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

Background: Antithrombotic therapy post-transcatheter aortic valve implantation (TAVI) has been widely debated in the past two decades. Data describing practice patterns of antithrombotic therapy are warranted. This study examined the trends in use of antithrombotic therapy post-TAVI in Denmark.

Methods: Danish patients with aortic stenosis who underwent first-time TAVI from 2008 to 2021 were identified from Danish registries. Patients were categorized according to atrial fibrillation (AF) status and antithrombotic therapy post-TAVI based on prescription fillings. The antithrombotic therapy groups: No antithrombotic therapy, single antiplatelet therapy (SAPT), dual antiplatelet therapy (DAPT), oral anticoagulant therapy (OAC), and oral anticoagulant therapy with antiplatelet therapy (OAC+). Use of antithrombotic therapy among survivors at 15 months was examined to assess persistence and possible changes in treatment.

Results: This study included 6447 patients undergoing TAVI. Among patients without AF (n = 3975), most patients received SAPT or DAPT. In AF-patients (n = 2472), most patients received OAC or OAC + . During the first 14 years of TAVI, there was a shift in the antithrombotic treatment pattern: For patients without AF, SAPT increased from 15.6% to 69.5% with a concomitant decrease in DAPT from 56.3% to 9.1%. For AF-patients OAC increased from 13.0% to 77.9% and OAC + decreased to 9.1%. Most patients without AF either remained with or shifted to SAPT. AF-patients either remained in or shifted to the OAC group.

Conclusion: Antithrombotic therapy patterns post-TAVI has changed over the first 14 years of TAVI in Denmark. Use of DAPT and OAC + decreased with a concomitant increase in SAPT and OAC.

Background: Inequalities in access to care for women, people of non-white ethnicity, who live in areas of social deprivation, and with multiple long-term conditions lead to inequity of outcomes. We investigated the intersectionality of these causes of health inequality on coronary revascularisation and clinical outcomes for admissions with acute coronary syndrome (ACS).

Methods: We included hospital admissions in England for types of acute coronary syndrome from April 2015 to April 2018 and linked Hospital Episode Statistics to the Office for National Statistics mortality data. The primary outcome was time to all-cause mortality. Time-to-event analyses examined the associations of sex, ethnicity and socioeconomic deprivation with revascularisation.

Results: Of 428 700 admissions with ACS, 212 015 (48.8%) received revascularisation within 30 days. Women, black ethnicity, multimorbid and frail patients were less likely to undergo revascularisation. South Asian ethnicities had higher (HR = 1.15, 95% CI 1.14-1.17) revascularisation rates and comparable risk-adjusted survival but higher re-admission rates when compared to other ethnic groups. Women had higher 1-year all-cause (25.5% vs 14.7%-STEMI; 24.9% vs 18.7%-NSTEMI) and cardiovascular (22.6% vs 13.2%-STEMI; 20.3% vs 15.6%-NSTEMI) mortality than men. After adjusting for confounders, women had a lower all-cause mortality when compared to men.

Discussion: Outcomes attributed to women and people of South Asian ethnicity may be attributable to age, comorbidity and frailty at presentation. Black ethnicity, geography and social deprivation may be sources of inequality. These findings highlight the unmet need and may provide potential targets for interventions that address inequalities.

Background: The burden of ischemic heart disease (IHD) due to low intake of seafood omega-3 fatty acids is a major global health concern, particularly impacting mortality and disability rates. Understanding these trends and demographic variations offers insights for targeted public health interventions.

Methods: This study used data from the Global Burden of Disease (GBD) 2021 database to analyze the IHD burden attributable to low omega-3 intake across 204 countries from 1990 to 2021, stratified by age, sex, and region. Key metrics included deaths, DALYs, YLDs, and YLLs. Joinpoint regression and ARIMA modeling were used to assess trends and project future burden through 2035.

