Ambulatory Cardiology or General Internal Medicine Assessment Prior to Scheduled Major Vascular Surgery is Associated with Improved Outcomes.

OBJECTIVE: To characterize the association between ambulatory cardiology or general internal medicine (GIM) assessment prior to surgery and outcomes following scheduled major vascular surgery. BACKGROUND: Cardiovascular risk assessment and management prior to high-risk surgery remains an evolving area of care. METHODS: This is population-based retrospective cohort study of all adults who underwent scheduled major vascular surgery in Ontario, Canada, April 1, 2004-March 31, 2019. Patients who had an ambulatory cardiology and/or GIM assessment within 6 months prior to surgery were compared to those who did not. The primary outcome was 30-day mortality. Secondary outcomes included: composite of 30-day mortality, myocardial infarction or stroke; 30-day cardiovascular death; 1-year mortality; composite of 1-year mortality, myocardial infarction or stroke; and 1-year cardiovascular death. Cox proportional hazard regression using inverse probability of treatment weighting (IPTW) was used to mitigate confounding by indication. RESULTS: Among 50,228 patients, 20,484 (40.8%) underwent an ambulatory assessment prior to surgery: 11,074 (54.1%) with cardiology, 8,071 (39.4%) with GIM and 1,339 (6.5%) with both. Compared to patients who did not, those who underwent an assessment had a higher Revised Cardiac Risk Index (N with Index over 2= 4,989[24.4%] vs. 4,587[15.4%], P<0.001) and more frequent pre-operative cardiac testing (N=7,772[37.9%] vs. 6,113[20.6%], P<0.001) but, lower 30-day mortality (N=551[2.7%] vs. 970[3.3%], P<0.001). After application of IPTW, cardiology or GIM assessment prior to surgery remained associated with a lower 30-day mortality (weighted Hazard Ratio [95%CI] = 0.73 [0.65-0.82]) and a lower rate of all secondary outcomes. CONCLUSIONS: Major vascular surgery patients assessed by a cardiology or GIM physician prior to surgery have better outcomes than those who are not. Further research is needed to better understand potential mechanisms of benefit.

Diuretic dose and long-term outcomes in elderly patients with heart failure after hospitalization.

BACKGROUND: The array of outcomes according to longitudinal furosemide doses in heart failure (HF) have not been evaluated. We examined the relationship of dynamic furosemide dose with mortality and hospitalizations for cardiovascular disease and renal dysfunction. METHODS: Among elderly patients with HF (>or=65 years) newly discharged from hospital, dynamic furosemide exposure was determined by examining dose fluctuations up to 5 years of follow-up using the Ontario Drug Benefit pharmacare database. Dynamic furosemide exposures were classified as low dose (LD; 1-59 mg/d), medium dose (MD; 60-119 mg/d), or high dose (HD; >or=120 mg/d). Outcomes were assessed by modeling furosemide exposure as a time-dependent covariate. RESULTS: Among 4,406 patients (78.4 +/- 7.0 years; 50.5% male), 46% changed furosemide dose categories within 1 year, and 63% changed dose categories over the follow-up period. High-dose furosemide patients were younger, were mostly male, and exhibited more ischemic or valvular disease, diabetes, atrial fibrillation, hypotension, hyponatremia, and higher baseline creatinine than LD. Compared with LD, MD exposure was associated with increased mortality with adjusted hazard ratio 1.96 (95% CI 1.79-2.15), whereas HD exposure conferred greater mortality risk with hazard ratio 3.00 (95% CI 2.72-3.31) after multiple covariate adjustment (both P < .001). Adjusted risks of hospitalization for HF (MD: 1.24 [95% CI 1.12-1.38] and HD: 1.43 [95% CI 1.26-1.63]), renal dysfunction (MD: 1.56 [95% CI 1.38-1.76] and HD: 2.16 [95% CI 1.88-2.49]), and arrhythmias (MD: 1.15 [95% CI 1.03-1.30] and HD: 1.45 [95% CI 1.27-1.66]) were also higher with increasing furosemide exposure. CONCLUSION: Exposure to higher furosemide doses is associated with worsened outcomes and is broadly predictive of death and morbidity.

