European Heart Journal - Quality of Care and Clinical Outcomes最新文献

Aims: Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in selected patients with heart failure (HF) and electrical dyssynchrony. This treatment receives class IA recommendations in European Society of Cardiology (ESC) guidelines. However, despite these strong recommendations, CRT implantation practice varies greatly in Europe. The purpose of the sub-analysis of CRT Survey II data was to describe how countries' health per capita expenditure affects CRT implantation practice.

Methods and results: Between 2015 and 2016, two ESC associations, European Heart Rhythm Association and Heart Failure Association, conducted the CRT Survey II, a survey of CRT implantations in 11 088 patients in 42 ESC member states. We analysed CRT patient selection and guideline adherence in those countries according to high or low health expenditure per capita. There were 21 high health expenditure countries (n = 6844 patients) and 21 (n = 3852) with low health expenditure. The countries with the lowest health expenditure were more likely to implant CRT in patients who had strong guideline recommendations for implantation, younger patients and those recently hospitalized for HF or with symptomatic HF (67% vs. 58%, P < 0.001). The ratio of CRT-Pacemaker (CRT-P) to CRT-Defibrillator (CRT-D) was similar in both spending groups, as was the percentage of CRT implantation in women.

Conclusion: CRT Survey II has demonstrated a non-uniform delivery of healthcare. Countries with low health expenditure per capita appear to be reserving CRT therapy for younger patients, those with class IA indication and patients with more severe symptoms of heart failure.

Background: Bifurcation lesions are associated with higher rates of major adverse cardiovascular events (MACE).

Aim: To investigate the impact of imaging-guided PCI in a real-world population with coronary bifurcation lesions.

Methods: From the ULTRA-BIFURCAT registry, we compared IVUS vs. angiographic guidance in a cohort of 3486 propensity matched patients. MACE a composite of all-cause death, myocardial infarction (MI), target-lesion revascularization (TLR) and stent-thrombosis was the primary endpoint. Subgroup analyses were performed for unprotected left main (ULM) and non-ULM disease.

Results: PSM generated 1743 pairs. MACE occurred in 154 (9%) patients in the IVUS guided group and in 199 (11%) patients in the angio-guided group (p = 0.09). IVUS guidance was associated with lower MACE in the ULM population [HR 0.62, 95% CI 0.46-0.83], but had no impact in the non-ULM population [HR 1.12, 95% CI 0.83-1.51], p for interaction = 0.006. IVUS was associated with reduction in all-MI [HR 0.32, 95% CI 0.16-0.64] in the ULM population and with lower ST in the non-ULM population [HR 0.24, 95% CI 0.08-0.71]. Provisional stenting was associated with lower MACE in the ULM population [HR 0.67, 95% CI 0.45-0.98], whereas kissing balloon [HR 0.75, 95% CI 0.56-0.99] and ultra-thin stents [HR 0.44, 95% CI 0.29-0.67] were protective factors in the non-ULM population.

Conclusions: In a real-world scenario, IVUS guidance during DES implantation is associated with a lower rate of MACE in patients with ULM coronary bifurcation lesions. In non-ULM bifurcations, no difference was observed on MACE, while IVUS guidance was associated with a lower rate of ST.

Aims: Proprotein convertase subtilisin/kexin type 9 monoclonal antibodies (PCSK9 mAbs) are recommended for high-risk patients if the low-density lipoprotein cholesterol (LDL-C) targets are not achieved with statins and ezetimibe. We studied persistence and adherence to 1) PCSK9 mAbs and 2) statins and ezetimibe in a nationwide cohort of incident PCSK9 mAb users.

Methods and results: Information on all PCSK9 mAb users ≤80 years from 2015 through 2023 were extracted from the Norwegian Drug Registry. Discontinuation was defined as a gap in treatment ≥180 days and ≥90 days. Adherence was measured as the proportion of days covered (PDC) during the initial year of PCSK9 mAb therapy. We analyzed adherence of statins and ezetimibe before and after PCSK9 mAb initiation. Of 4,784 patients initiating PCSK9 mAbs, median age was 63 years, 41% were female, 61% had atherosclerotic disease, and 34% had familial hypercholesterolemia. Within three years after initiation, 17% experienced a PCSK9 mAb treatment gap exceeding 180 days. In the 12-month period preceding PCSK9 mAb initiation, 74% dispensed statins whereas 67% dispensed ezetimibe. These numbers were reduced to 35% for statins and 42% for ezetimibe during the 12-month period after PCSK9 mAb initiation. Atherosclerotic disease, using ≥3 statins previously, and older age were significantly associated with discontinuation of statins and ezetimibe.

