safety Topic Advisory Group.

This paper outlines the approach that the WHO's Family of International Classifications (WHO-FIC) network is undertaking to create ICD-11. We also outline the more focused work of the Quality and Safety Topic Advisory Group, whose activities include the following: (i) cataloguing existing ICD-9 and ICD-10 quality and safety indicators; (ii) reviewing ICD morbidity coding rules for main condition, diagnosis timing, numbers of diagnosis fields and diagnosis clustering; (iii) substantial restructuring of the health-care related injury concepts coded in the ICD-10 chapters 19/20, (iv) mapping of ICD-11 quality and safety concepts to the information model of the WHO's International Classification for Patient Safety and the AHRQ Common Formats; (v) the review of vertical chapter content in all chapters of the ICD-11 beta version and (vi) downstream field testing of ICD-11 prior to its official 2015 release. The transition from ICD-10 to ICD-11 promises to produce an enhanced classification that will have better potential to capture important concepts relevant to measuring health system safety and quality-an important use case for the classification.

Measuring and reporting on quality in health care: a framework and road map for improving care.

Quality of care measurement and reporting at the provider, hospital, or health system level has become increasingly common in health systems around the world. Health system performance reports, whether they be confidentially distributed to the provider or made available to the public, are not only used as a stimulus for quality improvement, but can also be used to inform policy, apportion funding, or in rare cases, punish poorly performing providers. In this review, we outline several principles of quality of healthcare measurement and performance reporting, and describe a framework for optimal performance reporting that provides the greatest opportunity for the desired outcome-health system improvement. The quality reporting framework and roadmap that we present invokes opportunities for improving care in the domain of surgical oncology.

An exploratory study of neuroimaging, neurologic, and neuropsychological findings in veterans with traumatic brain injury and/or posttraumatic stress disorder.

Seventy-two veterans with traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), or both participated in assessment procedures to evaluate between group differences. Half the sample was randomly selected for magnetic resonance imaging (MRI). Neurologic examinations were conducted using the Neurologic Rating Scale (NRS). Neuropsychological measures included the Paced Auditory Serial Addition Test (PASAT), Rey Auditory Verbal Learning Test (RAVLT), Conners' Continuous Performance Test II (CPT II), and Halstead Impairment Index (HII) including the Booklet Category Test (BCT). Data were analyzed using linear regression. Participants with moderate/ severe TBI were significantly more likely to have trauma-related imaging findings, and more severe TBI predicted lower scores on the NRS. No significant between-group differences were identified on the HII, PASAT, RAVLT, or CPT II. TBI group performance was significantly better on the BCT. More severe TBI predicted abnormal imaging findings and lower NRS scores. Hypothesized between-group differences on neuropsychological measures were not supported.

Utility of the trauma symptom inventory for the assessment of post-traumatic stress symptoms in veterans with a history of psychological trauma and/or brain injury.

Correspondence of three core Trauma Symptom Inventory (TSI) posttraumatic stress disorder (PTSD) scales (Intrusive Experiences, Defensive Avoidance, and Anxious Arousal) and the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-IV) PTSD module were examined among 72 veterans with traumatic brain injury (TBI), PTSD, or both conditions. Subjects were classified into PTSD only, TBI only, or co-occurring PTSD and TBI groups based on TBI assessment and SCID-IV PTSD diagnosis. Linear regression was used to model TSI T-Scores as a function of group. Scores on all three scales significantly differed between the TBI and PTSD groups (PTSD only and co-occurring PTSD and TBI) in the expected direction. Study findings indicate that despite the potential overlap of symptoms between PTSD and TBI, the TSI appears to be a useful measure of trauma-related symptoms in veterans who may also have a TBI, particularly mild TBI. Limitations and areas for future research are discussed.

Inappropriateness of health care in Canada: a systematic review protocol.

