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1.
JACC Clin Electrophysiol ; 6(3): 341-347, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32192686

RESUMO

OBJECTIVES: This study sought to determine whether sex-specific differences in management and outcomes of syncope patients exist. BACKGROUND: Syncope is a common presentation to the emergency department (ED) and reason for hospital admission. METHODS: Patients ≥18 years of age, presenting to the ED with a primary diagnosis of syncope in Alberta, Canada, from January 1, 2007 to December 12, 2015 were included. ED records were linked to hospital records to identify patients admitted versus discharged from the ED. Outcomes included 30-day and 1-year all-cause mortality. Multivariable mixed-effect logistic regression assessed the association between sex and outcomes. RESULTS: Of the 63,274 ED syncope patients, 33,986 (53.7%) were women and 29,288 (46.3%) were men (p < 0.01). Compared with men, women were younger (51.6 ± 23.8 years for women vs. 55.1 ± 20.9 years for men; p < 0.001), less likely to arrive by ambulance (48.4% women vs. 51.7% men; p < 0.001), and had fewer comorbidities (67.9% women vs. 61.8% men with Charlson comorbidity score = 0; p < 0.001). Overall, 12.6% women and 16.8% men were admitted to hospital (p < 0.001). Regardless of discharge status, women had lower mortality rates (30-day admitted: 2.9% women and 4.4% men; p < 0.001; discharged: 0.2% women and 0.4% men; p < 0.001; and 1-year admitted: 12.6% women and 16.1% men; p < 0.001; discharged: 2.4% women and 3.7% men; p < 0.001). After adjusting for confounders, men were associated with 1.4-fold higher odds of death at 1 year. This was unchanged regardless of discharge status. CONCLUSIONS: Although women are more likely than men to present to the ED with syncope, they are less likely to be admitted to hospital. Mortality rates are lower for women, regardless of discharge status.

2.
J Rheumatol ; 47(2): 197-203, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31043549

RESUMO

OBJECTIVE: The effects of rheumatoid arthritis (RA) and spondyloarthritis (SpA) on maternal and neonatal outcomes at a population level have not previously been well compared. METHODS: A contemporary pregnancy cohort of 312,081 women and corresponding birth events was assembled for the province of Alberta from the random selection of 1 live birth event per woman. We identified 3 groups: (1) no inflammatory arthritis (no IA, n = 308,989), (2) RA (n = 631), and (3) SpA (n = 2461). We compared maternal and neonatal outcomes, comorbid conditions, and medication use among the 3 groups. Multivariable logistic regression models evaluated the independent association between RA and SpA, relative to no IA, and the outcomes of small for gestation age (SGA) and hypertensive disorders during pregnancy. RESULTS: Pregnant women with RA were significantly more likely to have preterm delivery (13.5%), cesarean delivery (33.9%), hypertensive disorders in pregnancy (10.5%), and SGA babies (15.6%), compared to pregnant women with either SpA or no IA. Nonsteroidal antiinflammatory drugs and corticosteroid use were significantly higher in pregnant women with RA compared to the other groups. Women with RA were significantly more likely to have an SGA baby (OR 1.51, 95% CI 1.21-1.88; p < 0.01), and hypertensive disorder in pregnancy (OR 1.51, 95% CI 1.16-1.97; p < 0.01), compared to women with no IA, while no difference was found between women with SpA and those with no IA. CONCLUSION: Women with RA have a higher risk of worse maternal and neonatal outcomes, whereas the risk of these events is similar between women with and without SpA.

3.
Eur Heart J Acute Cardiovasc Care ; 9(1_suppl): 45-58, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29652166

RESUMO

BACKGROUND: Despite guideline recommendations, the majority of patients with symptoms suggestive of acute coronary syndrome do not use emergency medical services to reach the emergency department (ED). The aim of this study was to investigate the factors associated with EMS utilisation and subsequent patient outcomes. METHODS: Using administrative data, all patients who presented to an ED in the metropolitan areas of Edmonton and Calgary in the years of 2007-2013 with main ED diagnosis of acute coronary syndrome, stable angina or chest pain were included. The travel distance was estimated using the geographic information system method to approximate the distance between the ED and patient home. The clinical endpoints were the 7-day and 30-day all-cause events (death, re-hospitalisation and repeat ED visit). RESULTS: Of 50,881 patients, 30.5% presented by emergency medical services. Patients with older age, female sex, ED diagnosis of acute coronary syndrome, more comorbidities and lower household income were more likely to use emergency medical services to reach the hospital. Longer travel distance was associated with higher emergency medical services use (odds ratio 1.09, 95% confidence interval 1.09-1.10), but it was not a predictor of clinical events. After adjustment for covariates and inverse propensity score weighting, emergency medical services use was associated with a higher risk of 7-day and 30-day clinical events. CONCLUSION: Several demographic and clinical features were associated with higher emergency medical services use including geographical variation. Although longer travel distance was shown to be linked to higher emergency medical services use, it was not an independent predictor of patient outcome. This has implications for the design of emergency medical services systems, triage and early diagnosis and treatment options.

