Is 'Cardiopulmonary' the New 'Cardiometabolic'? Making a Case for Systems Change in COPD.

Chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) have a syndemic relationship with shared risk factors and complex interplay between genetic, environmental, socioeconomic, and pathophysiological mechanisms. CVD is among the most common comorbidities in patients with COPD and vice versa. Patients with COPD, irrespective of their disease severity, are at increased risk of CVD morbidity and mortality, driven in part by COPD exacerbations. Despite these known interrelationships, CVD is underestimated and undertreated in patients with COPD. Similarly, COPD is an independent risk-enhancing factor for adverse cardiovascular (CV) events, yet it is not incorporated into current CV risk assessment tools, leading to under-recognition and undertreatment. There is a pressing need for systems change in COPD management to move beyond symptom control towards a comprehensive cardiopulmonary disease paradigm with proactive prevention of exacerbations and adverse cardiopulmonary outcomes and mortality. However, there is a dearth of evidence defining optimal cardiopulmonary care pathways. Fortunately, there is a precedent to support systems-level change in the field of diabetes, which evolved from glycemic control to comprehensive multi-organ risk assessment and management. Key elements included integrated multidisciplinary care, intensive risk factor management, coordination between primary and specialist care, care pathways and protocols, education and self management, and disease-modifying therapies. This commentary article draws parallels between the cardiometabolic and cardiopulmonary paradigms and makes a case for systems change towards multidisciplinary, integrated cardiopulmonary care, using the evolution in diabetes care as a potential framework.

A Research Agenda to Improve Outcomes in Patients with Chronic Obstructive Pulmonary Disease and Cardiovascular Disease: An Official American Thoracic Society Research Statement.

Background: Individuals with chronic obstructive pulmonary disease (COPD) are often at risk for or have comorbid cardiovascular disease and are likely to die of cardiovascular-related causes. Objectives: To prioritize a list of research topics related to the diagnosis and management of patients with COPD and comorbid cardiovascular diseases (heart failure, atherosclerotic vascular disease, and atrial fibrillation) by summarizing existing evidence and using consensus-based methods. Methods: A literature search was performed. References were reviewed by committee co-chairs. An international, multidisciplinary committee, including a patient advocate, met virtually to review evidence and identify research topics. A modified Delphi approach was used to prioritize topics in real time on the basis of their potential for advancing the field. Results: Gaps spanned the translational science spectrum from basic science to implementation: 1) disease mechanisms; 2) epidemiology; 3) subphenotyping; 4) diagnosis and management; 5) clinical trials; 6) care delivery; 7) medication access, adherence, and side effects; 8) risk factor mitigation; 9) cardiac and pulmonary rehabilitation; and 10) health equity. Seventeen experts participated, and quorum was achieved for all votes (>80%). Of 17 topics, ≥70% agreement was achieved for 12 topics after two rounds of voting. The range of summative Likert scores was -15 to 25. The highest priority was "Conduct pragmatic clinical trials with patient-centered outcomes that collect both pulmonary and cardiac data elements." Health equity was identified as an important topic that should be embedded within all research. Conclusions: We propose a prioritized research agenda with the purpose of stimulating high-impact research that will hopefully improve outcomes among people with COPD and cardiovascular disease.

Long-term outcomes among out-of-hospital cardiac arrest survivors with reversible versus non-reversible causes.