Comparison of Readmission and Death Among Patients With Cardiac Disease in Northern vs Southern Ontario.

BACKGROUND: Geographic factors may influence cardiovascular disease outcomes in Canada. Circulatory diseases are a major reason for higher population mortality rates in Northern Ontario, but it is unknown if hospitalized patients with cardiovascular disease experience differential outcomes compared with those in the South. METHODS: We examined 30-day and 1-year mortality and readmissions for patients hospitalized with acute myocardial infarction (AMI), heart failure (HF), atrial fibrillation (AF), or stroke in Northern compared with Southern Ontario, using the Canadian Institute for Health Information Discharge Abstract Database (2005-2016). Northern patients were defined as those residing and hospitalized in the Northwest or Northeast Local Health Integration Network regions. We used multiple Cox proportional hazards regression analysis for time-to-first event and Prentice-Williams-Peterson method to evaluate repeat and multiply admitted patients. RESULTS: A total of 47,745 Northern and 465,353 Southern patients hospitalized with AMI (n = 182,158), HF (n = 130,770), AF (n = 72,326), or stroke (n = 127,844) were studied. Rates of first readmission were higher among Northern patients for AMI (adjusted hazard ratio [HR], 1.32), HF (HR, 1.16), AF (HR, 1.21), and stroke (HR, 1.27) compared with Southern patients (all P < 0.001). Repeat readmission rates among Northern patients for AMI (HR, 1.23), HF (HR, 1.13), AF (HR, 1.18), and stroke (HR, 1.22) were also increased (all P < 0.001 vs Southern). Thirty-day mortality did not differ significantly between Northern and Southern patients. CONCLUSIONS: Readmissions were increased in those residing and hospitalized in the North. To reduce readmissions in the North, the quality of postacute transitional care should be examined further.

Association of Atrial Fibrillation and Oral Anticoagulant Use With Perioperative Outcomes After Major Noncardiac Surgery.

BACKGROUND: We examined the association of atrial fibrillation (AF) and oral anticoagulant use with perioperative death and bleeding among patients undergoing major noncardiac surgery. METHODS AND RESULTS: A population-based study of patients aged 66 years and older who underwent elective (n=87 257) or urgent (n=35 930) noncardiac surgery in Ontario, Canada (April 2012 to March 2015) was performed. Outcomes were compared between AF groups using inverse probability of treatment weighting using the propensity score. Of 4612 urgent surgical patients with AF, treatments before surgery included warfarin (n=1619), a direct oral anticoagulant (DOAC) (n=729), and no anticoagulation (n=2264). After urgent surgery, the death rate within 30 days was significantly higher in patients with AF compared with patients with no AF (hazard ratio [HR], 1.28; 95% confidence interval [CI], 1.12-1.45). In contrast, among 4769 elective surgical patients with AF treated with warfarin (n=1453), a DOAC (n=1165), or no anticoagulation (n=2151), prior AF was not associated with higher mortality. Comparing patients with AF who were or were not anticoagulated, there was no difference in 30-day mortality after urgent (HR, 0.95; 95% CI, 0.79-1.14) or elective (HR, 0.65; 95% CI, 0.38-1.09) surgery. There was no difference in 30-day mortality between patients with AF treated with a DOAC or warfarin after urgent (HR, 0.91; 95% CI, 0.70-1.18) or elective (HR, 1.64; 95% CI, 0.77-3.53) surgery. Bleeding and thromboembolic rates did not differ significantly among patients with AF prescribed a DOAC or warfarin. CONCLUSIONS: Prior AF was associated with 30-day mortality among patients undergoing urgent surgery. In patients with AF, neither the preoperative use of oral anticoagulants, nor the type of agent (either a DOAC or warfarin) were associated with the rate of 30-day mortality.

Sex differences in the management and outcomes of Ontario patients with cardiogenic shock complicating acute myocardial infarction.