4.
Europace ; 2019 Dec 04.
Artigo em Inglês | MEDLINE | ID: mdl-31800033

RESUMO

AIMS: The first presentation of atrial fibrillation (AF) is often to an emergency department (ED). We evaluated the association of subsequent specialist care with morbidity and mortality. METHODS AND RESULTS: Retrospective cohort study of all adults in Alberta, Canada, with a new primary diagnosis of AF treated and released during an index ED visit between 2009 and 2015. Types of physician follow-up within 3 months of ED visit was analysed using Cox proportional hazards models with time-varying covariates. Outcomes were evaluated at 1 year. Of 7986 patients, 476 (6.0%) had no physician follow-up within 3 months, whereas 2730 (34.2%) attended a non-specialist only, 1277 (16.0%) an internal medicine specialist, and 3503 (43.9%) cardiology. An increasing gradient of cardiac investigations occurred across these groups. Cardiology compared with non-cardiologist care was associated with approximately two-fold greater electrophysiology interventions and revascularization, and increased use of beta-blockers (48.9% vs. 43.0%, P < 0.0001), statins (31.4% vs. 26.7%, P < 0.0001), and oral anticoagulation in patients with CHADS2 scores ≥1 (53.7% vs. 43.6%, P < 0.0001). In the subsequent year, cardiology care was associated with fewer deaths [adjusted hazard ratio (aHR) 0.72, 95% confidence interval (CI) 0.55-0.93], strokes (aHR 0.60, 95% CI 0.37-0.96), or major bleeds (aHR 0.69, 95% CI 0.53-0.89). No differences in the risk of hospitalization or ED visits were associated with cardiology care. CONCLUSION: Cardiology care after an ED visit for symptomatic new-onset AF is associated with better prognosis. The benefit may be mediated through more intensive investigation, identification, and treatment of cardiovascular risk factors and disease.

5.
Eur Heart J Acute Cardiovasc Care ; : 2048872619883400, 2019 Oct 30.
Artigo em Inglês | MEDLINE | ID: mdl-31663772

RESUMO

BACKGROUND: Emerging evidence suggests that coronary intensive care units are evolving into intensive care environments with an increasing burden of non-cardiovascular illness, but previous studies have been limited to older populations or single center experiences. METHODS: Canadian national health-care data was used to identify all patients ≥18 years admitted to dedicated coronary intensive care units (2005-2015) and admissions were categorized as primary cardiac or non-cardiac. The outcomes of interest included longitudinal trends in admission diagnoses, critical care therapies, and all-cause in-hospital mortality. RESULTS: Among the 373,992 patients admitted to a coronary intensive care unit, minimal changes in the proportion of patients admitted with a primary cardiac (88.2% to 86.9%; p<0.001) and non-cardiac diagnoses (11.8% to 13.1%; p<0.001) were observed. Among cardiac admissions, a temporal increase in the proportion of ST-segment elevation myocardial infarction (19.4% to 24.1%, p<0.001), non-ST-segment elevation myocardial infarction (14.6% to 16.2%, p<0.001), heart failure (7.3% to 8.4%, p<0.001), shock (4.9% to 5.7%, p<0.001), and decline in unstable angina (4.9% to 4.0%, p<0.001) and stable coronary diseases (21.3% to 12.4%, p<0.001) was observed. The proportion of patients requiring critical care therapies (57.8% to 63.5%, p<0.001) including mechanical ventilation (9.6% to 13.1%, p<0.001) increased. In-hospital mortality rates for patients with primary cardiac (4.9% to 4.4%; adjusted odds ratio 0.71, 95% confidence interval 0.63-0.79) and non-cardiac (17.8% to 16.1%; adjusted odds ratio 0.84, 0.73-0.97) declined; results were consistent when stratified by academic vs community hospital, and by the presence of on-site percutaneous coronary intervention. CONCLUSION: In a national dataset we observed a changing case-mix among patients admitted to a coronary intensive care unit, though the proportion of patients with a primary cardiac diagnosis remained stable. There was an increase in clinical acuity highlighted by critical care therapies, but in-hospital mortality rates for both primary cardiac and non-cardiac conditions declined across all hospitals. Our findings confirm the changing coronary intensive care unit case-mix and have implications for future coronary intensive care unit training and staffing.

