POCUS literature primer: key papers on POCUS in cardiac arrest and shock.

OBJECTIVE: The objective of this study is to identify the top five most influential papers published on the use of point-of-care ultrasound (POCUS) in cardiac arrest and the top five most influential papers on the use of POCUS in shock in adult patients. METHODS: An expert panel of 14 members was recruited from the Canadian Association of Emergency Physicians (CAEP) Emergency Ultrasound Committee and the Canadian Ultrasound Fellowship Collaborative. The members of the panel are ultrasound fellowship trained or equivalent, are engaged in POCUS research, and are leaders in POCUS locally and nationally in Canada. A modified Delphi process was used, consisting of three rounds of sequential surveys and discussion to achieve consensus on the top five most influential papers for the use of POCUS in cardiac arrest and shock. RESULTS: The panel identified 39 relevant papers on POCUS in cardiac arrest and 42 relevant papers on POCUS in shock. All panel members participated in all three rounds of the modified Delphi process, and we ultimately identified the top five most influential papers on POCUS in cardiac arrest and also on POCUS in shock. Studies include descriptions and analysis of safe POCUS protocols that add value from a diagnostic and prognostic perspective in both populations during resuscitation. CONCLUSION: We have developed a reading list of the top five influential papers on the use of POCUS in cardiac arrest and shock to better inform residents, fellows, clinicians, and researchers on integrating and studying POCUS in a more evidence-based manner.

RéSUMé: OBJECTIF: L'objectif de cette étude est d'identifier les cinq articles les plus influents publiés sur l'utilisation de l'échographie au point de soin (POCUS) dans l'arrêt cardiaque et les cinq articles les plus influents sur l'utilisation de POCUS dans le choc chez les patients adultes. MéTHODES: Un comité d'experts composé de 14 membres a été recruté par le Comité d'échographie d'urgence de l'Association canadienne des médecins d'urgence (ACMU) et le Canadian Ultrasound Fellowship Collaborative. Les membres du comité sont formés en échographie ou l'équivalent, participent à la recherche sur le POCUS et sont des chefs de file du POCUS à l'échelle locale et nationale au Canada. Un processus Delphi modifié a été utilisé, consistant en trois séries de sondages séquentiels et de discussions pour parvenir à un consensus sur les cinq articles les plus influents pour l'utilisation de POCUS dans les arrêts cardiaques et les chocs. RéSULTATS: Le panel a identifié 39 articles pertinents sur le POCUS en arrêt cardiaque et 42 articles pertinents sur le POCUS en état de choc. Tous les membres du panel ont participé aux trois cycles du processus Delphi modifié, et nous avons finalement identifié les cinq articles les plus influents sur le POCUS en arrêt cardiaque et aussi sur le POCUS en état de choc. Les études comprennent des descriptions et des analyses de protocoles POCUS sûrs qui ajoutent de la valeur d'un point de vue diagnostique et pronostique dans les deux populations pendant la réanimation. CONCLUSION: Nous avons dressé une liste de lecture des cinq principaux articles influents sur l'utilisation du POCUS en cas d'arrêt cardiaque et de choc afin de mieux informer les résidents, les boursiers, les cliniciens et les chercheurs sur l'intégration et l'étude du POCUS d'une manière plus factuelle.

Point-of-Care Ultrasound (POCUS) Literature Primer: Key Papers on Renal and Biliary POCUS.

Objective The objective of this study is to identify the top five influential papers published on renal point-of-care ultrasound (POCUS) and the top five influential papers on biliary POCUS in adult patients. Methods A 14-member expert panel was recruited from the Canadian Association of Emergency Physicians (CAEP) Emergency Ultrasound Committee and the Canadian Ultrasound Fellowship Collaborative. All panel members have had ultrasound fellowship training or equivalent, are actively engaged in POCUS scholarship, and are involved with POCUS at their local site and nationally in Canada. We used a modified Delphi process consisting of three rounds of sequential surveys and discussion to achieve consensus on the top five influential papers for renal POCUS and biliary POCUS. Results The panel identified 27 relevant papers on renal POCUS and 30 relevant papers on biliary POCUS. All panel members participated in all three rounds of the modified Delphi process, and after completing this process, we identified the five most influential papers on renal POCUS and the five most influential papers on biliary POCUS. Conclusion We have developed a list, based on expert opinion, of the top five influential papers on renal and biliary POCUS to better inform all trainees and clinicians on how to use these applications in a more evidence-based manner. This list will also be of interest to clinicians and researchers who strive to further advance the field of POCUS.