BACKGROUND: There is increasing recognition in Canada and globally that a substantial proportion of health care delivered is inappropriate as evidenced by (1) harmful and/or ineffective practices being overused, (2) effective clinical practices being underused, and (3) other clinical practices being misused. Inappropriate health care leads to negative patient experiences, poor health outcomes, and inefficient use of scarce health care resources. The purpose of this study is to conduct a systematic review of inappropriate health care in Canada. Our specific objectives are to (1) systematically search and critically review published and grey literature for studies on inappropriate health care in Canada; (2) estimate the nature and magnitude of inappropriate health care in Canada and its provincial and territorial jurisdictions. METHODS: We will include all quantitative study designs reporting objective or subjective measurements of inappropriate health care in Canada over the last 10 years. We will search the following online databases: MEDLINE, Cochrane Central Register of Controlled Trials, EconLit, and ISI-Web of Knowledge, which contains Web of Science Core Collection-Citation Indexes, Science Citation Index Expanded, Conference Proceedings Citation Index-Science, and Conference Proceedings Citation Index-Social Science & Humanities. We will also search grey literature sources to identify provincial and national audits of inappropriate health care. Two authors will independently screen, assess data quality, and extract data for synthesis. Study findings will be synthesized narratively. We will organize our data into three care categorizations: preventive care, acute care, and chronic care. We will provide a compendium of inappropriate health care for each care category for Canada and each Canadian province and territory, where sufficient data exists, by calculating (1) overall medians of underuse, overuse, and misuse of clinical practices and (2) the range of medians of underuse, overuse, and misuse for each clinical practice investigated. DISCUSSION: This review will result in the first-ever evidence-based compendium of inappropriate health care in Canada. We will also develop detailed reports of inappropriate health care for each Canadian province and territory. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018093495.

CIHI's hospital standardized mortality ratio: friend or foe?

Hospital standardized mortality ratios (HSMRs) for acute care hospitals across Canada (excluding Quebec) were released in November 2007 by the Canadian Institute for Health Information. Since the release, some hospitals have undertaken in-depth analyses of their HSMRs to make sense of their results. In this issue of Healthcare Papers, Penfold et al. describe their experiences with the measure, pointing out shortcomings with using such a highly aggregated measure of hospital performance. We echo their concerns with the HSMR and highlight the caveats to interpreting this measure. However, we also point out that, despite its limitations, the HSMR stimulated the authors to probe, on behalf of their institution, factors that may have influenced mortality rates. This probing underlines the merit of HSMR reporting and the types of insights and knowledge that are likely to be gained if other institutions undertake similar evaluations.

Musculoskeletal fitness and weight gain in Canada.

BACKGROUND: Obesity is a growing health issue in Canada, and identifying the determinants of weight gain is important for the development of appropriate prevention strategies. PURPOSE: To quantify the association between musculoskeletal fitness (MSF) and subsequent weight gain and development of obesity. METHODS: The sample included 606 participants (20-69 yr; 291 men, 315 women) from the Physical Activity Longitudinal Study (PALS), a follow-up of participants from the 1981 Canadian Fitness Survey. Standardized assessments of height, weight, MSF (push-ups, sit-ups, grip strength, and trunk flexibility), and cardiorespiratory fitness were made at baseline (1981). Follow-up data on self-reported height and weight and body mass index (BMI) were collected by survey in 2002-2004. Logistic regression was used to predict obesity and weight gain of > or = 10 kg between 1981 and 2002-2004. RESULTS: During the 20-yr follow-up, the prevalence of obesity (BMI > or = 30 kg.m(-2)) increased from 3.1 to 15.2%, reflecting a mean weight gain of 7.4 kg (men: 6.7 kg; women: 8.1 kg). Further, independent of age, sex, baseline BMI, physical activity, cardiorespiratory fitness, smoking, alcohol consumption, and income, low MSF was associated with significantly higher odds of having gained at least 10 kg during follow-up (OR: 1.78, 95% CI: 1.14-2.79). CONCLUSIONS: The results indicate that MSF is a significant predictor of weight gain during a 20-yr period. Promoting participation in activities that enhance MSF may be beneficial in attenuating age-related weight gain and in preventing obesity among Canadians.