6.
J Cardiovasc Magn Reson ; 21(1): 58, 2019 09 12.
Artigo em Inglês | MEDLINE | ID: mdl-31511018

RESUMO

BACKGROUND: Pulmonary edema is a cardinal feature of heart failure but no quantitative tests are available in clinical practice. The goals of this study were to develop a simple cardiovascular magnetic resonance (CMR) approach for lung water quantification, to correlate CMR derived lung water with intra-cardiac pressures and to determine its prognostic significance. METHODS: Lung water density (LWD, %) was measured using a widely available single-shot fast spin-echo acquisition in two study cohorts. Validation Cohort: LWD was compared to left ventricular end-diastolic pressure or pulmonary capillary wedge pressure in 19 patients with heart failure undergoing cardiac catheterization. Prospective Cohort: LWD was measured in 256 subjects, including 121 with heart failure, 82 at-risk for heart failure and 53 healthy controls. Clinical outcomes were evaluated up to 1 year. RESULTS: Within the validation cohort, CMR LWD correlated to invasively measured left-sided filling pressures (R = 0.8, p < 0.05). In the prospective cohort, mean LWD was 16.6 ± 2.1% in controls, 17.9 ± 3.0% in patients at-risk and 19.3 ± 5.4% in patients with heart failure, p < 0.001. In patients with or at-risk for heart failure, LWD >  20.8% (mean + 2 standard deviations of healthy controls) was an independent predictor of death, hospitalization or emergency department visit within 1 year, hazard ratio 2.4 (1.1-5.1, p = 0.03). CONCLUSIONS: In patients with heart failure, increased CMR-derived lung water is associated with increased intra-cardiac filling pressures, and predicts 1 year outcomes. LWD could be incorporated in standard CMR scans.

7.
Can J Cardiol ; 35(10): 1412-1415, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31473069

RESUMO

Health administrative data are routinely used to assess disease burden, quality of care, and outcomes for atrial fibrillation (AF). Governments, administrators, and researchers define cohorts differently, based on 3 key factors: the case definition algorithm to identify AF, inclusion/exclusion of transient AF, and the lookback period to identify cases. We assessed the impact of varying these key factors on estimates of the use of guideline-indicated oral anticoagulation (OAC). Hospitalization, ED, and outpatient claim databases were linked in British Columbia. AF was defined by ICD-9 or 10 codes 427.3x or I48.x. We examined a specific (1 hospital or 1 ED or 2 outpatient) vs a sensitive (1 hospital or ED or outpatient) algorithm; inclusion/exclusion of AF associated with open-heart surgery; and lookback periods of 1 to 10 years. We found the more specific AF definition increased OAC utilization by 5% (58.7% vs 53.4%); excluding AF associated with open-heart surgery increased OAC utilization by 0.7% to 2.3%; and each additional lookback year identified more prevalent cases but reduced OAC utilization by approximately 1%. In 40 scenarios, generated by varying all 3 key factors, OAC utilization ranged from 52% to 72%. Assuming a ceiling of 90%, the estimated "treatment gap" therefore varied from 18% to 38%. The 2-fold variation in the OAC treatment gap was based entirely on cohort definition. This has significant implications for health policy and quality indicators.

8.
Pediatr Obes ; 14(11): e12561, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31318175

RESUMO

We evaluated changes in overweight, obesity, and severe obesity in a population of 4- to 6-year-olds from 2010 to 2017. Anthropometric data were collected during children's preschool immunization visits in Edmonton and Calgary, Alberta, Canada. Body mass index (BMI), BMI z scores, and weight status categories were based on the World Health Organization criteria. Across 8 years, we examined population-level data from 161 114 children in which the prevalence of overweight (17.8%-15.7%; P < .001) and obesity (4.7%-4.2%; .004) decreased, while severe obesity (2.4%-2.2%; .3) remained unchanged. Overweight decreased in both boys (19.2%-16.8%; P < .0001) and girls (16.4%-14.6%; .003); obesity decreased in boys (5.3%-4.4%; .005), but not girls (4.1%-3.9%; .2). Severe obesity was stable in both sexes. Annual household income and breast feeding had positive, but variable moderating effects on overweight and obesity exclusively. Overall, reductions in overweight and obesity were positive findings, but targeted strategies are needed to reduce severe obesity in preschoolers.

9.
J Am Heart Assoc ; 8(10): e011608, 2019 May 21.
Artigo em Inglês | MEDLINE | ID: mdl-31088190

RESUMO

Background We examined temporal trends, timing, and frequency, as well as adverse neonatal and maternal outcomes occurring in the first year postpartum among women experiencing syncope during pregnancy. Methods and Results This was a retrospective study of pregnancies between January 1, 2005, and December 31, 2014, in the province of Alberta, Canada. Of 481 930 pregnancies, 4667 had an episode of syncope. Poisson regression analysis found a 5% increase/year (rate ratio, 1.05; 95% CI, 1.04-1.06) in the age-adjusted incidence of syncope. Overall, 1506 (32.3%) of the syncope episodes first occurred in the first trimester, 2058 (44.1%) in the second trimester, and 1103 (23.6%) in the third trimester; and 8% (n=377) of pregnancies had >1 episode of syncope. Compared with women without syncope, women who experienced syncope were younger (age <25 years; 34.7% versus 20.8%; P<0.001), and primiparous (52.1% versus 42.4%; P<0.001). The rate of preterm birth was higher in pregnancies with syncope during the first trimester (18.3%), compared with the second (15.8%) and third trimesters (14.2%) and pregnancies without syncope (15.0%; P<0.01). The incidence of congenital anomalies among children born of pregnancies with multiple syncope episodes was significantly higher (4.9%) compared with children of pregnancies without syncope (2.9%; P<0.01). Within 1 year after delivery, women with syncope during pregnancy had higher rates of cardiac arrhythmias and syncope episodes than women with no syncope during pregnancy. Conclusions Pregnant women with syncope, especially when the syncopal event occurs during the first trimester, may be at a higher risk of adverse pregnancy outcomes as well as an increased incidence of cardiac arrhythmia and syncope postpartum.