Results: Globally, IHD-related deaths due to low omega-3 intake rose from 500,154 in 1990 to 627,342 in 2021, with the age-standardized death rate declining from 13.94 to 7.49 per 100,000. DALYs increased from 13 million in 1990 to over 15 million in 2021, though the age-standardized DALY rate dropped from 322.93 to 181.07 per 100,000. Regional disparities were significant; North Africa and the Middle East had a 2021 death rate of 18.76 per 100,000, compared to 2.74 per 100,000 in high-income regions. Age and sex stratification revealed that older populations and males bear a higher burden. Projections indicate a stable or rising trend in low-SDI regions through 2035.

Conclusion: This study highlights a substantial global burden of IHD linked to low omega-3 intake, with significant regional and demographic disparities. Increasing omega-3 intake, especially in high-burden regions, could help to mitigate future IHD impacts.

Objective: To analyze the temporal trends of oral anticoagulant (OAC) prescription, direct oral anticoagulant (DOAC) dose, clinical outcomes and factors associated with non-anticoagulation in patients with incident atrial fibrillation (AF).

Patients and methods: During January 1, 2011, to December 31, 2020, a total of 249,107 patients with newly diagnosed AF were identified, and the 1-year risks of ischemic stroke, intracranial hemorrhage (ICH), and all-cause mortality were analyzed.

Results: OAC prescription increased from 22.1% in 2011 to 57.7% in 2020 with DOAC accounting for 91.0% of overall OAC prescriptions. Compared to patients with incident AF diagnosed in 2011, there were increasing trends for a greater decrease in the risks of ischemic stroke during 2012 - 2020 and mortality during 2014 - 2020, while the risk of ICH did not change significantly. For DOAC users, higher dose use increased from 11.04% in 2012 to 44.29% in 2019-2020 temporally associated with a lower risk of ischemic stroke in the years 2015-2017 and 2018-2020 compared to 2012-2014. Determining factors refraining from OAC use included some "patient-related factors" and "non-patient" factors (AF diagnosed at clinics by physicians other than cardiologist/neurologist/internal medicine and citizens outside municipalities).

Conclusion: There was an increasing trend of OAC prescription, temporally associated with a decreased risk of ischemic stroke and mortality. Among DOACs users, the risk of ischemic stroke declined gradually, partly explained by the increasing prescriptions of higher dose DOACs. Both patient and non-patient factors were associated with non-anticoagulation. Further efforts are required to increase OAC prescription.

Introduction: The ESC and ACC/AHA regularly publish guidelines for the management of cardiovascular disease. By definition, a guideline should follow strict methodological criteria, and have a transparent, traceable and reproducible development process. We aimed to assess the overall strength of the recommendations and rigour of methodological development in ESC and ACC/AHA guidelines.

Methods: A systematic review of the ESC and ACC/AHA guidelines published from 2013 to 2024 was conducted. Documents Class of Recommendation (COR) and Level of Evidence (LOE) of recommendations were included. For each document, data regarding citation count (ISI and Scholar), and COR and LOE of the recommendations were extracted. Guidelines were assessed for rigour of methodological development using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument.

Results: Among the 76 included guidelines, the average citation-per-year was 344 (ISI) and 681 (Scholar). Forty-nine % of the recommendations were classified as COR I (strong recommendations), while 46% were based solely on expert opinion (LOE C). The overall AGREE II methodology domain score was 29 ± 6 (range 7-56), with lowest performance for the domains of systematic search of evidence, use of predefined criteria for selecting the evidence and external review. Both the strength of the recommendations and rigour of development showed a stable trend over the past 12 years. The ACC/AHA guidelines followed more rigorous development methods compared to ESC (AGREE II 36±3 vs. 24 ± 3).

Conclusions: Clinical guidelines from the main European and American cardiovascular societies are highly cited but show significant limitations in methodological rigour.

Aims: Bariatric surgery (BS) is a potential treatment option for patients with metabolic dysfunction-associated steatotic liver disease (MASLD) and obesity. These patients are also at substantial risk of developing cardiovascular events and associated mortality. We aimed to assess if BS could reduce major adverse cardiovascular events (MACE) and mortality and improve long-term survival.