BACKGROUND: Sex differences in the management of acute myocardial infarction (AMI) patients with cardiogenic shock (CS) have not been well studied. METHODS: We examined mortality and revascularization rates of 9750 patients with CS between 1992 and 2008 in the Ontario Myocardial Infarction Database. Men and women were compared in the entire cohort and in subgroups divided by age (aged < 75 years vs aged ≥ 75 years) and revascularization availability at presenting hospital. Logistic regression was used to determine the adjusted effect of sex on mortality and to determine predictors of revascularization. RESULTS: The incidence of CS was higher in women (3.7% of female vs 2.7% of male AMI patients; P < 0.001). Women with CS were older than men (mean age: 75.5 vs 71.1 years; P < 0.001) and less likely to present to revascularization-capable sites (16% vs 19.2%; P < 0.001). Unadjusted 1-year mortality rates were higher in women (80.3% vs 75.4%; P < 0.001). Women were less likely to be revascularized (12.6% vs 17.6%; P < 0.001) and less likely to be transferred when they presented to nonrevascularization sites (11.3% vs 14.2%; P < 0.001). The strongest predictor of revascularization was presentation to a revascularization-capable site (odds ratio, 17.69; P < 0.001). After regression adjustment, there were no significant differences in mortality or revascularization between the sexes. CONCLUSION: Women with CS are older than men with CS and are less likely to present to revascularization-capable sites. This accounts for the lower unadjusted revascularization rates among women compared with men. However, there are no significant sex-based differences in adjusted mortality rates.

Improving prognosis estimation in patients with heart failure and the cardiorenal syndrome.

The coexistence of heart failure and renal dysfunction constitutes the "cardiorenal syndrome" which is increasingly recognized as a marker of poor prognosis. Patients with cardiorenal dysfunction constitute a large and heterogeneous group where individuals can have markedly different outcomes and disease courses. Thus, the determination of prognosis in this high risk group of patients may pose challenges for clinicians and for researchers alike. In this paper, we discuss the cardiorenal syndrome as it pertains to the patient with heart failure and considerations for further refining prognosis and outcomes in patients with heart failure and renal dysfunction. Conventional assessments of left ventricular function, renal clearance, and functional status can be complemented with identification of coexistent comorbidities, medication needs, microalbuminuria, anemia, biomarker levels, and pulmonary pressures to derive additional prognostic data that can aid management and provide future research directions for this challenging patient group.

Bundle branch block patterns and long-term outcomes in heart failure.

BACKGROUND: The prognostic value of left and right bundle branch blocks (LBBB and RBBB) in hospitalized heart failure (HF) patients is unclear. We sought to determine the prognostic value of bundle branch blocks in patients hospitalized with heart failure. METHODS: The associations of BBB type with death, HF hospitalizations or cardiovascular hospitalizations over a five year follow-up were examined within the EFFECT study of hospitalized patients fulfilling the Framingham criteria for acute heart failure. Multinomial logistic regression was used to determine associations with BBB type, and survival was assessed using multiple Cox regression analysis. RESULTS: Among 9082 patients (16.3% with LBBB; 7.2% with RBBB), LBBB was independently associated with lower systolic pressure, tachycardia and hyponatremia (odds ratio [OR] of 0.93 per 10 mmHg, 1.04 per 10 beats/min, and 0.84 per 10 mmol/L, respectively). Men and diabetics (OR of 2.11 and 1.35, respectively) had greater odds of RBBB. After multiple covariate adjustment (n=7319), patients with LBBB had increased risk of HF hospitalization with adjusted hazard ratio [HR] of 1.32 (95% CI; 1.20-1.46, p<0.001) and cardiovascular hospitalization with HR of 1.13 (95% CI; 1.04-1.23, p=0.003). LBBB was associated with increased mortality with adjusted HR of 1.10 (95% CI, 1.02-1.18; p=0.011) in 7910 analysed patients. RBBB did not predict significantly increased risk of either death or hospitalization. CONCLUSIONS: Heart failure patients presenting with LBBB had greater clinical severity of heart failure at presentation and greater risk of death and hospitalization for heart failure or cardiovascular disease than those without BBB. In contrast, RBBB did not independently predict worse outcomes.

Temporal trends in cardiogenic shock treatment and outcomes among ontario patients with myocardial infarction between 1992 and 2008.