BACKGROUND: Reversible cause of out-of-hospital cardiac arrest (OHCA) is vaguely defined in international guidelines as an identifiable transient or potentially correctable condition. Moreover, studies evaluating long-term outcomes of patients experiencing OHCA due to reversible and non-reversible causes are lacking. We aimed to determine differences in long-term outcomes in OHCA-survivors according to different etiology. METHODS: From the British Columbia Cardiac Arrest registry, adults with non-traumatic OHCA (2009-2016) surviving to hospital discharge were identified. Patients were categorized by OHCA etiology combining reversibility and underlying ischemic etiology. The primary outcome was a composite of all-cause mortality, recurrent OHCA, or re-hospitalization for sudden cardiac arrest or ventricular arrhythmias. Using the Kaplan-Meier method and multivariable Cox regression models, we compared the risk of the composite outcome according to different OHCA-etiology. RESULTS: Of 1,325 OHCA hospital-discharge survivors (median age 62.8, 77.9% male), 431 (32.5%) had reversible ischemic, 415 (31.3%) non-reversible ischemic, 99 (7.5%) reversible non-ischemic and 380 (28.7%) non-reversible non-ischemic etiology. At 3 years post-discharge, Kaplan-Meier event-free rate was highest in patients with a reversible ischemic etiology (91%, 95% CI 87-94%), and lowest in those with a reversible non-ischemic etiology (62%, 95% CI 51-72%). In multivariate analyses, compared to non-reversible non-ischemic cause, reversible ischemic cause was associated with a significantly lower hazard ratio (HR) (0.52, 95% confidence interval [CI], 0.33-0.81), reversible non-ischemic cause with a significantly higher HR (1.53, 95% CI, 1.03-2.32) and non-reversible ischemic cause with a non-significant HR 0.92 (95% CI, 0.64-1.33) for the composite outcome. CONCLUSIONS: The presence of a reversible ischemic cause is associated with long-term OHCA-outcomes.

The Diagnostic Utility of Holter Monitoring in Catecholaminergic Polymorphic Ventricular Tachycardia.

BACKGROUND: Holter monitoring may raise suspicion of an underlying catecholaminergic polymorphic ventricular tachycardia (CPVT) diagnosis. Although not a primary investigation for CPVT, Holter monitoring is ubiquitously used as a diagnostic tool in the heart rhythm clinic. OBJECTIVES: The objective of this study was to explore Holter monitoring in CPVT diagnosis. METHODS: This retrospective cohort study analyzed off-therapy Holter monitoring from 13 ryanodine receptor 2-positive CPVT and 34 healthy patients from the Canadian Hearts in Rhythm Organization national registry. Using the Edwards method, the ratio of ambient-maximum heart rate during Holter monitoring was correlated with exertion level to separate premature ventricular contractions (PVCs) during periods of adrenergic and nonadrenergic stress. A receiver operating characteristic curve analysis determined the optimal threshold for isolating CPVT-induced PVCs during adrenergic states. RESULTS: PVC burden differed between groups (P = 0.001) but was within population norm, suggesting ambient PVCs are uncommon in CPVT. CPVT patients had higher PVC counts than healthy controls (P = 0.002), with a different distribution based on adrenergic state. The optimal threshold for separating PVCs into periods of adrenergic and nonadrenergic stress in CPVT patients was 76% of the maximum heart rate during the monitoring period. Compared with healthy controls, CPVT patients had a higher PVC count, limited to periods of adrenergic stress, defined by >76% maximum heart rate threshold (P = 0.002; area under the receiver operating characteristic curve: 0.84). Below this threshold, there was no significant PVC difference (P = 0.604). CONCLUSIONS: Holter monitor PVC counts alone are inadequate for CPVT diagnosis, owing to the adrenergic nature of the disease. Quantifying PVC prevalence at a heart rate threshold >76% identified CPVT with moderate sensitivity (69%) and high specificity (94%).

Distinguishing Primary Prevention From Secondary Prevention Implantable Cardioverter Defibrillators Using Administrative Health and Cardiac Device Registry Data.