Delivering Point-of-Care ultrasound teaching using a video conferencing technique.

Point-of-care ultrasound (POCUS) has usually been taught using a hands-on, in-person approach. We present a novel approach to delivering POCUS virtually using a dual image videoconferencing technique. We outline an easily implementable approach and summarize medical students' experience and feedback. This form of delivery has potential to improve instructional delivery in resource restricted settings or during pandemic restrictions where a hands-on approach may not be possible.

L'échographie au chevet fait généralement l'objet d'un enseignement pratique, en personne. Nous présentons une nouvelle approche, virtuelle, pour son enseignement, par visioconférence à double flux vidéo. L'approche que nous décrivons est facile à mettre en œuvre. Nous résumons l'expérience et les commentaires des étudiants en médecine sur cette modalité qui est susceptible d'améliorer l'enseignement dans des contextes où les ressources sont limitées ou en cas de pandémie, lorsque l'approche pratique n'est pas possible.

Point of Care Ultrasound Literature Primer: Key Papers on Focused Assessment With Sonography in Trauma (FAST) and Extended FAST.

Objective The objective of this study is to identify the top five most influential papers published on focused assessment with sonography in trauma (FAST) and the top five most influential papers on the extended FAST (E-FAST) in adult patients. Methods An expert panel was recruited from the Canadian Association of Emergency Physicians (CAEP) Emergency Ultrasound Committee and the Canadian Ultrasound Fellowship Collaborative. These experts are ultrasound fellowship-trained or equivalent, are involved with point-of-care ultrasound (POCUS) research and scholarship, and are leaders in both the POCUS program at their local site and within the national Canadian POCUS community. This 14-member expert group used a modified Delphi process consisting of three rounds of sequential surveys and discussion to achieve consensus on the top five most influential papers for FAST and E-FAST. Results The expert panel identified 56 relevant papers on FAST and 40 relevant papers on E-FAST. After completing all three rounds of the modified Delphi process, the authors identified the top five most influential papers on FAST and the top five most influential papers on E-FAST. Conclusion We have developed a reading list of the top five influential papers for FAST and E-FAST that will benefit residents, fellows, and clinicians who are interested in using POCUS in an evidence-informed manner.

Just the Facts: Recommendations on point-of-care ultrasound use and machine infection control during the coronavirus disease 2019 pandemic.

The World Health Organization declared the novel coronavirus disease 2019 (COVID-19) to be a pandemic on March 11, 2020, and, currently, there are over 10,000 confirmed cases in Canada, with this number expected to grow exponentially. There has been widespread interest in the use of point-of-care ultrasound (POCUS) in the management of patients with suspected COVID-19. The CAEP Emergency Ultrasound Committee has developed recommendations on the use of POCUS in these patients, with an emphasis on machine infection control measures.

The Canadian Medical Student Ultrasound Curriculum: A Statement From the Canadian Ultrasound Consensus for Undergraduate Medical Education Group.

OBJECTIVES: This study sought to establish by expert review a consensus-based, focused ultrasound curriculum, consisting of a foundational set of focused ultrasound skills that all Canadian medical students would be expected to attain at the end of the medical school program. METHODS: An expert panel of 21 point-of-care ultrasound and educational leaders representing 15 of 17 (88%) Canadian medical schools was formed and participated in a modified Delphi consensus method. Experts anonymously rated 195 curricular elements on their appropriateness to include in a medical school curriculum using a 5-point Likert scale. The group defined consensus as 70% or more experts agreeing to include or exclude an element. We determined a priori that no more than 3 rounds of voting would be performed. RESULTS: Of the 195 curricular elements considered in the first round of voting, the group reached consensus to include 78 and exclude 24. In the second round, consensus was reached to include 4 and exclude 63 elements. In our final round, with 1 additional item added to the survey, the group reached consensus to include an additional 3 and exclude 8 elements. A total of 85 curricular elements reached consensus to be included, with 95 to be excluded. Sixteen elements did not reach consensus to be included or excluded. CONCLUSIONS: By expert opinion-based consensus, the Canadian Ultrasound Consensus for Undergraduate Medical Education Group recommends that 85 curricular elements be considered for inclusion for teaching in the Canadian medical school focused ultrasound curricula.

