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1.
Can J Cardiol ; 35(9): 1124-1133, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31472811

RESUMO

BACKGROUND: Contrast-induced acute kidney injury (CI-AKI) is a common and serious complication of invasive cardiac procedures. Quality improvement programs have been associated with a lower incidence of CI-AKI over time, but there is a lack of high-quality evidence on clinical decision support for prevention of CI-AKI and its impact on processes of care and clinical outcomes. METHODS: The Contrast-Reducing Injury Sustained by Kidneys (Contrast RISK) study will implement an evidence-based multifaceted intervention designed to reduce the incidence of CI-AKI, encompassing automated identification of patients at increased risk for CI-AKI, point-of-care information on safe contrast volume targets, personalized recommendations for hemodynamic optimization of intravenous fluids, and follow-up information for patients at risk. Implementation will use cardiologist academic detailing, computerized clinical decision support, and audit and feedback. All 31 physicians practicing in all 3 of Alberta's cardiac catheterization laboratories will participate using a cluster-randomized stepped-wedge design. The order in which they are introduced to this intervention will be randomized within 8 clusters. The primary outcome is CI-AKI incidence, with secondary outcomes of CI-AKI avoidance strategies and downstream adverse major kidney and cardiovascular events. An economic evaluation will accompany the main trial. CONCLUSIONS: The Contrast RISK study leverages information technology systems to identify patient risk combined with evidence-based protocols, audit, and feedback to reduce CI-AKI in cardiac catheterization laboratories across Alberta. If effective, this intervention can be broadly scaled and sustained to improve the safety of cardiac catheterization.

3.
J Crit Care ; 54: 117-121, 2019 Aug 09.
Artigo em Inglês | MEDLINE | ID: mdl-31421527

RESUMO

PURPOSE: The APPROACH cardiovascular surgical intensive care unit (CVICU) readmission score has excellent discrimination and calibration for CVICU readmission after discharge to a surgical ward; however, it has not been prospectively validated. MATERIAL AND METHODS: In a prospective consecutive cohort of 805 patients ≥18 years admitted to the CVICU after coronary artery bypass and/or valvular surgery, the APPROACH CVICU readmission score was calculated at the time of discharge to a surgical ward. The study compared observed versus predicted CVICU readmission and the model discrimination was evaluated using AUC c-index. The incremental prognostic utility of 6 pre-specified prospectively collected respiratory (re-intubation, tracheostomy, oxygen at discharge) and hemodynamic variables (heart rate, systolic blood pressure, inotropes at discharge) were tested using net reclassification index (NRI) and integrated discrimination improvement (IDI). RESULTS: A total of 37 (4.6%) patients were readmitted to the CVICU. The median CVICU length of stay (9.0 vs 2.0 days, p < .001) and all-cause in-hospital mortality (8.1% vs 0.4%, p < .001) was higher among readmitted patients. The model had good discrimination (c-index = 0.748). Systolic blood pressure at discharge yielded the largest improvement in model discrimination (c-index = 0.782; Hosmer-Lemshow p = .749). CONCLUSIONS: In a prospective validation cohort, the APPROACH CVICU readmission risk score had good discrimination and could be operationalized in future research and clinical practice.

4.
Can J Cardiol ; 35(6): 753-760, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31151711

RESUMO

BACKGROUND: Few studies have explored the influence of short-term exposure to atmospheric pressure changes on the abrupt onset of ST-elevation myocardial infarction (STEMI). We sought to evaluate the association between acute atmospheric pressure changes and the occurrence of STEMI. METHODS: We studied STEMI patients from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) from March 1, 2002 to December 31, 2016 in a case-crossover study design. Each case was matched with control intervals according to the same day of week, month, and year. All STEMI patients were linked with the nearest weather station within a 40-km radius according to residential postal code. The effect of exposure to air pressure changes, rate of air pressure changes, acute air pressure increase, and acute air pressure decrease 1 day to 7 days earlier on the onset of STEMI were analyzed with conditional logistic regression. All models were adjusted with daily average temperature, relative humidity, and average levels of 5 air pollutants. RESULTS: In 11,379 STEMI patients, positive associations with the onset of STEMI were only found at 7 days after exposure to acute air pressure decrease (odds ratio, 1.12; 95% confidence interval, 1.03-1.21), which was consistent in sensitivity and subgroup analyses. All the other models showed no evidence of statistically significant associations. CONCLUSIONS: Acute air pressure decrease is associated with higher odds of a STEMI event 7 days after exposure. Weather advisories might be issued when atmospheric pressure decrease occurs.