10.
Can J Cardiol ; 35(4): 430-437, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30935633

RESUMO

BACKGROUND: The effect of sex on self-reported frailty in acute coronary syndromes (ACS) is unclear. We examined the prevalence of self-reported frailty and its association with all-cause death among men and women. METHODS: Elderly (≥ 65 years) male (n = 2691) and female (n = 2305) patients with ACS enrolled in the Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes (TRILOGY ACS) trial were screened using the Fried Frailty Index. Sex differences in prevalence of frailty symptoms and categories (not frail; prefrail [1 to 2 symptoms]; and frail [≥ 3 symptoms]) and their prognostic importance were examined. RESULTS: Women were older and had higher rates of comorbidities than men. A total of 739 (27.5%) men and 645 (28%) women reported ≥ 1 frailty symptom. Prevalence of frailty increased with age among men but not women. During a median follow-up of 17.3 months, 353 (13.1%) men and 266 (11.5%) women died. After adjusting for age, prefrail men had a 35% increased risk (hazard ratio [HR] 1.35; 95% confidence interval [CI], 1.07-1.71), and frail men had an 80% increased risk (HR 1.80; 95% CI, 1.22-2.67) of death relative to not-frail men. The age-adjusted HR for death in prefrail women was 1.40 (95% CI, 1.07-1.84), and 1.55 (95% CI, 0.96-2.49) in frail women relative to not-frail women. Self-reported slow walk time and decreased physical activity appeared to provide the most prognostic information. CONCLUSION: Self-reported frailty was similar among men and women with ACS. Frailty increased with age only among men, in whom it added more prognostic information. Patient-reported frailty may identify elderly patients with ACS, particularly men, at high-risk of mortality.


Assuntos
Síndrome Coronariana Aguda/mortalidade , Fragilidade/mortalidade , Síndrome Coronariana Aguda/tratamento farmacológico , Idoso , Envelhecimento , Clopidogrel/uso terapêutico , Comorbidade , Exercício , Feminino , Força da Mão , Humanos , Masculino , Inibidores da Agregação de Plaquetas/uso terapêutico , Cloridrato de Prasugrel/uso terapêutico , Prevalência , Prognóstico , Autorrelato , Fatores Sexuais , Velocidade de Caminhada
11.
Eur Heart J Acute Cardiovasc Care ; 8(7): 660-666, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30977391

RESUMO

AIMS: Registries have reported large inter-hospital differences in intensive care unit admission rates for patients with acute heart failure, but little is known about the potential economic impact of over-admission of low-risk patients with heart failure to higher cost intensive care units. We described the variability in intensive care unit admission practices, the provision of critical care therapies, and estimated the potential national cost savings if all hospitals adopted low intensive care unit admission practices for patients admitted with heart failure. METHODS: Using a national population health dataset, we identified 349,693 heart failure admission hospitalisations with a primary diagnosis of heart failure between 2007 and 2016. Hospitals were categorised as low (first quartile), medium (second and third quartile) and high (fourth quartiles) intensive care unit utilisation. RESULTS: The mean intensive care unit admission rate was 16.4% (inter-hospital range 0.3-51%) including 5.4% in low, 14.5% in medium and 30% in high utilisation hospitals. Intensive care unit therapies in low, medium and high intensive care unit utilisation hospitals were 54.5%, 45.1% and 24.1% (P<0.001), respectively and the inhospital mortality rate was not significantly different. The proportion of hospital costs incurred by intensive care unit care was 7.8% in low, 19.8% in medium and 28.2% in high (P<0.001) admission hospitals. The potential cost savings of altering intensive care unit utilisation practices for patients with heart failure was CAN$234.8m over the study period. CONCLUSIONS: In a national cohort of patients hospitalised with heart failure, we observed that low intensive care unit utilisation centres had lower hospital costs with no differences in mortality rates. The development of standardised admission criteria for high-cost and high acuity intensive care unit beds could reduce costs to the healthcare system.


Assuntos
Cuidados Críticos/economia , Custos de Cuidados de Saúde/tendências , Insuficiência Cardíaca/economia , Hospitalização/economia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Canadá/epidemiologia , Feminino , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/terapia , Humanos , Masculino , Morbidade/tendências , Estudos Retrospectivos
12.
JAMA Cardiol ; 4(5): 444-453, 2019 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-30969316