Bilateral Retinal Detachments Caused by Severe Preeclampsia Diagnosed with Point-of-Care Ultrasound.

Bilateral retinal detachments are a rare complication of preeclampsia. We present a case report of a patient with an unknown pregnancy who presented with acute bilateral vision loss and elevated blood pressure. Point-of-care ocular ultrasound revealed bilateral retinal detachments. She was diagnosed with severe preeclampsia and taken for an urgent caesarean section with the delivery of a 26-week-old infant.

Defining the learning curve of point-of-care ultrasound for confirming endotracheal tube placement by emergency physicians.

BACKGROUND: Unrecognized esophageal intubations are associated with significant patient morbidity and mortality. No single confirmatory device has been shown to be 100 % accurate at ruling out esophageal intubations in the emergency department. Recent studies have demonstrated that point-of-care ultrasound (POCUS) may be a useful adjunct for confirming endotracheal tube placement; however, the amount of practice required to become proficient at this technique is unclear. The purpose of this study is to determine the amount of practice required by emergency physicians to become proficient at interpreting ultrasound video clips of esophageal and endotracheal intubations. METHODS: Emergency physicians and emergency medicine residents completed a baseline interpretation test followed by a 10 min online tutorial. They then interpreted POCUS clips of esophageal and endotracheal intubations in a randomly selected order. If an incorrect response was provided, the participant completed another practice session with feedback. This process continued until they correctly interpreted ten consecutive ultrasound clips. Descriptive statistics were used to summarize the data. RESULTS: Of the 87 eligible physicians, 66 (75.9 %) completed the study. The mean score on the baseline test was 42.9 % (SD 32.7 %). After the tutorial, 90.9 % (60/66) of the participants achieved proficiency after one practice attempt and 100 % achieved proficiency after two practice attempts. Six intubation ultrasound clips were misinterpreted, for a total error rate of 0.9 % (6/684). Overall, the participants had a sensitivity of 98.3 % (95 % CI 96.3-99.4 %) and specificity of 100 % (95 % CI 98.9-100 %) for detecting correct tube location. Scans were interpreted within an average of 4 s (SD 2.9 s) of the intubation. CONCLUSIONS: After a brief online tutorial and only two practice attempts, emergency physicians were able to quickly and accurately interpret ultrasound intubation clips of esophageal and endotracheal intubations.

There Are Sex Differences in the Demographics and Risk Profiles of Emergency Department (ED) Patients With Atrial Fibrillation and Flutter, but no Apparent Differences in ED Management or Outcomes.