5.
COPD ; 16(1): 66-71, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30897970

RESUMO

Chronic obstructive pulmonary disease (COPD) and coronary artery disease (CAD) are leading causes of morbidity and mortality. There are conflicting results regarding the association between COPD and CAD. We sought to measure the association between COPD and angiographically diagnosed CAD in a population-based cohort. We performed a retrospective analysis using data from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH), a prospectively collected registry capturing all patients undergoing coronary angiography in Alberta, Canada, since 1995. We included adult patients who had undergone coronary angiogram between April 1, 2007 and March 31, 2014. CAD was present if at least one coronary artery had a significant stenosis ≥50%. COPD was present if the patient had a documented COPD history and was prescribed bronchodilators or inhaled steroids. We evaluated the association between COPD and CAD using univariable and multivariable logistic regression. There were 26,137 patients included with a mean age of 63.3 ± 12.2 years, and 19,542 (74.8%) were male. The crude odds ratio (OR) of having CAD was 0.83 (95% CI 0.74-0.92) for patients with COPD compared to those without COPD. The adjusted OR was 0.75 (95% CI 0.67-0.84) after controlling for age, sex, smoking history, body mass index, hypertension, diabetes, hyperlipidemia, peripheral artery disease and cardiac family history. In patients undergoing coronary angiography, COPD was negatively associated with CAD with and without the adjustment for classic risk factors. COPD patients should be properly examined for heart disease to reduce premature mortality.

6.
CMAJ ; 191(11): E299-E307, 2019 Mar 18.
Artigo em Inglês | MEDLINE | ID: mdl-30885968

RESUMO

BACKGROUND: Comorbidity indexes derived from administrative databases are essential tools of research in global health. We sought to develop and validate a novel cardiac-specific comorbidity index, and to compare its accuracy with the generic Charlson-Deyo and Elixhauser comorbidity indexes. METHODS: We derived the cardiac-specific comorbidity index from consecutive patients who were admitted to hospital at a tertiary-care cardiology hospital in Quebec. We used logistic regression analysis and incorporated age, sex and 22 clinically relevant comorbidities to build the index. We compared the cardiac-specific comorbidity index with refitted Charlson-Deyo and Elixhauser comorbidity indexes using the C-statistic and net reclassification improvement to predict in-hospital death, and the Akaike information criterion to predict length of stay. We validated our findings externally in an independent cohort obtained from a provincial registry of coronary disease in Alberta. RESULTS: The novel cardiac-specific comorbidity index outperformed the refitted generic Charlson-Deyo and Elixhauser comorbidity indexes for predicting in-hospital mortality in the derivation population (n = 10 137): C-statistic 0.95 (95% confidence interval [CI] 0.94-0.9) v. 0.81 (95% CI 0.77-0.84) and 0.86 (95% CI 0.82-0.89), respectively. In the validation population (n = 17 877), the cardiac-specific comorbidity index was similarly better: C-statistic 0.92 (95% CI 0.89-0.94) v. 0.76 (95% CI 0.71-0.81) and 0.82 (95% CI 0.78-0.86), respectively, and also numerically outperformed the Charlson-Deyo and Elixhauser comorbidity indexes for predicting 1-year mortality (C-statistic 0.78 [95% CI 0.76-0.80] v. 0.75 [95% CI 0.73-0.77] and 0.77 [95% CI 0.75-0.79], respectively). Similarly, the cardiac-specific comorbidity index showed better fit for the prediction of length of stay. The net reclassification improvement using the cardiac-specific comorbidity index for the prediction of death was 0.290 compared with the Charlson-Deyo comorbidity index and 0.192 compared with the Elixhauser comorbidity index. INTERPRETATION: The cardiac-specific comorbidity index predicted in-hospital and 1-year death and length of stay in cardiovascular populations better than existing generic models. This novel index may be useful for research of cardiology outcomes performed with large administrative databases.