Background: Administrative health data and cardiac device registries can be used to empirically evaluate outcomes and costs after implantable cardioverter defibrillator (ICD) implantation. These datasets often have incomplete information on the indication for implantation (primary vs secondary prevention of sudden cardiac death). Methods: We used 16 years of population-based cardiac device registry and administrative health data from British Columbia, Canada, to derive and internally validate statistical models that predict the likely indication for ICD implantation. We used chart review data as the reference standard for ICD indication in the Cardiac Device Registry database (CDR; 2004-2012 [Cardiac Services BC]) and nonmissing indication as the reference standard in the Heart Information System registry database (HEARTis; 2013-2019 [Cardiac Services BC]). We created 3 logistic regression prediction models in each database: one using only registry data, one using only administrative data, and one using both registry and administrative data. We assessed the predictive performance of each model using standard metrics after optimism correction with 200 bootstrap resamples. Results: Models that used registry data alone demonstrated excellent predictive performance (sensitivity ≥ 89%; specificity ≥ 87%). Models that used only administrative data performed well (sensitivity ≥ 84%; specificity ≥ 70%). Models that used both registry and administrative data showed modest gains over those that used registry data alone (sensitivity ≥ 90%; specificity ≥ 89%). Conclusions: Administrative health data and cardiac device registry data can distinguish secondary prevention ICDs from primary prevention ICDs with acceptable sensitivity and specificity. Imputation of missing ICD indication might make these data resources more useful for research and health system monitoring.

Contexte: Les données administratives de santé et les registres des dispositifs cardiaques peuvent être utilisés pour évaluer de manière empirique les résultats et les coûts associés aux défibrillateurs cardioverteurs implantables (DCI). Or, ces ensembles de données comportent souvent des informations incomplètes sur l'indication de l'implant (prévention primaire ou secondaire de la mort subite d'origine cardiaque). Méthodologie: Nous avons analysé 16 ans de données provenant du registre populationnel des dispositifs cardiaques et des données administratives de santé de la Colombie-Britannique, au Canada, pour alimenter des modèles statistiques prédisant l'indication probable de l'implant d'un DCI et pour effectuer une validation interne de ces modèles. Nous avons utilisé les données de la revue des dossiers médicaux comme norme de référence de l'indication des DCI dans le registre des dispositifs cardiaques (Cardiac Device Registry; 2004-2012 [Cardiac Services BC]) et les indications consignées comme norme de référence dans la banque de données Heart Information System (HEARTis; 2013-2019 [Cardiac Services BC]). Nous avons créé 3 modèles prédictifs par régression logistique dans chaque base de données : une utilisant seulement les données du registre, une utilisant seulement les données administratives et une utilisant les deux types de données. Nous avons évalué la performance de chaque modèle en matière de prédiction à l'aide de mesures normalisées, après correction pour l'optimisme de l'erreur à l'aide de 200 nouveaux échantillons obtenus par la méthode bootstrap. Résultats: Les modèles utilisant seulement les données du registre avaient une excellente performance prédictive (sensibilité ≥ 89 %; spécificité ≥ 87 %). Les modèles qui n'utilisaient que les données administratives donnaient quant à eux de bons résultats (sensibilité ≥ 84 %; spécificité ≥ 70 %). Enfin, les modèles qui utilisaient les données administratives et les données du registre ont donné des gains modestes par rapport aux modèles qui n'utilisaient que les données du registre (sensibilité ≥ 90 %; spécificité ≥ 89 %). Conclusions: Les données administratives de santé et les données des registres de dispositifs cardiaques permettent de distinguer les DCI implantés en prévention secondaire des DCI implantés en prévention primaire avec une sensibilité et une spécificité acceptables. Dans les cas où elle est absente, l'attribution d'une indication pour les DCI pourrait donc rendre ces ressources plus utiles pour la recherche et la surveillance du système de santé.

Qualitative Analysis of Patient Decisional Needs for Medications to Treat Heart Failure.