OBJECTIVES: In non-emergency department (ED) settings, women with atrial fibrillation and flutter (AFF) have different presentations, treatments, and outcomes than men: they are older, less likely to be treated with rhythm control strategies or appropriate anticoagulation, and more likely to have strokes. This has not been investigated in ED patients. METHODS: Records from consecutive ED patients from January 1 to December 31, 2009, with electrocardiogram-proven AFF at two urban hospitals were collected. Review of administrative and clinical data identified patient demographics, clinical characteristics, comorbidities, and ED treatments. The regional ED database was queried to determine 30-day and 1-year follow-up visits, and the provincial vital statistics database was referenced to obtain 30-day and 1-year mortality; all outcomes were stratified by sex. The primary outcome, which reflected overall appropriateness of ED care, was the proportion of patients who were discharged home at their index ED visits, who then had unscheduled 30-day ED revisits. Secondary outcomes included the proportion of eligible patients who underwent acute rhythm control strategies and the proportion of high-risk patients who had previously inadequately anticoagulation strategies corrected by the emergency physician. Additional outcomes included the ED length of stay (LOS) and 30-day and 1-year rates of stroke and death. RESULTS: A total of 1,112 records were reviewed: 470 women (42.3%) and 642 men. Women were a median 8 years (interquartile range = 3 to 13 years) older than men, had higher rates of cardiovascular comorbidities, and were more likely to present with atypical symptoms such as weakness or dyspnea. On their index ED visits, 50.2% of women and 41.3% of men were admitted. At 30 days, 39 of 234 (16.7%) women and 55 of 377 (14.6%) men who were discharged at their index ED visits had made revisits, for a risk difference of 2.1% (95% confidence interval = -3.9% to 8.5%). There were no apparent sex differences in the use of acute rhythm control or in the appropriateness of anticoagulation decisions. ED LOS was similar between women and men, as were 30-day and 1-year stroke or death rates. CONCLUSIONS: Female ED AFF patients were older, had more comorbidities, and were more likely to be admitted. However, the overall management and outcomes, including 30-day revisits, appeared to be similar to that of males, indicating that there appeared to be little sex-based discrepancy in ED care and outcomes.

Emergency Department Patients With Atrial Fibrillation or Flutter and an Acute Underlying Medical Illness May Not Benefit From Attempts to Control Rate or Rhythm.

STUDY OBJECTIVE: Although the management and outcomes of emergency department (ED) patients with atrial fibrillation or flutter have been explored, such studies have typically excluded patients with acute underlying medical illnesses. We seek to describe the ED treatment and outcomes of these complex patients with atrial fibrillation or flutter. METHODS: This retrospective descriptive cohort study used an ECG database from 2 urban EDs to identify consecutive ED patients with an ECG demonstrating atrial fibrillation or flutter from January 1, 2009, to December 31, 2009. We categorized patients with atrial fibrillation or flutter as "complex" according to prespecified criteria and then grouped them as being managed with rate or rhythm control attempts, or not. The primary outcome was safety of rate or rhythm control, measured by whether patients had a predefined adverse event or not. The secondary outcome was the success of rate or rhythm control, defined as rate control decreasing the pulse rate by 20 beats/min and successful rhythm control, both within 4 hours of treatment initiation. Descriptive statistics were used to compare the 2 groups. RESULTS: Four hundred sixteen complex patients with atrial fibrillation or flutter were identified. Patients managed with rate or rhythm control were similar in all baseline characteristics and illness distribution to patients who were not managed in this manner. The 135 patients with attempted rate control (105) or rhythm control (30) had 55 adverse events (40.7%; 95% confidence interval [CI] 32.5% to 49.5%), whereas the 281 patients not managed with rate or rhythm control had 20 adverse events (7.1%; 95% CI 4.5% to 10.9%), for a risk difference of 33.6% (95% CI 24.3% to 42.5%) and a relative risk of 5.7 (95% CI 3.6 to 9.1). Twenty of 105 patients (19.1%; 95% CI 12.3% to 28.1%) were successfully rate controlled, whereas 4 of 30 (13.3%; 95% CI 4.4% to 31.6%) were successfully rhythm controlled. CONCLUSION: In ED patients with complex atrial fibrillation or flutter, attempts at rate and rhythm control are associated with a nearly 6-fold higher adverse event rate than that for patients who are not managed with rate or rhythm control. Success rates of rate or rhythm control attempts appear low.

Missed opportunities for appropriate anticoagulation among emergency department patients with uncomplicated atrial fibrillation or flutter.