7.
Qual Life Res ; 28(5): 1365-1376, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30607784

RESUMO

PURPOSE: Perceived social support is known to be an important predictor of health outcomes in patients with acute coronary syndrome (ACS). This study investigates patterns of longitudinal trajectories of patient-reported perceived social support in individuals with ACS. METHODS: Data are from 3013 patients from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry who had their first cardiac catheterization between 2004 and 2011. Perceived social support was assessed using the 19-item Medical Outcomes Study Social Support Survey (MOS) 2 weeks, 1 year, and 3 years post catheterization. Group-based trajectory analysis based on longitudinal multiple imputation model was used to identify distinct subgroups of trajectories of perceived social support over a 3-year follow-up period. RESULTS: Three distinct social support trajectory subgroups were identified, namely: "High" social support group (60%), "Intermediate" social support group (30%), and "Low" social support subgroup (10%). Being female (OR = 1.67; 95% CI = [1.18-2.36]), depression (OR = 8.10; 95% CI = [4.27-15.36]) and smoking (OR = 1.70; 95% CI = [1.23-2.35]) were predictors of the differences among these trajectory subgroups. CONCLUSION: Although the majority of ACS patients showed increased or fairly stable trajectories of social support, about 10% of the cohort reported declining social support. These findings can inform targeted psycho-social interventions to improve their perceived social support and health outcomes.


Assuntos
Síndrome Coronariana Aguda/psicologia , Doença das Coronárias/psicologia , Avaliação de Resultados (Cuidados de Saúde) , Qualidade de Vida/psicologia , Autorrelato , Apoio Social , Síndrome Coronariana Aguda/terapia , Idoso , Alberta , Cateterismo Cardíaco , Estudos de Coortes , Doença das Coronárias/terapia , Depressão/psicologia , Transtorno Depressivo/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Percepção , Sistema de Registros
8.
J Am Heart Assoc ; 7(20): e009917, 2018 Oct 16.
Artigo em Inglês | MEDLINE | ID: mdl-30371293

RESUMO

Background Postoperative clinical outcomes associated with the preoperative continuation or discontinuation of angiotensin-converting enzyme inhibitors ( ACEIs ) or angiotensin receptor blockers ( ARBs ) before cardiac surgery remain unclear. Methods and Results In a single-center, open-label, randomized, registry-based clinical trial, patients undergoing nonemergent cardiac surgery were assigned to ACEI / ARB continuation or discontinuation 2 days before surgery. Among the 584 patients screened, 261 met study criteria and 126 (48.3%) patients were enrolled. In total,121 patients (96% adherence; 60 to continuation and 61 to ACEI / ARB discontinuation) underwent surgery and completed the study protocol, and follow-up was 100% complete. Postoperative intravenous vasopressor use (78.3% versus 75.4%, P=0.703), vasodilator use (71.7% versus 80.3%, P=0.265), vasoplegic shock (31.7% versus 27.9%, P=0.648), median duration of vasopressor (10 versus 5 hours, P=0.494), and vasodilator requirements (10 versus 9 hours, P=0.469) were not significantly different between the continuation and discontinuation arms. No differences were observed in the incidence of acute kidney injury (1.7% versus 1.6%, P=0.991), stroke (no events, mortality (1.7% versus 1.6%, P=0.991), median duration of mechanical ventilation (6 versus 6 hours, P=0.680), and median intensive care unit length of stay (43 versus 27 hours, P=0.420) between the treatment arms. Conclusions A randomized study evaluating the routine continuation or discontinuation of ACEIs or ARB s before cardiac surgery was feasible, and treatment assignment was not associated with differences in postoperative physiological or clinical outcomes. These preliminary findings suggest that preoperative ACEI / ARB management strategies did not affect the postoperative course of patients undergoing cardiac surgery. Clinical Trial Registration URL : https://www.clinicaltrials.gov . Unique identifier: NCT 02096406.

10.
Can J Cardiol ; 34(7): 821-826, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29861205

RESUMO

Delivering evidence-based, personalized care that engages patients requires profound changes in the structure, process, and organization of care, along with revised incentives to support such changes. Health care providers must absorb and apply a vast, usually overwhelming, amount of scientific information to provide high-quality patient care. Accordingly, care remains inconsistent, with unintentional adverse consequences. Decision support tools can provide patient-specific assessments that support clinical decisions, improve prescribing practices, reduce medication errors, improve the delivery of primary as well as secondary prevention, and improve adherence to standards of care. Decision support tools are created using an individual patient's genetic, sociodemographic, and clinical characteristics to improve the delivery of precise, personalized care. Implementation requires ease of use for busy clinicians; uptake improves with active education, and gradual adoption of a tool integrated into care processes without disrupting clinical work flow. As health care systems continue to evolve and computerized support increases, increased implementation of decision support tools that are provided automatically as part of usual work flow, with clinically actionable recommendations at the point of care, requiring accountability for deviations from recommended therapy, represent an important opportunity to enhance quality of care by tailoring treatment to risk, improving the consistency of health care delivery, increasing patient knowledge and engagement, and avoiding specific therapeutic interventions in patients who will receive no benefit. However, successful implementation also requires strategies to engage providers in accepting and using these tools to improve care.