BACKGROUND: The development of tools to support shared decision-making should be informed by patients' decisional needs and treatment preferences, which are largely unknown for heart failure (HF) with reduced ejection fraction (HFrEF) pharmacotherapy decisions. We aimed to identify patients' decisional needs when considering HFrEF medication options. METHODS: This was a qualitative study using semi-structured interviews. We recruited patients with HFrEF from 2 Canadian ambulatory HF clinics and clinicians from Canadian HF guideline panels, HF clinics, and Canadian HF Society membership. We identified themes through inductive thematic analysis. RESULTS: Participants included 15 patients and 12 clinicians. Six themes and associated subthemes emerged related to HFrEF pharmacotherapy decision-making: (1) patient decisional needs included lack of awareness of a choice or options, difficult decision timing and stage, information overload, and inadequate motivation, support and resources; (2) patients' decisional conflict varied substantially, driven by unclear trade-offs; (3) treatment attribute preferences-patients focused on both benefits and downsides of treatment, whereas clinicians centered discussion on benefits; (4) quality of life-patients' definition of quality of life depended on pre-HF activity, though most patients demonstrated adaptability in adjusting their daily activities to manage HF; (5) shared decision-making process-clinicians' described a process more akin to informed consent; (6) decision support-multimedia decision aids, virtual appointments, and primary-care comanagement emerged as potential enablers of shared decision-making. CONCLUSIONS: Patients with HFrEF have several decisional needs, which are consistent with those that may respond to decision aids. These findings can inform the development of HFrEF pharmacotherapy decision aids to address these decisional needs and facilitate shared decision-making.

Impact of the method of calculating 30-day readmission rate after hospitalization for heart failure. Data from the VancOuver CoastAL Acute Heart Failure (VOCAL-AHF) registry.

BACKGROUND: Thirty-day readmission rate after heart failure (HF) hospitalization is widely used to evaluate healthcare quality. Methodology may substantially influence estimated rates. We assessed the impact of different definitions on HF and all-cause readmission rates. METHODS: Readmission rates were examined in 1835 patients discharged following HF hospitalization using 64 unique definitions derived from five methodological factors: (1) International Classification of Diseases-10 codes (broad vs. narrow), (2) index admission selection (single admission only first-in-year vs. random sample; or multiple admissions in year with vs. without 30-day blanking period), (3) variable denominator (number alive at discharge vs. number alive at 30 days), (4) follow-up period start (discharge date vs. day following discharge), and (5) annual reference period (calendar vs. fiscal). The impact of different factors was assessed using linear regression. RESULTS: The calculated 30-day readmission rate for HF varied more than two-fold depending solely on the methodological approach (6.5-15.0%). All-cause admission rates exhibited similar variation (18.8-29.9%). The highest rates included all consecutive index admissions (HF 11.1-15.0%, all-cause 24.0-29.9%), and the lowest only one index admission per patient per year (HF 6.5-11.3%, all-cause 18.8-22.7%). When including multiple index admissions and compared with blanking the 30-day post-discharge, not blanking was associated with 2.3% higher readmission rates. Selecting a single admission per year with a first-in-year approach lowered readmission rates by 1.5%, while random-sampling admissions lowered estimates further by 5.2% (P < 0.001). CONCLUSION: Calculated 30-day readmission rates varied more than two-fold by altering methods. Transparent and consistent methods are needed to ensure reproducible and comparable reporting.

Navigating the Landscape of Medical Device Advisories: A Special Report From the Canadian Heart Rhythm Society Device Advisory Committee.

Cardiac implantable electronic devices (CIEDs) are often important for regulating cardiac rate and rhythm. Pacemakers and defibrillators are among the top 10 most implanted medical devices, with > 1.5 million devices implanted annually. Although millions of patients have benefited with improved quality of life and survival, CIED systems are becoming increasingly complex and do not always perform according to expectations. Advisory notices communicate important information about the safety and performance of a medical device to health care providers and patients. Medical device recalls are common, with > 35 unique device recalls in the past 5 years. From an ethical standpoint, CIED recalls highlight a range of considerations including the consent process, duty to report, how best to promote autonomous decision-making, trust in the health care system, as well as disproportionate effects of these considerations on equity-deserving groups. The purpose of the current article is to review and advise regarding the process around medical device advisory and recall, with a specific focus on clinicians caring for patients affected by these devices. We have sought the input of a lawyer, a patient advocacy group, and an ethicist to guide the clinical management of, and communications regarding, device recalls and advisories. Diligent surveillance and a clear, transparent patient consent process regarding these small but potentially serious device anomalies is paramount in ensuring patients believe they are safe and informed. Meaningful patient engagement helps to ensure optimal communication and disclosure mechanisms before implantation and throughout follow-up, accessibility of information in the initial implant and recall action process, and trust in health care systems and providers.