STUDY OBJECTIVE: Emergency department (ED) patients with atrial fibrillation or flutter are at risk of stroke, and guidelines recommend anticoagulation for patients with increased cardiovascular risk. Emergency physicians have a unique opportunity to provide appropriate anticoagulation for such patients, and we wished to investigate whether this was accomplished. METHODS: This retrospective cohort study used a database from 2 urban EDs to identify consecutive patients with an ED discharge diagnosis of atrial fibrillation or flutter from April 1, 2006, to March 31, 2010, who were managed solely by the emergency physician. Comorbidities, rhythms, and management were obtained by chart review, and complicated patients (those with an acute underlying medical condition) were excluded by predefined criteria. Patient medications on ED presentations were obtained through the provincial Pharmanet database. Patients were stratified into CHADS 2 (congestive heart failure, hypertension, age > 75, diabetes, stroke/transient ischemic attack) scores, and the primary outcome was the proportion of higher-risk (CHADS 2 score >0) patients who were discharged home with the incorrect anticoagulation by the emergency physician. The secondary outcome was the number of lower-risk (CHADS 2=0) patients who began receiving warfarin by the emergency physician orders. The regional ED database was interrogated to ascertain the number of patients who had a stroke at 30 days. RESULTS: Consecutive patients (1,090) were enrolled and 732 were discharged home with no cardiology consultation (657 fibrillation and 75 flutter). Of 151 higher-risk (CHADS 2 score >0) patients who should have been anticoagulated, 80 (53.0%; 95% confidence interval 44.7% to 61.0%) were discharged home from the ED without appropriate anticoagulation. In this group, 1 patient had an ischemic stroke at 24 days. Among 300 lower-risk patients (CHADS 2 score=0), 25 (8.3%; 95% confidence interval 5.6% to 12.2%) had warfarin initiated. CONCLUSION: In this cohort of ED patients with uncomplicated atrial fibrillation or flutter who were discharged without cardiology involvement, many were not appropriately anticoagulated before ED arrival, and more than half of such patients did not appear to have corrective measures initiated by the emergency physician. This may represent a potential opportunity to improve patient care and outcomes.

Safety and efficiency of calcium channel blockers versus beta-blockers for rate control in patients with atrial fibrillation and no acute underlying medical illness.

OBJECTIVES: Many patients with atrial fibrillation (AF) are not candidates for rhythm control and may require rate control, typically with beta-blocking (BB) or calcium channel blocking (CCB) agents. Although these patients appear to have a low 30-day rate of stroke or death, it is unclear if one class of agent is safer or more effective. The objective was to determine whether BBs or CCBs would have a lower hospital admission rate and to measure 30-day safety outcomes including stroke, death, and emergency department (ED) revisits. METHODS: This retrospective cohort study used a database from two urban EDs to identify consecutive patients with ED discharge diagnoses of AF from April 1, 2006, to March 31, 2010. Comorbidities, rhythms, management, and immediate outcomes were obtained by manual chart review, and patients with acute underlying medical conditions were excluded by predefined criteria. Patients managed only with rate control agents were eligible for review, and patients receiving BB agents were compared to those receiving CCB agents. The primary outcome was the proportion of patients requiring hospital admission; secondary outcomes included the ED length of stay (LOS), the proportion of patients having adverse events, the proportion of patients returning within 7 or 30 days, and the number of patients having a stroke or dying within 30 days. RESULTS: A total of 259 consecutive patients were enrolled, with 100 receiving CCBs and 159 receiving BBs. Baseline demographics and comorbidities were similar. Twenty-seven percent of BB patients were admitted, and 31.0% of CCB patients were admitted (difference = 4.0%, 95% confidence interval [CI] = -7.7% to 16.1%), and there were no significant differences in ED LOS, adverse events, or 7- or 30-day ED revisits. One patient who received metoprolol had a stroke, and one patient who received diltiazem died within 30 days. CONCLUSIONS: In this cohort of ED patients with AF and no acute underlying medical illness who underwent rate control only, patients receiving CCBs had similar hospital admission rates to those receiving BBs, while both classes of medications appeared equally safe at 30 days. Both CCBs and BBs are acceptable options for rate control.

Combined polymorphisms in oxidative stress genes predict coronary artery disease and oxidative stress in coronary angiography patients.