12.
Circ Cardiovasc Qual Outcomes ; 11(3): e003661, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29545392

RESUMO

BACKGROUND: Health-related quality of life (HRQOL) assessment is an important health outcome for measuring the efficacy of treatments and interventions for coronary artery disease (CAD). HRQOL is known to improve over the first year after interventions for CAD, but there is limited knowledge of the changes in HRQOL beyond 1 year. We investigated heterogeneity in long-term trajectories of HRQOL in patients with CAD. METHODS AND RESULTS: Data were obtained from 6226 patients identified from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease with at least 1-vessel CAD who underwent their first catheterization between 2006 and 2009. HRQOL was assessed using the Seattle Angina Questionnaire, a 19-item disease-specific measure of HRQOL for patients with CAD. Group-based trajectory analysis was used to identify various subgroups of Seattle Angina Questionnaire trajectories over time while adjusting for missing data through a longitudinal multiple imputation model. Multinomial logistic regression was used to identify the predictors of differences among the identified subgroups. Our analysis revealed significant improvements in HRQOL across all the 5 domains of Seattle Angina Questionnaire overtime for the whole data. Multitrajectory analyses revealed 4 HRQOL trajectory subgroups including high (25.1%), largely increased (32.3%), largely decreased (25.0%), and low (17.6%) trajectories. Age, sex, body mass index, diabetes mellitus, previous history of myocardial infarction, smoking, depression, anxiety, type of treatment received, and perceived social support were significant predictors of differences among these trajectory subgroups. CONCLUSIONS: This study highlights variations in longitudinal trajectories of HRQOL in patients with CAD. Despite overall improvements in HRQOL, about a quarter of our cohort experienced a significant decline in their HRQOL over the 5-year period. Understanding these HRQOL trajectories may help personalize prognostic information, identify patients and HRQOL domains on which clinical interventions are most beneficial, and support treatment decisions for patients with CAD.

13.
Am J Cardiol ; 121(7): 888-895, 2018 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-29394999

RESUMO

Half of women and 1/3 of men with angina and ischemia on stress testing have ischemia with no obstructive coronary artery disease (INOCA). These patients have quality of life (QoL) impairment comparable with patients with obstructive coronary artery disease. Clinicians generally treat INOCA with traditional antianginal agents despite previous studies demonstrating variable response to these medications. We performed a systematic review to evaluate the efficacy and safety of available pharmacologic therapies for INOCA. We systematically searched the Cochrane Central Register of Controlled Trials, Embase, MEDLINE, and the World Health Organization International Clinical Trials Registry Platform in July 2017 for randomized controlled trials (RCTs) evaluating pharmacologic agents for INOCA. The primary outcome of interest was QoL. Secondary outcomes included subjective and objective efficacy measures and safety outcomes. We included 35 RCTs from 333 identified studies. Interventions that improved QoL with moderate-quality evidence included angiotensin-converting enzyme (ACE) inhibitor (±statin) and ranolazine. Low-to-very-low-quality evidence also suggests that ACE inhibitors, ß blockers, calcium-channel blockers, nicorandil, ranolazine, and statins may decrease angina frequency and delay ischemia on stress testing. Other interventions, most notably nitrates, did not significantly improve any outcome. In conclusion, evidence for pharmacologic treatment of INOCA is generally poor, and higher-quality RCTs using a standardized definition of INOCA are needed. Moderate-quality evidence suggests that ACE inhibitors and ranolazine improve QoL. Other interventions had low-quality evidence or no evidence of efficacy.