RESUMO

Importance: Over the past decade, reducing 30-day readmission rates has been emphasized in the United States (including via the implementation of the Hospital Readmissions Reduction Program) but not Canada. Objective: To examine changes that occurred from April 1, 2005, to December 31, 2015, in the United States and Canada for hospitalization length of stay and 30-day readmission rates of patients with heart failure. Design, Setting, and Participants: This cohort study included patients admitted with a primary diagnosis of heart failure to Canadian and US hospitals between April 1, 2005, and December 31, 2015, using International Classification of Diseases, Ninth Revision code 428.xx and Tenth Revision code I50. The study examined secular trends in length of stay and readmissions in both countries and tested for changes after implementation of the Hospital Readmissions Reduction Program using segmented regression models and the association between length of stay and readmissions using patient-level and hospital-level multivariable logistic regression models. Data analysis was completed from February 2018 to August 2018. Main Outcomes and Measures: Thirty-day readmissions. Results: Between 2005 and 2015, mean length of stay declined marginally in Canadian hospitals (from a mean [SD] of 7.5 [5.7] to 7.3 [5.6] days; P < .001) but remained stable in US hospitals (mean [SD], 4.9 [3.7] days to 4.9 [3.5] days). Thirty-day readmission rates declined similarly in Canada (from 4088 of 20 758 patients [19.7%] to 3823 of 21 733 patients [17.6%] for all-cause readmissions; P < .001; and from 1743 of 20 758 patients [8.4%] to 1490 of 21 733 patients [6.9%] for heart failure-specific readmissions; P < .001) and the United States (from 21.2% to 18.5% for all-cause readmissions; from 7.6% to 5.7% for heart failure-specific readmissions; both P < .001). There were small but statistically significant positive correlations between length of stay and 30-day readmissions in both Canada (odds ratio, 1.01 [95% CI, 1.01-1.01]) and the United States (odds ratio, 1.01 [95% CI, 1.01-1.01]). Interrupted time-series analysis comparing readmission rates before and after the Hospital Readmissions Reduction Program implementation revealed no significant difference in either country for all-cause readmission rates before and after October 2012. There was also no change in the slope of the temporal trends; in Canada, all-cause readmissions were decreasing 1.1% per year before implementation and 1.3% after implementation (P = .84 for slope change) compared with 1.6% per year in the United States before implementation and 1.8% per year after October 2012 (P = .60 for slope change). Conclusions and Relevance: Both Canada and the United States exhibited similar temporal declines in 30-day all-cause readmissions over the past decade. These findings suggest that the Hospital Readmissions Reduction Program did not appear to be associated with this secular trend or length of stay for heart failure in the United States.

13.
Diabetologia ; 62(2): 249-258, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30421138

RESUMO

AIMS/HYPOTHESIS: This study aimed to examine the association of maternal diabetes, being large for gestational age (LGA) and breast-feeding with being overweight or obese in pre-school-aged children. METHODS: Data on height and weight at the time of their pre-school (age 4-6 years) immunisation visit between January 2009 and August 2017, as well as breast-feeding status in the first 5 months of life, for 81,226 children born between January 2005 and August 2013 were linked with maternal hospitalisation and outpatient records and birth registry data. Children were grouped into six categories based on maternal diabetes status during pregnancy (no diabetes, gestational diabetes or pre-existing diabetes) and birthweight (appropriate for gestational age [AGA] or LGA). WHO criteria were used to identify children who were overweight or obese. RESULTS: There were 69,506 children in the no diabetes/AGA group (control), 5926 in the no diabetes/LGA group, 4563 in the gestational diabetes/AGA group, 573 in the gestational diabetes/LGA group, 480 in the pre-existing diabetes/AGA group and 178 in the pre-existing diabetes/LGA group. The rate of being overweight/obese at pre-school age ranged from 20.5% in the control group to 42.9% in the gestational diabetes/LGA group. The adjusted attributable risk per cent for LGA alone (39.4%) was significantly higher than that for maternal gestational diabetes (16.0%) or pre-existing diabetes alone (15.1%); the risk for the combinations of gestational diabetes/LGA and pre-existing diabetes/LGA were 50.1% and 39.1%, respectively. Further stratification of the pre-existing diabetes groups found the prevalence of being overweight/obese was 21.2% in the type 1/AGA group, 31.4% in the type 1/LGA group (similar to those in the no diabetes groups), 26.7% in the type 2/AGA group and 42.5% in the type 2/LGA group. Breast-feeding was associated with a lower likelihood of being overweight/obese in childhood in all groups except gestational diabetes/LGA and pre-existing diabetes/LGA (both type 1 and type 2). CONCLUSION/INTERPRETATION: LGA is a stronger marker for risk of being overweight/obese in early childhood, compared with maternal diabetes during pregnancy. Rates of being overweight/obese in childhood were highest in LGA children born to mothers with gestational diabetes or pre-existing type 2 diabetes. Breast-feeding was associated with a lower risk of being overweight/obese in childhood in the majority of children; however, this association was not maintained in LGA children of mothers with diabetes.