Implications of Cardiopulmonary Risk for the Management of COPD: A Narrative Review.

Chronic obstructive pulmonary disease (COPD) constitutes a major global health burden and is the third leading cause of death worldwide. A high proportion of patients with COPD have cardiovascular disease, but there is also evidence that COPD is a risk factor for adverse outcomes in cardiovascular disease. Patients with COPD frequently die of respiratory and cardiovascular causes, yet the identification and management of cardiopulmonary risk remain suboptimal owing to limited awareness and clinical intervention. Acute exacerbations punctuate the progression of COPD in many patients, reducing lung function and increasing the risk of subsequent exacerbations and cardiovascular events that may lead to early death. This narrative review defines and summarises the principles of COPD-associated cardiopulmonary risk, and examines respiratory interventions currently available to modify this risk, as well as providing expert opinion on future approaches to addressing cardiopulmonary risk.

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 (2020-2021) from the British Columbia COVID-19 Cohort. The exposure of interest was severe acute respiratory syndrome coronavirus 2 (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 hazard ratio [aHR] 1.34; 95% confidence interval [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 intensive care unit admission (aHR 6.25; 95% CI, 4.59-8.52) compared with 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.

Sex Differences in High-Cost Users of Healthcare for Atrial Fibrillation.

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.

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.

Validation of machine learning models for estimation of left ventricular ejection fraction on point-of-care ultrasound: insights on features that impact performance.

BACKGROUND: Machine learning (ML) algorithms can accurately estimate left ventricular ejection fraction (LVEF) from echocardiography, but their performance on cardiac point-of-care ultrasound (POCUS) is not well understood. OBJECTIVES: We evaluate the performance of an ML model for estimation of LVEF on cardiac POCUS compared with Level III echocardiographers' interpretation and formal echo reported LVEF. METHODS: Clinicians at a tertiary care heart failure clinic prospectively scanned 138 participants using hand-carried devices. Video data were analyzed offline by an ML model for LVEF. We compared the ML model's performance with Level III echocardiographers' interpretation and echo reported LVEF. RESULTS: There were 138 participants scanned, yielding 1257 videos. The ML model generated LVEF predictions on 341 videos. We observed a good intraclass correlation (ICC) between the ML model's predictions and the reference standards (ICC = 0.77-0.84). When comparing LVEF estimates for randomized single POCUS videos, the ICC between the ML model and Level III echocardiographers' estimates was 0.772, and it was 0.778 for videos where quantitative LVEF was feasible. When the Level III echocardiographer reviewed all POCUS videos for a participant, the ICC improved to 0.794 and 0.843 when only accounting for studies that could be segmented. The ML model's LVEF estimates also correlated well with LVEF derived from formal echocardiogram reports (ICC = 0.798). CONCLUSION: Our results suggest that clinician-driven cardiac POCUS produces ML model LVEF estimates that correlate well with expert interpretation and echo reported LVEF.

Heart failure with preserved ejection fraction: everything the clinician needs to know.

Heart failure with preserved ejection fraction (HFpEF) is increasingly recognised and diagnosed in clinical practice, a trend driven by an ageing population and a rise in contributing comorbidities, such as obesity and diabetes. Representing at least half of all heart failure cases, HFpEF is recognised as a complex clinical syndrome. Its diagnosis and management are challenging due to its diverse pathophysiology, varied epidemiological patterns, and evolving diagnostic and treatment approaches. This Seminar synthesises the latest insights on HFpEF, integrating findings from recent clinical trials, epidemiological research, and the latest guideline recommendations. We delve into the definition, pathogenesis, epidemiology, diagnostic criteria, and management strategies (non-pharmacological and pharmacological) for HFpEF. We highlight ongoing clinical trials and future developments in the field. Specifically, this Seminar offers practical guidance tailored for primary care practitioners, generalists, and cardiologists who do not specialise in heart failure, simplifying the complexities in the diagnosis and management of HFpEF. We provide practical, evidence-based recommendations, emphasising the importance of addressing comorbidities and integrating the latest pharmacological treatments, such as SGLT2 inhibitors.