14.
Ann Intern Med ; 168(4): 237-244, 2018 Feb 20.
Artigo em Inglês | MEDLINE | ID: mdl-29132159

RESUMO

Background: Uncertainty remains about the effects of aspirin in patients with prior percutaneous coronary intervention (PCI) having noncardiac surgery. Objective: To evaluate benefits and harms of perioperative aspirin in patients with prior PCI. Design: Nonprespecified subgroup analysis of a multicenter factorial trial. Computerized Internet randomization was done between 2010 and 2013. Patients, clinicians, data collectors, and outcome adjudicators were blinded to treatment assignment. (ClinicalTrials.gov: NCT01082874). Setting: 135 centers in 23 countries. Patients: Adults aged 45 years or older who had or were at risk for atherosclerotic disease and were having noncardiac surgery. Exclusions were placement of a bare-metal stent within 6 weeks, placement of a drug-eluting stent within 1 year, or receipt of nonstudy aspirin within 72 hours before surgery. Intervention: Aspirin therapy (overall trial, n = 4998; subgroup, n = 234) or placebo (overall trial, n = 5012; subgroup, n = 236) initiated within 4 hours before surgery and continued throughout the perioperative period. Of the 470 subgroup patients, 99.9% completed follow-up. Measurements: The 30-day primary outcome was death or nonfatal myocardial infarction; bleeding was a secondary outcome. Results: In patients with prior PCI, aspirin reduced the risk for the primary outcome (absolute risk reduction, 5.5% [95% CI, 0.4% to 10.5%]; hazard ratio [HR], 0.50 [CI, 0.26 to 0.95]; P for interaction = 0.036) and for myocardial infarction (absolute risk reduction, 5.9% [CI, 1.0% to 10.8%]; HR, 0.44 [CI, 0.22 to 0.87]; P for interaction = 0.021). The effect on the composite of major and life-threatening bleeding in patients with prior PCI was uncertain (absolute risk increase, 1.3% [CI, -2.6% to 5.2%]). In the overall population, aspirin increased the risk for major bleeding (absolute risk increase, 0.8% [CI, 0.1% to 1.6%]; HR, 1.22 [CI, 1.01 to 1.48]; P for interaction = 0.50). Limitation: Nonprespecified subgroup analysis with small sample. Conclusion: Perioperative aspirin may be more likely to benefit rather than harm patients with prior PCI. Primary Funding Source: Canadian Institutes of Health Research.

15.
BMC Cardiovasc Disord ; 17(1): 275, 2017 Nov 02.
Artigo em Inglês | MEDLINE | ID: mdl-29096604

RESUMO

BACKGROUND: Available cardiac surgery risk scores have not been validated in octogenarians. Our objective was to compare the predictive ability of the Society of Thoracic Surgeons (STS) score, EuroSCORE I, and EuroSCORE II in elderly patients undergoing isolated coronary artery bypass grafting surgery (CABG). METHODS: All patients who underwent isolated CABG (2002 - 2008) were identified from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) registry. All patients aged 80 and older (n = 304) were then matched 1:2 with a randomly selected control group of patients under age 80 (n = 608 of 4732). Risk scores were calculated. Discriminatory accuracy of the risk models was assessed by plotting the areas under the receiver operator characteristic (AUC) and comparing the observed to predicted operative mortality. RESULTS: Octogenarians had a significantly higher predicted mortality by STS Score (3 ± 2% vs. 1 ± 1%; p < 0.001), additive EuroSCORE (8 ± 3% vs. 4 ± 3%; p < 0.001), logistic EuroSCORE (15 ± 14% vs. 5 ± 6%; p < 0.001), and EuroSCORE II (4 ± 3% vs. 2 ± 2%; p < 0.001) compared to patients under age 80 years. Observed mortality was 2% and 1% for patients age 80 and older and under age 80, respectively (p = 0.323). AUC revealed areas for STS, additive and logistic EuroSCORE I and EuroSCORE II, respectively, for patients age 80 and older (0.671, 0.709, 0.694, 0.794) and under age 80 (0.829, 0.750, 0.785, 0.845). CONCLUSION: All risk prediction models assessed overestimated surgical risk, particularly in octogenarians. EuroSCORE II demonstrated better discriminatory accuracy in this population. Inclusion of new variables into these risk models, such as frailty, may allow for more accurate prediction of true operative risk.