Conclusion: In this high-risk cohort of incident PCSK9 mAb users, more than 1 out of 2 stopped taking statin treatment whereas 40% discontinued ezetimibe. There is a major potential for improving adherence to oral LLD treatment following initiation of PCSK9 mAb.

Background: A virtual ward (VW) supports patients who would otherwise need hospitalisation by providing acute care, remote monitoring, investigations, and treatment at home. By March 2024 the VW programme had treated 10 950 patients across six speciality VWs, including heart failure (HF). This evaluation presents the economic assessment of the Liverpool HF VW.

Method: A comprehensive economic cost comparison model was developed by York Health Economics Consortium (University of York) to compare the costs of the VW to standard hospital inpatient care (SC). The model included direct VW costs and additional costs across the care pathway. Costs and resource use for 648 patients admitted to the HF VW were calculated for 30 days post discharge and total cohort costs were extrapolated to a full year. Primary outcomes included costs related to length of stay, readmissions, and NHS 111 contact.

Results: The total cost for the HF VW pathway, including set-up costs, was £467 524. This results in an incremental net cost benefit of £735 512 compared to the total SC cost of £1 203 036, indicating a substantial net cost benefit of £1 135 per patient per episode (PPPE). This advantage remains despite initial setup expenses and ongoing costs such as home visits, virtual consultations, point-of-care (POC) testing and home monitoring equipment.

Conclusion: Our HF VW model offers a substantial net cost benefit, driven by reduced hospital stays, fewer emergency department visits, and lower readmission rates. The study highlights the importance of considering system-wide impacts and continuous monitoring of VWs as they develop.

Background: Ischemic heart disease (IHD) is a major cause of heart failure (HF), a condition expected to increasingly affect global health and economics. This study evaluates the global burden, trends, and disparities of HF linked to IHD, aiming to inform health policy development.

Methods: Data from the Global Burden of Disease Study 2021 (GBD2021) is analyzed using Joinpoint regression, decomposition analysis, and Bayesian age-period-cohort analysis (BAPC). Health disparities are assessed through the Socio-demographic Index (SDI) via the Slope Index of Inequality (SII) and the Concentration Index (CI), with future trends projected from 2022 to 2045.

Results: In 2021, global HF cases due to IHD were over 19.16 million, with an age-standardized prevalence rate (ASPR) of 228.31 per 100 000 [95% UI, 188.18 to 279.55] and age-standardized years lived with disability (ASYLDs) rate of 20.43 per 100 000 [95% UI, 13.55 to 28.7].In 2021, there was a 2.87% increase in ASPR and ASYLDs compared to 1990, primarily driven by population growth and aging.Significant reductions in global ASPR and ASYLDs disparities are observed, though the disease burden has intensified in countries with lower SDI levels. Projections indicate that by 2045, while the prevalence and YLDs for HF caused by IHD will increase, while the ASPR and ASYLDs are expected to decrease.

Conclusion: The global burden of HF from IHD remains a significant concern. Urgent improvements in the allocation of medical resources and the implementation of effective prevention and management strategies are necessary to address this issue.

Background: Recent evidence indicates that degenerative valvular heart disease (VHD) and psoriasis share overlapping risk factors and simultaneous presence of inflammation, yet this relationship has not been thoroughly explored.

Methods: Drawing on the prospective cohort data from the UK Biobank, baseline information on psoriasis and the incidence of eight specific types of degenerative VHD-aortic stenosis (AS), aortic regurgitation, mitral stenosis, mitral regurgitation, tricuspid stenosis, tricuspid regurgitation, pulmonary stenosis, and pulmonary regurgitation-during the follow-up period were recorded. Cox proportional hazards models were conducted to estimate the association between psoriasis and the risk of degenerative VHD, adjusted for demographic indicators, lifestyle factors, comorbidities, and medication.