Assuntos
Aleitamento Materno , Diabetes Mellitus Tipo 2/complicações , Diabetes Gestacional/metabolismo , Macrossomia Fetal/etiologia , Sobrepeso/etiologia , Obesidade Pediátrica/etiologia , Índice de Massa Corporal , Criança , Pré-Escolar , Diabetes Mellitus Tipo 2/metabolismo , Feminino , Humanos , Recém-Nascido , Masculino , Sobrepeso/metabolismo , Obesidade Pediátrica/metabolismo , Gravidez , Gravidez em Diabéticas/metabolismo , Fatores de Risco
14.
Arterioscler Thromb Vasc Biol ; 39(2): 276-284, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30580559

RESUMO

Objective- Although patients with diabetes mellitus (DM) are considered at high risk of cardiovascular events, there is growing evidence that this notion is incorrect. Atherosclerosis imaging may identify patients at risk. Approach and Results- We performed coronary atherosclerosis with 18F-sodium fluoride (NaF) positron emission tomography/computed tomography and gated chest computed tomography for coronary artery calcium in 88 consecutive ambulatory patients with DM on a stable medical regimen. NaF has been shown to localize avidly in culprit lesions of patients with acute coronary syndromes and may identify unstable plaques. NaF activity was measured as target (coronary arteries)-to-background (left ventricular pool) ratio (TBR). High TBR was defined as ≥1.5. The mean age of the cohort was 54±14 years, 55% had type 2 DM, 65% were men, the median HgbA1c (hemoglobin A1c) and LDL (low-density lipoprotein) cholesterol were 7.5% (interquartile range, 7.1-8.5) and 1.9 mmol/L (interquartile range, 1.5-2.6), respectively. Mean coronary artery calcium score was 374±773, and median TBR was 1.2. Coronary artery TBR ≥1.5 was detected in 13 (15%) patients. In univariable analyses, male sex ( P=0.0002), estimated glomerular filtration rate ( P=0.02), and total coronary artery calcium score ( P=0.04) were associated with TBR. In multivariable analyses, TBR >median was associated with male sex ( P=0.0001) and statin use ( P=0.042). Conclusions- In ambulatory patients with DM asymptomatic for cardiovascular disease, the prevalence of potentially vulnerable plaques detected with NaF was low, but in the absence of follow-up data at this stage, we cannot assess the import of this information. Future research will establish whether NaF imaging helps risk stratify patients with DM. Clinical Trial Registration- URL: http://www.clinicaltrials.gov . Unique identifier: NCT03530176.


Assuntos
Doença da Artéria Coronariana/diagnóstico por imagem , Complicações do Diabetes/diagnóstico por imagem , Radioisótopos de Flúor , Compostos Radiofarmacêuticos , Fluoreto de Sódio , Adulto , Idoso , Idoso de 80 Anos ou mais , Cálcio/análise , Vasos Coronários/química , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
15.
Eur Heart J Acute Cardiovasc Care ; : 2048872618812135, 2018 Nov 13.
Artigo em Inglês | MEDLINE | ID: mdl-30421616

RESUMO

AIMS:: The purpose of this study was to compare outcomes associated with medical management of ST-elevation myocardial infarction and non-ST-elevation myocardial infarction patients presenting to hospitals with and without onsite catheterization facilities. METHODS: All patients ( n=25,921) with ST-elevation myocardial infarction ( n=10,563) or non-ST-elevation myocardial infarction ( n=15,358) in Alberta, Canada between April 2010-March 2016 were categorized according to availability of catheterization facilities at the hospital they presented to and their management strategy (medically managed without coronary angiography or medically managed after coronary angiography). RESULTS:: Overall, 51% presented to hospitals without catheterization facilities; and 34% were managed medically (18% without coronary angiography, and 16% after coronary angiography). Rates of medical management were higher at hospitals without versus those with catheterization facilities (43% vs. 24%, p<0.01). However, both the rate of presentation to hospitals without catheterization facilities (70% non-ST-elevation myocardial infarction, 24% ST-elevation myocardial infarction, p<0.01) and medical management (45% non-ST-elevation myocardial infarction, 18% ST-elevation myocardial infarction, p<0.01) differed by myocardial infarction type. The lack of catheterization facilities at the presenting hospital had no association with in-hospital mortality in patients medically managed without coronary angiography, but was associated with a lower risk of mortality among patients medically managed after coronary angiography. However, the latter benefit was restricted to non-ST-elevation myocardial infarction patients only (adjusted hazard ratio 0.43, 95% confidence interval: 0.25-0.76). CONCLUSION:: The availability of catheterization facilities at the hospital at which non-ST-elevation myocardial infarction and ST-elevation myocardial infarction patients presented influenced their likelihood of being medically managed, but was not associated with adverse short- or long-term mortality outcomes.