Assuntos
Ponte de Artéria Coronária/mortalidade , Doença das Coronárias/cirurgia , Medição de Risco/métodos , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Ponte de Artéria Coronária/efeitos adversos , Doença das Coronárias/complicações , Feminino , Humanos , Masculino , Curva ROC , Estudos Retrospectivos
16.
Heart Surg Forum ; 20(4): E132-E138, 2017 08 24.
Artigo em Inglês | MEDLINE | ID: mdl-28846526

RESUMO

BACKGROUND: Coronary artery bypass grafting (CABG) with multiple distal target (MDT) grafts requires less graft material and reduces cardiopulmonary bypass time; however, there may be a higher incidence of graft failure. A real-world analysis reporting long-term outcomes associated with MDT grafts is lacking. MATERIAL AND METHODS: In 6262 consecutive patients who underwent an isolated first CABG from 2004-2012, patients with MDTs were propensity matched to those with single distal target (SDT) grafts. Logistic regression adjusted for traditional, anatomical, and functional definitions of complete revascularization (CR). Outcomes included 30-day, 1-year, and long-term mortality (median 6.29 years). Results: A total of 549 (8.8%) CABG patients had a MDT graft. CR defined using traditional (96.1% versus 92.0%, P = .005), anatomical (89.0% versus 80.20%, P < .001), and functional (90.7% versus 82.6, P < .001) definitions was more frequent in MDT patients. No significant differences in mortality were observed at 30 days (2% versus 3.3%, P = .18), 1-year (3.8% versus 4.9%, P = .37), or through end of follow-up (18.0% versus 16.6% P = .52) between the MDT and SDT groups, respectively. Similarly, no differences were observed after adjustment for all definitions of CR. Graft failure in MDT and SDT patients was 37.8% and 27.6%, respectively (P = .18). CONCLUSION: In a contemporary population-based cohort, no differences in mortality were observed between CABG patients with MDT and SDT grafts. Our findings support the safety of MDT grafts to facilitate CR in patients and when graft material is limited.


Assuntos
Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/cirurgia , Complicações Pós-Operatórias/epidemiologia , Veia Safena/transplante , Idoso , Alberta/epidemiologia , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/mortalidade , Feminino , Seguimentos , Humanos , Incidência , Masculino , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Fatores de Tempo , Resultado do Tratamento
17.
Can J Cardiol ; 33(8): 961-962, 2017 08.
Artigo em Inglês | MEDLINE | ID: mdl-28666615

Assuntos
Envelhecimento , Humanos
18.
Can J Cardiol ; 33(6): 724-736, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-28545621

RESUMO

BACKGROUND: Identification of patients at risk of contrast-induced acute kidney injury (CI-AKI) is valuable for targeted prevention strategies accompanying cardiac catheterization. METHODS: We searched MedLine and EMBASE for articles that developed or validated a clinical prediction model for CI-AKI or dialysis after angiography or percutaneous coronary intervention. Random effects meta-analysis was used to pool c-statistics of models. Heterogeneity was explored using stratified analyses and meta-regression. RESULTS: We identified 75 articles describing 74 models predicting CI-AKI, 10 predicting CI-AKI and dialysis, and 1 predicting dialysis. Sixty-three developed a new risk model whereas 20 articles reported external validation of previously developed models. Thirty models included sufficient information to obtain individual patient risk estimates; 9 using only preprocedure variables whereas 21 included preprocedural and postprocedure variables. There was heterogeneity in the discrimination of CI-AKI prediction models (median [total range] in c-statistic 0.78 [0.57-0.95]; I2 = 95.8%, Cochran Q-statistic P < 0.001). However, there was no difference in the discrimination of models using only preprocedure variables compared with models that included postprocedural variables (P = 0.868). Models predicting dialysis had good discrimination without heterogeneity (median [total range] c-statistic: 0.88 [0.87-0.89]; I2 = 0.0%, Cochran Q-statistic P = 0.981). Seven prediction models were externally validated; however, 2 of these models showed heterogeneous discriminative performance and 2 others lacked information on calibration in external cohorts. CONCLUSIONS: Three published models were identified that produced generalizable risk estimates for predicting CI-AKI. Further research is needed to evaluate the effect of their implementation in clinical care.