Heightened long-term cardiovascular risks after exacerbation of chronic obstructive pulmonary disease.

OBJECTIVE: To examine the risk of adverse cardiovascular (CV) events following an exacerbation of chronic obstructive pulmonary disease (COPD). METHODS: This retrospective cohort study identified patients with COPD using administrative data from Alberta, Canada from 2014 to 2019. Exposure periods were 12 months following moderate or severe exacerbations; the reference period was time preceding a first exacerbation. The primary outcome was the composite of all-cause death or a first hospitalisation for acute coronary syndrome, heart failure (HF), arrhythmia or cerebral ischaemia. Time-dependent Cox regression models estimated covariate-adjusted risks associated with six exposure subperiods following exacerbation. RESULTS: Among 1 42 787 patients (mean age 68.1 years and 51.7% men) 61 981 (43.4%) experienced at least one exacerbation and 34 068 (23.9%) died during median follow-up of 64 months. The primary outcome occurred in 43 564 (30.5%) patients with an incidence rate prior to exacerbation of 5.43 (95% CI 5.36 to 5.50) per 100 person-years. This increased to 95.61 per 100 person-years in the 1-7 days postexacerbation (adjusted HR 15.86, 95% CI 15.17 to 16.58) and remained increased for up to 1 year. The risk of both the composite and individual CV events was increased following either a moderate or a severe exacerbation, though greater and more prolonged following severe exacerbation. The highest magnitude of increased risk was observed for HF decompensation (1-7 days, HR 72.34, 95% CI 64.43 to 81.22). CONCLUSION: Moderate and severe COPD exacerbations are independent risk factors for adverse CV events, especially HF decompensation. The impact of optimising COPD management on CV outcomes should be evaluated.

Atrial fibrillation progression after cryoablation vs. radiofrequency ablation: the CIRCA-DOSE trial.

BACKGROUND AND AIMS: Atrial fibrillation (AF) is a chronic progressive disorder. Persistent forms of AF are associated with increased rates of thromboembolism, heart failure, and death. Catheter ablation modifies the pathogenic mechanism of AF progression. No randomized studies have evaluated the impact of the ablation energy on progression to persistent atrial tachyarrhythmia. METHODS: Three hundred forty-six patients with drug-refractory paroxysmal AF were enrolled and randomly assigned to contact-force-guided RF ablation (CF-RF ablation, 115), 4 min cryoballoon ablation (CRYO-4, 115), or 2 min cryoballoon ablation (CRYO-2, 116). Implantable cardiac monitors placed at study entry were used for follow-up. The main outcome was the first episode of persistent atrial tachyarrhythmia. Secondary outcomes included atrial tachyarrhythmia recurrence and arrhythmia burden on the implantable monitor. RESULTS: At a median of 944.0 (interquartile range [IQR], 612.5-1104) days, 0 of 115 patients (0.0%) randomly assigned to CF-RF, 8 of 115 patients (7.0%) assigned to CRYO-4, and 5 of 116 patients (4.3%) assigned to CRYO-2 experienced an episode of persistent atrial tachyarrhythmia (P = .03). A documented recurrence of any atrial tachyarrhythmia ≥30 s occurred in 56.5%, 53.9%, and 62.9% of those randomized to CF-RF, CRYO-4, and CRYO-2, respectively; P = .65. Compared with that of the pre-ablation monitoring period, AF burden was reduced by a median of 99.5% (IQR 94.0%, 100.0%) with CF-RF, 99.9% (IQR 93.3%-100.0%) with CRYO-4, and 99.1%% (IQR 87.0%-100.0%) with CRYO-2 (P = .38). CONCLUSIONS: Catheter ablation of paroxysmal AF using radiofrequency energy was associated with fewer patients developing persistent AF on follow-up.