BACKGROUND: Clinical trials have demonstrated that emergent revascularization improves survival of patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). However, rates of uptake and impact on outcomes remain uncertain. METHODS AND RESULTS: We identified 9750 patients (3.1%) with CS among 311 183 AMI patients in the Ontario Myocardial Infarction Database between 1992 and 2008 (55.8% men; mean age, 73 years). CS incidence, mortality, revascularization, and transfers from nonrevascularization sites were studied over 3 periods: period 1, before the 1999 American College of Cardiology/American Heart Association AMI guidelines recommending urgent revascularization for patients <75 years; period 2 (1999 to 2004); and period 3, after 2004 guideline revisions suggesting revascularization for patients ≥75 years. Compared with period 1, period 3 was marked by significantly lower CS incidence (3.4% versus 2.6%), increase in transfers from nonrevascularization sites (10.6% versus 23.9%), and adjusted 1-year mortality rates (81.9% versus 71.5%; all comparisons statistically significant). Admission to nonrevascularization sites was associated with lower revascularization rates (8.6% versus 46.6%, P<0.001) and higher adjusted 1-year mortality rates (78.8% [95% confidence interval, 77.4 to 80.2] versus 71.9% [95% confidence interval, 69.8 to 74.1]). Patients ≥75 years of age were less likely to be revascularized or transferred. The greatest increase in transfers from nonrevascularization sites occurred between periods 1 and 2 for patients <75 years (16.5% to 31.4%; P<0.001) and between periods 2 and 3 for patients ≥75 years (6.7% to 12.8%; P<0.001). CONCLUSIONS: Publication of American College of Cardiology/American Heart Association guidelines was followed by increased revascularization and transfer rates, along with declining mortality rates among Ontario AMI patients with CS. These results highlight possibilities for further improvement, particularly among patients eligible for transfer from nonrevascularization sites.

Perception of asthma as a factor in career choice among young adults with asthma.

BACKGROUND/AIM: Asthma is a common chronic condition that can be aggravated by workplace exposures. Young adults with asthma should know how their future occupation might affect their asthma, and potentially, their quality of life. The aim of the present study was to assess the awareness of young adults to occupational risks for asthma and high-risk occupations, as well as their perception of the role of asthma in career choice. METHODS: Young adults 16 to 22 years of age with reported physician-diagnosed asthma were recruited to complete a questionnaire eliciting information regarding asthma control, career choice and awareness of occupational exposure risks. RESULTS: A small majority of the study cohort (56.4%) could identify occupations that cause or exacerbate asthma, and 34.7% indicated that asthma was an important factor in their career plans. Family physicians were most responsible for asthma management (80.2%), but young adults were more likely to discuss asthma and career plans with their parents (43.6%) or friends (29.7%) than with their family physician (13.9%; P<0.001). CONCLUSION: Young adults with asthma have suboptimal awareness of potential work-related asthma risks. Family physicians most commonly provide asthma care to these young adults. However, few young adults are talking to their family physicians about career choices and asthma. This observation represents an area of asthma care that needs to be explored in young adults with asthma.

The contribution of familial and heritable risks in heart failure.

PURPOSE OF REVIEW: The purpose of this review is to summarize the recent literature regarding the familial heritability of heart failure and to discuss the possible mechanisms through which this risk is mediated. RECENT FINDINGS: Data from the Framingham Heart Study recently showed that the parental occurrence of heart failure increases the risk of heart failure in offspring. Although the mechanisms mediating this increased risk are not elucidated, heritable risks of heart failure may result from genes affecting the cardiac or vascular systems. Alternatively, familial risk may be mediated partly through the inheritance of recognized or as yet unidentified risk factors for heart failure. Heritable components or genetic loci for quantitative traits contribute to the development of hypertension, coronary artery disease, cardiomyopathies, valvular heart disease, and metabolic conditions, which collectively increase the risk of heart failure. SUMMARY: A careful assessment of the family history of heart failure and associated risk factors may identify treatable targets that can potentially reduce the likelihood of developing heart failure, and can assist in the implementation of preventive strategies for risk populations with stages A and B heart failure.