Assuntos
Lesão Renal Aguda/epidemiologia , Cateterismo Cardíaco/efeitos adversos , Meios de Contraste/efeitos adversos , Lesão Renal Aguda/induzido quimicamente , Cateterismo Cardíaco/métodos , Angiografia Coronária/efeitos adversos , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/cirurgia , Saúde Global , Humanos , Incidência , Modelos Teóricos , Intervenção Coronária Percutânea/efeitos adversos , Fatores de Risco
19.
BMC Health Serv Res ; 17(1): 354, 2017 05 16.
Artigo em Inglês | MEDLINE | ID: mdl-28511683

RESUMO

BACKGROUND: Specialized cardiology services have contributed to reduced mortality in acute coronary syndromes (ACS).  We sought to evaluate the outcomes of ACS patients admitted to non-cardiology services in Southern Alberta. METHODS: Retrospective chart review performed on all troponin-positive patients in the Calgary Health Region identified those diagnosed with ACS by their attending team. Patients admitted to non-cardiology and cardiology services were compared, using linked data from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) registry and the Strategic Clinical Network for Cardiovascular Health and Stroke. RESULTS: From January 1, 2007 to December 31, 2008, 2105 ACS patients were identified, with 1636 (77.7%) admitted to cardiology and 469 (22.3%) to non-cardiology services. Patients admitted to non-cardiology services were older, had more comorbidities, and rarely received cardiology consultation (5.1%). Cardiac catheterization was underutilized (5.1% vs 86.4% in cardiology patients (p < 0.0001)), as was evidence-based pharmacotherapy (p < 0.0001). Following adjustment for baseline comorbidities, 30-day through 4-year mortality was significantly higher on non-cardiology vs. cardiology services (49.1% vs. 11.0% respectively at 4-years, p < 0.0001). CONCLUSION: In a large ACS population in the Calgary Health Region, 25% were admitted to non-cardiology services. These patients had worse outcomes, despite adjustment for baseline risk factor differences. Although many patients were appropriately admitted to non-cardiology services, the low use of investigations and secondary prevention medications may contribute to poorer patient outcome. Further research is required to identify process of care strategies to improve outcomes and lessen the burden of illness for patients and the health care system.


Assuntos
Síndrome Coronariana Aguda/terapia , Serviço Hospitalar de Cardiologia/estatística & dados numéricos , Síndrome Coronariana Aguda/mortalidade , Idoso , Alberta/epidemiologia , Cateterismo Cardíaco/estatística & dados numéricos , Cardiologia/estatística & dados numéricos , Comorbidade , Doença das Coronárias/epidemiologia , Assistência à Saúde/estatística & dados numéricos , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Prevenção Secundária , Resultado do Tratamento
20.
Can J Cardiol ; 33(6): 806-813, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-28455163

RESUMO

BACKGROUND: Atrial fibrillation and flutter (AFF) are the most common arrhythmias presenting to emergency departments (EDs). We examined sex differences in outcomes for patients with AFF discharged from the ED in Alberta, Canada. METHODS: ED presentations for AFF during 1999-2011 that ended in discharge were extracted from administrative databases for all Alberta residents (age ≥ 35 years). Multivariable models determined the effect of sex on the time to ED return for AFF, the first follow-up visit with a physician, the first follow-up visit with a specialist (cardiologist or internal medicine physician), and death. RESULTS: There were 21,062 patients/ED presentations (47.5% women). About 10% returned to the ED for AFF after discharge; the time to return was similar for both sexes (P = 0.39). Time to a first physician visit was shorter (unadjusted hazard ratio [uHR] = 1.10) and time to a specialist follow-up visit was longer (uHR = 0.93) for women than for men. Interactions between sex and age, socioeconomic groups, and comorbidities were identified that changed the effect of sex on time to follow-up. More women died by 30 (1.3% vs 0.9%; P = 0.009) and 90 (2.9% vs 2.4%, P = 0.02) days. The time between ED discharge and death was shorter for women in 1 socioeconomic group (P = 0.008) and for those with peripheral vascular disease (P = 0.02) or diabetes (P = 0.03). CONCLUSIONS: We identified sex differences for time to return to the ED, follow-up visit, and death (most importantly, increased mortality rates among women at 30 and 90 days), and time to death remained significant after adjustment for other demographic and health-related variables. Our findings have important potential implications for physicians in the emergency setting.


Assuntos
Fibrilação Atrial/epidemiologia , Flutter Atrial/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Alta do Paciente , Idoso , Alberta/epidemiologia , Bases de Dados Factuais , Feminino , Seguimentos , Humanos , Incidência , Masculino , Prognóstico , Estudos Retrospectivos , Distribuição por Sexo , Fatores Sexuais , Taxa de Sobrevida/tendências , Fatores de Tempo
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