Oxidative stress has been implicated in all stages of atherosclerosis, but how inherited variations in oxidative stress genes influence the severity of cardiovascular disease is not known. We tested associations between polymorphisms in candidate oxidative stress genes, plasma oxidative stress biomarkers, and cardiovascular mortality in an angiography cohort. Single nucleotide polymorphisms (SNPs) across 15 genes were selected by linkage disequilibrium tagging. Genotyping was performed using customized arrayed primer extension micro-arrays, with automated genotype calling methods. Effects of SNPs and haplotypes on plasma oxidative stress and coronary artery disease (CAD) were estimated using a stochastic estimation maximization algorithm. Proportionate hazards analyses were used to determine effects of single and combined genetic markers on cardiovascular mortality risk, and on the following oxidative stress biomarkers: myeloperoxidase (MPO), nitrotyrosine, oxidized low-density lipoprotein, and antioxidant capacity. Oxidative stress gene SNPs associated with CAD were combined into an oxidative stress risk allele score, which predicted disease presence (1.5-fold risk increase per allele, P < 0.001). Combined risk alleles were also associated with elevated plasma MPO (P < 0.003), an oxidative stress biomarker that predicts cardiovascular mortality. Genetic markers that represent lifetime oxidative stress burden may implicate specific oxidative stress pathways in the pathogenesis of atherosclerosis, and offer therapeutic opportunities.

Thirty-day and 1-year outcomes of emergency department patients with atrial fibrillation and no acute underlying medical cause.

STUDY OBJECTIVE: Atrial fibrillation is the most common dysrhythmia observed in the emergency department (ED), yet there is little research describing long-term outcomes after ED management. Our objective is to describe ED treatment approach, conversion success rates, ED adverse events, and 30-day and 1-year outcomes for a cohort of ED patients with atrial fibrillation and no acute underlying medical cause. METHODS: This retrospective cohort study used a database from 2 urban EDs to identify consecutive patients with an ED discharge diagnosis of atrial fibrillation from April 1, 2006, to March 31, 2010. Comorbidities, rhythms, management, and immediate outcomes were obtained by manual chart review, and patients with an acute underlying medical condition were excluded by predefined criteria. Patients were stratified into 5 groups according to ED management: electrocardioversion, chemical cardioversion, spontaneous cardioversion, rate control only, and no arrhythmia-specific treatment. To identify deaths, strokes, and ED revisits within 1 year, each patient's unique provincial health number was linked to the provincial vital statistics registry and the regional ED database. Primary outcome was the number of patients having either stroke or death of any cause at 30 days, stratified by treatment group. RESULTS: Of 927 consecutive eligible patients, 121 (13.1%) converted to sinus rhythm before ED intervention, 357 (38.5%) received ED rhythm control, and 449 (48.4%) did not receive rhythm control. Overall, 142 of 927 patients (15.3%) were admitted to the hospital at the index ED visit. At 30 days, 2 patients had a stroke and 5 died (combined outcome rate 0.8%; 95% confidence interval 0.3% to 1.6%). All 7 of these patients were admitted at the index ED visit. CONCLUSION: In this large cohort of ED patients with atrial fibrillation and no acute underlying medical cause, the 30-day rate for stroke or death was less than 1%. Nearly 85% of patients-regardless of treatment approach or conversion to sinus rhythm-were discharged at the index ED visit, and none of these patients had a stroke or died at 30 days.

Circulating surfactant protein-D and the risk of cardiovascular morbidity and mortality.

AIMS: Surfactant protein-D (SP-D) is a lung-specific protein that is detectable in human plasma. We determined the relationship of circulating SP-D to cardiovascular disease (CVD) and total mortality in subjects with and without CVD. METHODS AND RESULTS: Plasma SP-D levels were measured in 806 patients who underwent coronary angiography to assess its predictive value for cardiovascular mortality. Serum SP-D levels were also measured in a replication cohort to assess its relationship with CVD events in 4468 ex- and current smokers without a known history of coronary artery disease (CAD). Patients who died during follow-up had significantly higher plasma SP-D levels than those who survived (median 85.4 vs. 64.8 ng/mL; P < 0.0001). Those in the highest quintile of SP-D had 4.4-fold higher risk of CVD mortality than those in the lowest quintile (P < 0.0001) independent of age, sex, and plasma lipid levels. In a group of current and ex-smokers without a known history of CAD, serum SP-D levels were elevated in those who died or were hospitalized for CVD compared with those who did not (median 99.8 vs. 90.6 ng/mL; P = 0.0001). CONCLUSION: Circulating SP-D is a good predictor of cardiovascular morbidity and mortality and adds prognostic information to well-established risk factors such as age, sex, and plasma lipids and is a promising biomarker to link lung inflammation/injury to CVD.