Physical activity, cardiorespiratory fitness and body mass index as predictors of substantial weight gain and obesity: the Canadian physical activity longitudinal study.

BACKGROUND: Obesity is a growing health issue in Canada and the identification of the determinants of obesity is important for the development of prevention strategies. The purpose of this investigation was to determine the relationships between physical activity, cardiorespiratory fitness, body mass index (BMI), and the development of future obesity. METHODS: The sample included 459 adults (18+ y; 223 men, 236 women) from the Canadian Physical Activity Longitudinal Study (PALS; 2002-04). Data on physical activity, smoking, alcohol consumption, BMI, and cardiorespiratory fitness (VO2max) were collected in 1981 and 1988. The mean BMI, physical activity, and VO2max were calculated across the 1981 and 1988 measures. Self-reported height and weight were collected in the 2002-04 survey, and participants were classified as overweight (BMI 25 to 29.9 kg/m2) or obese (BMI 230 kg/m2). Logistic regression was used to predict overweight, obesity or substantial weight gain (10 kg or more) in 2002-04, controlling for age, sex, smoking and alcohol use. RESULTS: Higher VO2max in 1981-88 was associated with lower odds of obesity in 2002-04 (OR = 0.87; 95% Cl: 0.76-0.99, p < 0.05), and higher BMI in 1981-88 was associated with higher odds of obesity in 2002-04 (1.84; 1.52-2.20, p < 0.0001). In women, higher VO2max (0.82; 0.72-0.93) resulted in lower odds of a 10 kg weight gain. CONCLUSIONS: The results indicate that cardiorespiratory fitness and previous BMI are important predictors of future weight gain and obesity, and should be incorporated in strategies to identify individuals at increased risk of obesity.

A comparison of head dynamic response and brain tissue stress and strain using accident reconstructions for concussion, concussion with persistent postconcussive symptoms, and subdural hematoma.

OBJECT: Concussions typically resolve within several days, but in a few cases the symptoms last for a month or longer and are termed persistent postconcussive symptoms (PPCS). These persisting symptoms may also be associated with more serious brain trauma similar to subdural hematoma (SDH). The objective of this study was to investigate the head dynamic and brain tissue responses of injury reconstructions resulting in concussion, PPCS, and SDH. METHODS: Reconstruction cases were obtained from sports medicine clinics and hospitals. All subjects received a direct blow to the head resulting in symptoms. Those symptoms that resolved in 9 days or fewer were defined as concussions (n = 3). Those with symptoms lasting longer than 18 months were defined as PPCS (n = 3), and 3 patients presented with SDHs (n = 3). A Hybrid III headform was used in reconstruction to obtain linear and rotational accelerations of the head. These dynamic response data were then input into the University College Dublin Brain Trauma Model to calculate maximum principal strain and von Mises stress. A Kruskal-Wallis test followed by Tukey post hoc tests were used to compare head dynamic and brain tissue responses between injury groups. Statistical significance was set at p < 0.05. RESULTS: A significant difference was identified for peak resultant linear and rotational acceleration between injury groups. Post hoc analyses revealed the SDH group had higher linear and rotational acceleration responses (316 g and 23,181 rad/sec(2), respectively) than the concussion group (149 g and 8111 rad/sec(2), respectively; p < 0.05). No significant differences were found between groups for either brain tissue measures of maximum principal strain or von Mises stress. CONCLUSIONS: The reconstruction of accidents resulting in a concussion with transient symptoms (low severity) and SDHs revealed a positive relationship between an increase in head dynamic response and the risk for more serious brain injury. This type of relationship was not found for brain tissue stress and strain results derived by finite element analysis. Future research should be undertaken using a larger sample size to confirm these initial findings. Understanding the relationship between the head dynamic and brain tissue response and the nature of the injury provides important information for developing strategies for injury prevention.