Methods and results: Using the TriNetX data, adult patients (>18 years) with the diagnosis of MASLD, obesity (i.e. body mass index [BMI] ≥35 kg/m2), and pre-existing coronary artery disease (CAD) between January 1, 2005, to December 31, 2022, were included. Patients with a BS were compared to those with no history of BS. Primary outcomes were the incidence of MACE, heart failure, cerebrovascular events, and coronary artery procedures or surgeries at years 1, 3, 5, 7, and 10. The secondary outcome was all-cause mortality at years 1, 3, 5, 7, and 10. We performed 1:1 propensity score matching (PSM), sensitivity analysis, and survival analysis. After PSM, both groups had a total of 1038 patients. At year 1, BS patients had a significantly lower incidence of MACE (HR = 0.56, 95% CI, 0.39-0.80), cerebrovascular disease (HR = 0.62, 95% CI, 0.46-0.82), and coronary artery procedures and surgeries (HR = 0.65, 95% CI, 0.42-0.98). Similarly, at 3, 5, 7, and 10, BS patients had a significantly lower incidence of MACE, heart failure, cerebrovascular disease, and coronary artery procedures and surgeries. BS patients had significantly lower 3, 5, 7, 10-year all-cause mortality. Sensitivity analysis confirmed these findings.

Conclusions: BS in patients with MASLD, obesity, and pre-existing CAD can considerably reduce the risk of recurring cardiovascular events and markedly improve survival immediately within the first year of BS and can persist long-term, even a decade after BS.

Aims: This study aims to explore the efficacy of reperfusion strategies on the clinical outcomes of ST-elevation myocardial infarction (STEMI) patients over 80 years old in China.

Methods and results: A retrospective cohort study was performed on STEMI patients over 80 years old who underwent reperfusion strategies and no reperfusion between January 2014 and December 2021, based on the Chinese Cardiovascular Association (CCA) Database-Chest Pain Center. This study included a total of 42,699 patients (mean age 84.1 ± 3.6 years, 52.2% male), among whom 19,280 (45.2%) underwent no reperfusion, 20,924 (49.0%) underwent primary percutaneous coronary intervention (PCI), and 2495 (5.8%) underwent thrombolytic therapy. After adjusting for potential confounders, multivariable logistic regression analysis revealed that patients who underwent primary PCI strategy showed a significantly lower risk of in-hospital mortality [odds ratio (OR) = 0.62, 95% confidence interval (CI): 0.57-0.67, P < 0.001] and the composite outcome (OR = 0.83, 95% CI: 0.79-0.87, P < 0.001) compared to those who received no reperfusion. In contrast, patients with thrombolytic therapy exhibited a non-significantly higher risk of in-hospital mortality (OR = 0.99, 95% CI: 0.86-1.14, P = 0.890) and a significantly elevated risk of the composite outcome (OR = 1.15, 95% CI: 1.05-1.27, P = 0.004). During a median follow-up of 6.7 months post-hospital admission, there was a percentage 31.4% of patients died, and patients in the primary PCI group consistently demonstrated a reduced incidence of all-cause mortality (hazard ratio (HR) = 0.58, 95% CI: 0.56-0.61, P < 0.001).

Conclusion: STEMI patients over 80 years old who underwent the primary PCI strategy are more likely to have favourable clinical outcomes compared to those who received no reperfusion, whereas thrombolytic therapy warrants careful assessment and monitoring.

Background: Spot urinary sodium concentration (UNa) is advocated in guidelines to assess diuretic response and titrate dosage in acute heart failure (AHF). However, no randomized controlled trial data exist to support this approach. We performed a prospective pilot trial to investigate the feasibility of this approach.