Myeloperoxidase and C-reactive protein have combined utility for long-term prediction of cardiovascular mortality after coronary angiography.

OBJECTIVES: We evaluated the relative and combined value of oxidative stress biomarkers for predicting cardiovascular mortality in patients undergoing selective coronary angiography. BACKGROUND: Oxidative stress participates in all stages of cardiovascular disease, from lipoprotein modification to plaque rupture, and biomarkers of oxidative stress predict development of coronary artery disease (CAD). Oxidative stress biomarkers merit investigation for the value they may offer for long-term cardiovascular risk prediction. METHODS: Myeloperoxidase (MPO), nitrotyrosine, oxidized low-density lipoprotein, and antioxidant capacity were measured in a prospective cohort of 885 selective coronary angiography patients followed up for >13 years for cardiovascular mortality. RESULTS: MPO independently predicted CAD, and top tertile MPO levels predicted a 2.4-fold risk of cardiovascular mortality (95% confidence interval [CI]: 1.47 to 2.98), compared with patients with lowest tertile MPO levels. MPO also improved risk model discrimination and patient risk category classification. Elevations in multiple oxidative stress biomarkers predicted increased mortality risk; however, the strongest risk prediction was achieved by assessing MPO and C-reactive protein (CRP) together. Patients with either MPO or CRP elevated had 5.3-fold higher cardiovascular mortality risk (95% CI: 1.86 to 14.9), and patients with high levels of both MPO and CRP had a 4.3-fold risk compared with patients with only elevated marker (95% CI: 2.26 to 8.31). These results remained significant with adjustment for cardiovascular risk factors and baseline disease burden. CONCLUSIONS: MPO accurately predicted cardiovascular mortality risk in coronary angiography patients. Considering MPO and CRP together may improve long-term risk assessment and CAD patient outcomes.

Neighbourhood socioeconomics status predicts non-cardiovascular mortality in cardiac patients with access to universal health care.

BACKGROUND: Although the Canadian health care system provides essential services to all residents, evidence suggests that socioeconomic gradients in disease outcomes still persist. The main objective of our study was to investigate whether mortality, from cardiovascular disease or other causes, varies by neighbourhood socioeconomic gradients in patients accessing the healthcare system for cardiovascular disease management. METHODS AND FINDINGS: A cohort of 485 patients with angiographic evidence of coronary artery disease (CAD) and neighbourhood socioeconomic status information was followed for 13.3 years. Survival analyses were completed with adjustment for potentially confounding risk factors. There were 64 cases of cardiovascular mortality and 66 deaths from non-cardiovascular chronic diseases. No socioeconomic differentials in cardiovascular mortality were observed. However, lower neighbourhood employment, education, and median family income did predict an increased risk of mortality from non-cardiovascular chronic diseases. For each quintile decrease in neighbourhood socioeconomic status, non-cardiovascular mortality risk rose by 21-30%. Covariate-adjusted hazard ratios (95% confidence interval) for non-cardiovascular mortality were 1.21 (1.02-1.42), 1.21 (1.01-1.46), and 1.30 (1.06-1.60), for each quintile decrease in neighbourhood education, employment, and income, respectively. These patterns were primarily attributable to mortality from cancer. Estimated risks for mortality from cancer rose by 42% and 62% for each one quintile decrease in neighbourhood median income and employment rate, respectively. Although only baseline clinical information was collected and patient-level socioeconomic data were not available, our results suggest that environmental socioeconomic factors have a significant impact on CAD patient survival. CONCLUSIONS: Despite public health care access, CAD patients who reside in lower-socioeconomic neighbourhoods show increased vulnerability to non-cardiovascular chronic disease mortality, particularly in the domain of cancer. These findings prompt further research exploring mechanisms of neighbourhood effects on health, and ways they may be ameliorated.