An overview of the methods and data used in the CCORT Canadian Cardiovascular Atlas project.

The Canadian Cardiovascular Atlas project, an initiative of the Canadian Cardiovascular Outcomes Research Team (CCORT), will be published as a series of 20 articles in future issues of the Canadian Journal of Cardiology. Through a wide range of data sources and analyses from a number of collaborators across Canada, the CCORT Atlas will provide a comprehensive overview of the current state of cardiac care and disease in Canada. Administrative data, clinical registries and community survey data will be analyzed at the provincial and health region levels. The purposes of this article are to 1) provide an overview of the data types and sources used in the Atlas project, 2) give a general description of the methods and analyses used to report Atlas data and 3) describe how Atlas maps were created and how they can be interpreted.

Trends in cardiovascular drug utilization and drug expenditures in Canada between 1996 and 2001.

BACKGROUND: There is increasing interest in studying trends in drug utilization because drug costs are the fastest growing sector of the health care system. OBJECTIVES: To focus on the trends in the utilization of and expenditures for cardiovascular drugs in Canada by drug class and by province over a six-year period. METHODS: Data from the IMS Health Canada CompuScript Audit database were used for this study from the period of February 1996 to January 2002. Patterns of drug utilization and expenditures in Canada were described for cardiovascular drug classes, individual agents within classes and by provincial analyses. RESULTS: Substantial increases in both the utilization of and the expenditures for cardiovascular medications have occurred in Canada over the last six years. Newer medication classes such as angiotensin converting enzyme inhibitors and statins now comprise the majority of cardiovascular drugs prescribed, along with continued high use of diuretics. Increases in some drug classes, such as angiotensin converting enzyme inhibitors, statins and beta-blockers, appear to be based on trial evidence or guidelines. However, marketing may play a larger role in the increases in use of angiotensin receptor blockers and specific drugs, such as amlodipine besylate and atorvastatin, because their increased utilization cannot be explained by major clinical trial evidence and/or practice guidelines. CONCLUSIONS: Changes in patterns of cardiovascular drug utilization and expenditures in Canada may be associated with clinical trial evidence, clinical practice guidelines, policy changes and/or marketing initiatives.

Introduction to the Canadian Cardiovascular Outcomes Research Team's (CCORT) Canadian Cardiovascular Atlas project.

The Canadian Cardiovascular Outcomes Research Team's (CCORT) Canadian Cardiovascular Atlas project was developed to provide Canadians with a national report on the state of cardiovascular health and health services in Canada. Written by a group of Canada's leading experts in cardiovascular outcomes research, the CCORT cardiac Atlas will cover a wide variety of topics ranging from cardiac risk factors and cardiac mortality rates to the treatment of patients with acute myocardial infarction and congestive heart failure and the outcomes of invasive cardiac procedures across Canada. Data in the Atlas will be presented at a national, provincial and health region level. The Atlas will be published as a series of 20 articles and chapters in future issues of The Canadian Journal of Cardiology and on CCORT's web site (www.ccort.ca). The journal version of the Atlas chapters will be written for a clinical audience and will include editorials written by invited experts, whereas the web-based version of each chapter will be written for a more general audience and will include additional supplemental information (for example, interactive colour maps and tables) that cannot be included in the journal version. Material from the Journal and the web will eventually be compiled into a book that will be distributed across Canada. This article serves as an introduction to the Atlas project and describes the rationale for and objectives of the CCORT national cardiac Atlas project.

Outcomes of acute myocardial infarction in Canada.