16.
Can J Cardiol ; 34(10): 1365-1368, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30269834

RESUMO

Acute coronary syndromes (ACS) and heart failure (HF) are the leading diagnoses in patients admitted to critical care units (CCUs). Little is known about the differences between CCU resource use and outcomes across hospital types. The Canadian Institute for Health Information was used to identify patients hospitalized with primary diagnoses of ACS or HF. CCUs were categorized as teaching, large community, medium community, and small community hospitals. Outcomes included CCU rates of admission, use of critical care therapy/procedures, and in-hospital mortality. Among 204,900 patients hospitalized with ACS or HF, 73,338 (35.8%, hospital range 0% to 81.4%) were admitted to CCUs, and it varied across hospital types: 41.0% in teaching, 30.0% in large, 45.4% in medium, and 30.9% in small community hospitals (P < 0.001). The percentage of patients admitted to CCUs who received critical care therapies in teaching, large, medium, and small hospitals were as follows: 73.6%, 50.9%, 24.6%, and 8.8% (P < 0.0001). Compared with the in-hospital mortality rate for patients admitted to CCUs in teaching hospitals (8.2%), outcomes were worse for CCU patients in large (11.0%, adjusted odds ratio [aOR] 1.50; 95% CI, 1.19-1.90), medium (10.5%, aOR 1.56; 95% CI, 1.27-1.92), and small community hospitals (9.2%, aOR 1.59; 95% CI, 1.20-2.10). Patients admitted with ACS or HF to teaching hospital CCUs had a higher observed use of critical care therapies and lower mortality compared with community hospitals. These differences highlight the need to examine differences in CCU admission thresholds, resource utilization, and outcomes across hospitals types.


Assuntos
Síndrome Coronariana Aguda/epidemiologia , Unidades de Cuidados Coronarianos/estatística & dados numéricos , Insuficiência Cardíaca/epidemiologia , Hospitais Comunitários , Hospitais de Ensino , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Vigilância da População , Síndrome Coronariana Aguda/economia , Síndrome Coronariana Aguda/terapia , Idoso , Canadá/epidemiologia , Feminino , Insuficiência Cardíaca/economia , Insuficiência Cardíaca/terapia , Mortalidade Hospitalar/tendências , Humanos , Masculino , Morbidade/tendências , Razão de Chances , Admissão do Paciente/tendências
17.
J Am Heart Assoc ; 7(18): e009859, 2018 09 18.
Artigo em Inglês | MEDLINE | ID: mdl-30371219

RESUMO

Background Little is known about the prognostic implications of frailty, a state of susceptibility to stressors and poor recovery to homeostasis in older people, after myocardial infarction ( MI ). Methods and Results We studied 3944 MI patients aged ≥65 years treated at 41 Australian hospitals from 2009 to 2016 in the CONCORDANCE ( Australian Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events ) registry. Frailty index ( FI ) was determined using the health deficit accumulation method. All-cause and cardiac-specific mortality at 6 months were compared between frail ( FI >0.25) and nonfrail ( FI ≤0.25) patients. Among 1275 patients with ST-segment-elevation MI (STEMI), 192 (15%) were frail, and among 2669 non-STEMI ( NSTEMI) patients, 902 (34%) were frail. Compared with nonfrail counterparts, frail STEMI patients received 30% less reperfusion therapy and 22% less revascularization during index hospitalization; frail NSTEMI patients received 30% less diagnostic angiography and 39% less revascularization. Unadjusted 6-month all-cause mortality ( STEMI : 13% versus 3%; NSTEMI : 13% versus 4%) and cardiac-specific mortality ( STEMI : 6% versus 1.4%, NSTEMI : 3.2% versus 1.2%) were higher among frail patients. After adjustment for known prognosticators, FI was significantly associated with higher 6-month all-cause ( STEMI : odds ratio: 1.74 per 0.1 FI [ 95% confidence interval, 1.37-2.22], P<0.001; NSTEMI : odds ratio: 1.62 per 0.1 FI [95% confidence interval, 1.40-1.87], P<0.001) but not cardiac-specific mortality ( STEMI : P=0.99; NSTEMI : P=0.93). Conclusions Frail patients receive lower rates of invasive cardiac care during MI hospitalization. Increased frailty was independently associated with increased postdischarge all-cause mortality but not cardiac-specific mortality. These findings inform identification of frailty during MI hospitalization as a potential opportunity to address competing risks for mortality in this high-risk population.


Assuntos
Fragilidade/etiologia , Infarto do Miocárdio/complicações , Sistema de Registros , Idoso , Idoso de 80 Anos ou mais , Austrália/epidemiologia , Causas de Morte/tendências , Eletrocardiografia , Feminino , Seguimentos , Fragilidade/epidemiologia , Mortalidade Hospitalar/tendências , Humanos , Incidência , Masculino , Infarto do Miocárdio/mortalidade , Prognóstico , Estudos Prospectivos , Fatores de Risco , Taxa de Sobrevida/tendências
18.
Can J Cardiol ; 34(10): 1298-1306, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30170782

RESUMO

BACKGROUND: Little is known about the resource use and cost burden of acute myocardial infarction (AMI) beyond the index event. We examined resource use and care costs during the first and each subsequent year, among patients with incident AMI. METHODS: Patients aged ≥18 years who were admitted with incident AMI at emergency departments or hospitals in Alberta, Canada, between April 2004 and March 2014 were included. Incident cases were defined as those without an AMI hospitalization in the previous 10 years. Inpatient, outpatient, practitioner claims, drug claims, and vital statistics were linked and follow-up data were available until March 2016. Resource use and care costs per patient for each year after the AMI were calculated. RESULTS: The analysis included 41,210 patients with incident AMI (non-ST-segment elevation myocardial infarction [NSTEMI] = 50.8%, ST-segment elevation myocardial infarction = 36.8%, and undefined myocardial infarction [MI] = 12.5%). Resource use and care costs were highest during the first year. Compared with other MI groups, patients with ST-segment elevation myocardial infarction had more frequent outpatient visits (mean 1.64 vs 0.99 [NSTEMI] and 0.87 [undefined MI] visits) but spent fewer days in hospital (mean 7.72 vs 9.23 [NSTEMI] and 8.5 [undefined MI] days) during the first year. AMI costs were $19,842 during the first year and $845 per year for the next 5 years. Hospitalization costs accounted for the majority of costs during the first year (81.1%), whereas drug costs did for the next 5 years (62.1%). CONCLUSIONS: The long-term annual cost burden of AMI is modest compared with care costs during the first year. Although hospitalization dominates first year costs, pharmaceuticals do so in the long term.