Epidemiology and treatment of heart failure with chronic obstructive pulmonary disease in Canadian primary care.

AIMS: Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are largely managed in primary care, but their intersection in terms of disease burden, healthcare utilization, and treatment is ill-defined. METHODS AND RESULTS: We examined a retrospective cohort including all patients with HF or COPD in the Canadian Primary Care Sentinel Surveillance Network from 2010 to 2018. The population size in 2018 with HF, COPD, and HF with COPD was 15 778, 27 927, and 4768 patients, respectively. While disease incidence declined, age-sex-standardized prevalence per 100 population increased for HF alone from 2.33 to 3.63, COPD alone from 3.44 to 5.96, and COPD with HF from 12.70 to 15.67. Annual visit rates were high and stable around 8 for COPD alone but declined significantly over time for HF alone (9.3-8.1, P = 0.04) or for patients with both conditions (14.3-11.9, P = 0.006). For HF alone, cardiovascular visits were common (29.4%), while respiratory visits were infrequent (3.5%), with the majority of visits being non-cardiorespiratory. For COPD alone, respiratory and cardiovascular visits were common (16.4% and 11.3%) and the majority were again non-cardiorespiratory. For concurrent disease, 39.0% of visits were cardiorespiratory. The commonest non-cardiorespiratory visit reasons were non-specific symptoms or signs, endocrine, musculoskeletal, and mental health. In patients with HF with and without COPD, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor use was similar, while mineralocorticoid receptor antagonist use was marginally higher with concurrent COPD. Beta-blocker use was initially lower with concurrent COPD compared with HF alone (69.3% vs. 74.0%), but this progressively declined by 2018 (74.5% vs. 73.5%). CONCLUSIONS: The prevalence of HF and COPD continues to rise. Although patients with either or both conditions are high utilizers of primary care, the majority of visits relate to non-cardiorespiratory comorbidities. Medical therapy for HF was similar and the initially lower beta-blocker utilization disappeared over time.

Kidney function monitoring and trajectories in patients with atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) and chronic kidney disease (CKD) frequently co-exist. The frequency of kidney monitoring and range of kidney function in patients with AF in clinical practice are uncertain. METHODS: All adult Albertans with AF between 2008 and 2017 were identified using ICD-9 and -10 codes 427.3 and I48. Kidney Disease Improving Global Outcomes (KDIGO) risk categories were defined using eGFR by the Chronic Kidney Disease Epidemiology Collaborative equation and albuminuria results within 6 months of eGFR measurement. eGFR trajectories were compared from baseline to maximum value within the following year. RESULTS: Among 105,946 patients with AF, 16.0% were KDIGO category G1 (eGFR ≥ 90), 49.0% G2 (60-89.9), 19.8% G3a (45-59.9), 11.4% G3b (30-44.9), and G4 3.8% (15-29.9). Albuminuria was normal/mild 83.4%, moderate 11.7%, and severe 4.9%. Kidney monitoring was more common among people with lower eGFR and worse albuminuria, from approximately twice annually for G1-2/A1-2 to 8 times annually in stage G4A3. Approximately 60-80% of patients received guideline-recommended monitoring, consistent across KDIGO stages. With lower baseline eGFR, annual change in eGFR decreased while the relative proportion of patients who worsened compared to improved increased: for baseline eGFR 60-89.9, 16.7% worsened vs 6.7% improved, but for eGFR 30-44.9, 8.8% worsened but only 1.0% improved. CONCLUSION: The frequency of kidney function monitoring in patients with AF increased with worsening KDIGO risk category and adhered to KDIGO guidelines in approximately three quarters of patients. A minority of patients had moderate to severe eGFR impairment, of whom most remained stable over 1 year.