BACKGROUND: Little information is available on recent population-based trends in the outcomes of patients who have had an acute myocardial infarction (AMI) in Canada. METHODS: Data were analyzed from the Discharge Abstract Database and Hospital Morbidity Database of the Canadian Institute for Health Information. All new cases of AMI in Canada between fiscal 1997/98 and fiscal 1999/2000 of patients at least 20 years old were examined. Data were also analyzed from these databases for hospital readmissions for a second AMI, angina and congestive heart failure (CHF). RESULTS: There were 139,523 new AMI cases. The overall crude in-hospital AMI mortality rate in Canada was 12.3%. In-hospital mortality rate after an AMI was worse for women than for men in Canada (16.7% and 9.9%, respectively). The age- and sex-standardized in-hospital mortality rate varied from a low of 10.5% (95% CI 8.4% to 12.6%) in Prince Edward Island to a high of 13.1% (95% CI 12.8% to 13.5%) in Quebec. Among AMI survivors, 12.5% were readmitted within one year for angina, 7.7% for a second AMI and 7.5% for CHF. There were wide interregional differences in age- and sex-standardized mortality rates and one-year readmission rates. CONCLUSIONS: AMI is associated with a substantial acute mortality rate in Canada, especially in the elderly and female patients. Identifying the causes of interregional differences in patient outcomes should be a priority for future research.

Current and future concepts in helmet and sports injury prevention.

Since the introduction of head protection, a decrease in sports-related traumatic brain injuries has been reported. The incidence of concussive injury, however, has remained the same or on the rise. These trends suggest that current helmets and helmet standards are not effective in protecting against concussive injuries. This article presents a literature review that describes the discrepancy between how helmets are designed and tested and how concussions occur. Most helmet standards typically use a linear drop system and measure criterion such as head Injury criteria, Gadd Severity Index, and peak linear acceleration based on research involving severe traumatic brain injuries. Concussions in sports occur in a number of different ways that can be categorized into collision, falls, punches, and projectiles. Concussive injuries are linked to strains induced by rotational acceleration. Because helmet standards use a linear drop system simulating fall-type injury events, the majority of injury mechanisms are neglected. In response to the need for protection against concussion, helmet manufacturers have begun to innovate and design helmets using other injury criteria such as rotational acceleration and brain tissue distortion measures via finite-element analysis. In addition to these initiatives, research has been conducted to develop impact protocols that more closely reflect how concussions occur in sports. Future research involves a better understanding of how sports-related concussions occur and identifying variables that best describe them. These variables can be used to guide helmet innovation and helmet standards to improve the quality of helmet protection for concussive injury.

Role of endothelin-1 in the hyper-responsiveness to nitrovasodilators following acute NOS inhibition.

BACKGROUND AND PURPOSE: Acute NOS inhibition in humans and animals is associated with hypersensitivity to NO donors. The mechanisms underlying this phenomenon have not been fully elucidated. The purpose of the present study was to assess whether hypersensitivity to NOS-blockade is linked to endothelin-1 (ET-1) signalling. EXPERIMENTAL APPROACH: Sprague Dawley rats were instrumented with indwelling arterial and venous catheters for continuous assessments of haemodynamic parameters and drug delivery, respectively. Mesenteric arteries were isolated and tested for reactivity by wire myography. KEY RESULTS: NOS blockade with L-N(G)-nitroarginine methyl ester (L-NAME) caused a pronounced increase in arterial blood pressure (BP) (∼40 mmHg). In L-NAME-treated animals, the dose of sodium nitroprusside (SNP) required to cause a significant reduction in arterial BP was lower than in vehicle-treated rats (P < 0.001), and the magnitude of the reduction in BP was greater. Similar results were obtained with other NO mimetics, but not isoprenaline; moreover, decreasing the BP back to baseline levels with prazosin after L-NAME treatment did not attenuate the hyper-responsiveness to NO donors. The increased responsiveness to NO donors was abolished by pretreatment with the ET(A/B) receptor antagonist, PD145065, or the ET(A) receptor-specific antagonist ABT627. Ex vivo, L-NAME treatment potentiated the constriction induced by big endothelin-1 (bET-1), the precursor to active ET-1, but had no effect on the ET-1-mediated constriction. CONCLUSIONS AND IMPLICATIONS: These data suggest that the increased sensitivity to NO donors is mediated, at least in part, by ET-1 in vivo, and the mechanism may involve the conversion of bET-1 to ET-1.