Assuntos
Recursos em Saúde/estatística & dados numéricos , Custos Hospitalares , Hospitalização/economia , Assistência de Longa Duração/economia , Infarto do Miocárdio/economia , Pacientes Ambulatoriais , Médicos/economia , Idoso , Idoso de 80 Anos ou mais , Alberta/epidemiologia , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo
19.
Can J Cardiol ; 34(10): 1289-1297, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30205987

RESUMO

BACKGROUND: Data regarding health care resource utilization (HRU) in early childhood among children with congenital heart disease (CHD) are scarce. Therefore, we sought to describe the extent of HRU incurred among children with CHD in the first 5 years of life. METHODS: This population-based retrospective cohort study included all children born between January 2005 and March 2014 in Alberta, Canada. We linked inpatient, outpatient, practitioner claims, and drug dispensing databases with vital statistics (birth and death registries). RESULTS: In the first year of life, the cumulative hospitalization rate per 100 children was 335 (95% confidence interval: 312-360) for single ventricle (SV) children, 200 (194-206) for moderate-complex CHD, and 152 (149-156) for simple CHD vs 109 (108-109) among children without CHD (P < 0.001). The ambulatory-care visit rate per 100 children was 4871 (4780-4963) for SV, 2278 (2258-2299) for moderate-complex, and 1416 (1405-1426) for simple CHD vs 246 (246-247) for children without CHD (P < 0.001). The rates of physician claims and drug dispensing also demonstrated similar patterns. The median total hospitalization length of stay during the first year of life was 54 days (interquartile range: 26-95) in SV, 15 (4-39) in moderate-complex, and 6 (2-26) in simple CHD compared with 2 (1-3) among children without CHD (P < 0.001). These differences remained throughout the first 5 years of life, with children with CHD having consistently higher hospitalization rates and emergency department visit rates in every year of age compared with children without CHD. CONCLUSIONS: Cumulative HRU is high among children with CHD in the first 5 years of life and increases with increasing CHD severity. Improving survival of SV lesions will require increasing resource allocation to this group.


Assuntos
Recursos em Saúde/organização & administração , Cardiopatias Congênitas/terapia , Hospitalização/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Vigilância da População , Sistema de Registros , Alberta/epidemiologia , Criança , Pré-Escolar , Feminino , Cardiopatias Congênitas/epidemiologia , Humanos , Incidência , Lactente , Pacientes Internados , Masculino , Estudos Retrospectivos , Taxa de Sobrevida/tendências
20.
Heart Rhythm ; 15(12): 1791-1799, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30063211

RESUMO

BACKGROUND: The implantable cardioverter-defibrillator (ICD) may be associated with a high risk of complications in patients with catecholaminergic polymorphic ventricular tachycardia (CPVT). However, ICDs in this population have not been systematically evaluated. OBJECTIVE: The purpose of this study was to characterize the use and outcomes of ICDs in CPVT. METHODS: We conducted a systematic review using Embase, MEDLINE, PubMed, and Google Scholar to identify studies that included patients with CPVT who had an ICD. RESULTS: Fifty-three studies describing 1429 patients with CPVT were included. In total, 503 patients (35.2%) had an ICD (median age 15.0 years; interquartile range 11.0-21.0 years). Among ICD recipients with a reported medication status, 96.7% were prescribed ß-blockers and 13.2% flecainide. Sympathetic denervation was performed in 23.2%. Nearly half of patients received an ICD for primary prevention (47.3%), and 12.8% were prescribed optimal antiarrhythmic therapy. During follow-up, 40.1% had ≥1 appropriate shock, 20.8% experienced ≥1 inappropriate shock, 19.6% had electrical storm, and 7 patients (1.4%) died. An ICD-associated electrical storm was implicated in 4 deaths. Additional complications such as lead failure, endocarditis, or surgical revisions were observed in 96 of 296 patients (32.4%). A subanalysis of the 10 studies encompassing 330 patients with the most detailed ICD-related data showed similar trends. CONCLUSION: In this population with CPVT, ICDs were common and associated with a high burden of shocks and complications. The reliance on primary prevention ICDs, and poor uptake of adjuvant antiarrhythmic therapies, suggests that improved adherence to guideline-directed management could reduce ICD use and harm.


Assuntos
Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis , Eletrocardiografia , Taquicardia Ventricular/terapia , Humanos , Resultado do Tratamento
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