Results: A total of 494 510 participants were included in the study. Among the participants without psoriasis, 13 672 events of degenerative VHD were observed during a median follow-up of 13.78 years, yielding an incidence rate of 2.14 per 1 000 person-years. In contrast, In the psoriasis group (n = 10 917), 422 events of degenerative VHD were reported during a median follow-up of 13.70 years, corresponding to an incidence rate of 2.93 per 1 000 person-years. After fully adjusting, participants with psoriasis had a significantly increased risk of AS (HR, 1.24; 95% CI, 1.07-1.43), yet no significant associations were observed between psoriasis and the risk of other degenerative valve diseases. In sex subgroup analyses, there was an interaction between sex and psoriasis in the occurrence of AS (p-interaction = 0.039), suggesting a high risk in women.

Conclusions: Psoriasis was significantly associated with the risk of new-onset AS and may be more distinct in females, while no significant associations were observed between psoriasis and the risk of developing other degenerative valve diseases.

Introduction: Hypertrophic cardiomyopathy (HCM) is the most prevalent inherited cardiac disease. The impact of HCM on quality of life (QoL) and societal costs remains poorly understood. This prospective multi-centre burden of disease study estimated QoL and societal costs of genotyped HCM patients and genotype-positive phenotype-negative (G+/P-) subjects.

Methods: Participants were categorized into three groups based on genotype and phenotype: 1) G+/P- (left ventricular (LV) wall thickness <13 mm), 2) non-obstructive HCM (nHCM, LV outflow tract (LVOT) gradient <30 mmHg), and 3) obstructive HCM (oHCM, LVOT gradient ≥30 mmHg). We assessed QoL with EQ-5D-5L and Kansas City Cardiomyopathy Questionnaires (KCCQ). Societal costs were measured using medical consumption (iMCQ) and productivity cost (iPCQ) questionnaires. We performed subanalyses within three age groups: <40, 40-59, and ≥60 years.

Results: From three Dutch hospitals, 506 subjects were enrolled (84 G+/P-, 313 nHCM, 109 oHCM; median age 59 years, 39% female). HCM (both nHCM and oHCM) patients reported reduced QoL vs G+/P- subjects (KCCQ: 88 vs 98, EQ-5D-5L: 0.88 vs 0.96; both p<0.001). oHCM patients reported lower KCCQ scores than nHCM patients (83 vs 89, p=0.036). Societal costs were significantly higher in HCM patients (€19,035/year vs €7,385/year) compared to G+/P- controls, mainly explained by higher healthcare costs and productivity losses. Being symptomatic and of younger age (<60 years) particularly led to decreased QoL and increased costs.

Conclusion: HCM is associated with decreased QoL and increased societal costs, especially in younger and symptomatic patients. oHCM patients were more frequently symptomatic than nHCM patients. This study highlights the substantial disease burden of HCM and can aid in assessing new therapy cost-effectiveness for HCM in the future.

Background: Cardiovascular disease (CVD) is a leading cause of death globally, with low physical activity (LPA) as a significant modifiable risk factor. The prevalence of LPA remains high, necessitating a comprehensive assessment of its impact on CVD.

Methods: We applied Joinpoint regression to assess trends in deaths and Disability-Adjusted Life Years (DALYs) and employed ARIMA models to project future BMI-related burdens.

Results: From 1990 to 2021, CVD-related deaths due to LPA rose from 218,938 to 371,736 globally, with the most significant increases in Southeast Asia and Sub-Saharan Africa. DALYs surged from 4.47 million to 7.29 million. Although age-standardized death rates showed a slight decline in high-income countries (-2.27% EAPC), lower-income regions experienced a steady rise. YLDs grew from 344,680 to 725,181, while YLLs increased from 4.13 million to 6.57 million, with older adults (75+ years) carrying the highest burden.

Conclusion: The growing burden of CVD linked to LPA highlights the urgent need for interventions, particularly in low- and middle-income countries, to reduce future risks and improve public health outcomes.