Effect of alcohol consumption on biological markers associated with risk of coronary heart disease: systematic review and meta-analysis of interventional studies.

OBJECTIVE: To systematically review interventional studies of the effects of alcohol consumption on 21 biological markers associated with risk of coronary heart disease in adults without known cardiovascular disease. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Medline (1950 to October 2009) and Embase (1980 to October 2009) without limits. STUDY SELECTION: Two reviewers independently selected studies that examined adults without known cardiovascular disease and that compared fasting levels of specific biological markers associated with coronary heart disease after alcohol use with those after a period of no alcohol use (controls). 4690 articles were screened for eligibility, the full texts of 124 studies reviewed, and 63 relevant articles selected. RESULTS: Of 63 eligible studies, 44 on 13 biomarkers were meta-analysed in fixed or random effects models. Quality was assessed by sensitivity analysis of studies grouped by design. Analyses were stratified by type of beverage (wine, beer, spirits). Alcohol significantly increased levels of high density lipoprotein cholesterol (pooled mean difference 0.094 mmol/L, 95% confidence interval 0.064 to 0.123), apolipoprotein A1 (0.101 g/L, 0.073 to 0.129), and adiponectin (0.56 mg/L, 0.39 to 0.72). Alcohol showed a dose-response relation with high density lipoprotein cholesterol (test for trend P = 0.013). Alcohol decreased fibrinogen levels (-0.20 g/L, -0.29 to -0.11) but did not affect triglyceride levels. Results were similar for crossover and before and after studies, and across beverage types. CONCLUSIONS: Favourable changes in several cardiovascular biomarkers (higher levels of high density lipoprotein cholesterol and adiponectin and lower levels of fibrinogen) provide indirect pathophysiological support for a protective effect of moderate alcohol use on coronary heart disease.

Association of alcohol consumption with selected cardiovascular disease outcomes: a systematic review and meta-analysis.

OBJECTIVE: To conduct a comprehensive systematic review and meta-analysis of studies assessing the effect of alcohol consumption on multiple cardiovascular outcomes. DESIGN: Systematic review and meta-analysis. DATA SOURCES: A search of Medline (1950 through September 2009) and Embase (1980 through September 2009) supplemented by manual searches of bibliographies and conference proceedings. Inclusion criteria Prospective cohort studies on the association between alcohol consumption and overall mortality from cardiovascular disease, incidence of and mortality from coronary heart disease, and incidence of and mortality from stroke. Studies reviewed Of 4235 studies reviewed for eligibility, quality, and data extraction, 84 were included in the final analysis. RESULTS: The pooled adjusted relative risks for alcohol drinkers relative to non-drinkers in random effects models for the outcomes of interest were 0.75 (95% confidence interval 0.70 to 0.80) for cardiovascular disease mortality (21 studies), 0.71 (0.66 to 0.77) for incident coronary heart disease (29 studies), 0.75 (0.68 to 0.81) for coronary heart disease mortality (31 studies), 0.98 (0.91 to 1.06) for incident stroke (17 studies), and 1.06 (0.91 to 1.23) for stroke mortality (10 studies). Dose-response analysis revealed that the lowest risk of coronary heart disease mortality occurred with 1-2 drinks a day, but for stroke mortality it occurred with ≤1 drink per day. Secondary analysis of mortality from all causes showed lower risk for drinkers compared with non-drinkers (relative risk 0.87 (0.83 to 0.92)). CONCLUSIONS: Light to moderate alcohol consumption is associated with a reduced risk of multiple cardiovascular outcomes.