Methods and results: Sixty patients with AHF (n = 30 in each arm) were randomly assigned to titration of loop diuretics for the first 48 h of admission according to UNa levels (intervention arm) or based on clinical signs and symptoms of congestion (standard care arm). Diuretic insufficiency was defined as UNa <50 mmol/L. Endpoints relating to diuretic efficacy, safety, and AHF outcomes were evaluated. UNa-guided therapy patients experienced less acute kidney injury (20% vs. 50%, P = 0.01) and a tendency towards less hypokalaemia (serum K+ <3.5 mmol, 7% vs. 27%, P = 0.04), with greater weight loss (3.3 kg vs. 2.1 kg, P = 0.01). They reported a greater reduction in the clinical congestion score (-4.7 vs. -2.6, P < 0.01) and were more likely to report marked symptom improvement (40% vs. 13.3%, P = 0.04) at 48 h. There was no difference in the length of hospital stay (median length of stay: 8 days in both groups, P = 0.98), 30-day mortality, or readmission rate.

Conclusion: UNa-guided titration of diuretic therapy in AHF is feasible and safer than titration based on clinical signs and symptoms of congestion, with more effective decongestion at 48 h. Further large-scale trials are needed to determine if the superiority of this approach translates into improved patient outcomes.

Trial registration number: ACTRN12621000950864.

Background: Demand for transcatheter aortic valve implantation (TAVI) has increased in the last decade, resulting in prolonged wait-times and undesirable health outcomes in many health systems. Risk-based prioritization and wait-times benchmarks can improve equitable access to patients.

Methods and results: We used simulation models to follow-up a synthetic population of 50 000 individuals from referral to completion of TAVI. Based on their risk of adverse events, patients could be classified as 'low-', 'medium-', and 'high-risk', and shorter wait-times were assigned for the higher risk groups. We assessed the impacts of the size and wait-times for each risk group on waitlist mortality, hospitalization, and urgent TAVIs. All scenarios had the same resource constraints, allowing us to explore the trade-offs between faster access for prioritized patients and deferred access for non-prioritized groups. Increasing the proportion of patients categorized as high-risk, and providing more rapid access to the higher-risk groups achieved the greatest reductions in mortality, hospitalizations and urgent TAVIs (relative reductions of up to 29%, 23%, and 38%, respectively). However, this occurs at the expense of excessive wait-times in the non-prioritized low-risk group (up to 25 weeks). We propose wait-times of up to 3 weeks for high-risk patients and 7 weeks for medium-risk patients.

Conclusion: Prioritizing higher-risk patients with faster access leads to better health outcomes, however this also results in unacceptably long wait-times for the non-prioritized groups in settings with limited capacity. Decision-makers must be aware of these implications when developing and implementing waitlist prioritization strategies.

Background: Cardiovascular disease (CVD) is the leading cause of mortality and disability globally. We examined healthcare service utilization and costs attributable to CVD in Ireland in the period before the introduction of a major healthcare reform in 2016.

Methods: Secondary analysis of data from 8113 participants of the first wave of The Irish Longitudinal Study on Ageing. Cardiovascular disease was defined as having a self-reported doctor's diagnosis of myocardial infarction, angina, heart failure, stroke, atrial fibrillation, or transient ischaemic attack. Participants self-reported the utilization of healthcare services in the year preceding the interview. Negative binomial regression with average marginal effects (AMEs) was used to estimate the incremental number of general practitioner (GP) and outpatient department (OPD) visits, accident and emergency department attendances and hospitalizations in population with CVD relative to population without CVD. We calculated the corresponding costs at individual and population levels, by gender and age groups.

Results: The prevalence of CVD was 18.2% (95% CI: 17.3, 19.0) Participants with CVD reported higher utilization of all healthcare services. In adjusted models, having CVD was associated with incremental 1.19 [95% confidence interval (CI): 0.99, 1.39] GP and 0.79 (95% CI: 0.65, 0.93) OPD visits. There were twice as many incremental hospitalizations in males with CVD compared to females with CVD [AME (95% CI): 0.20 (0.16, 0.23) vs. 0.10 (0.07, 0.14)]. The incremental cost of healthcare service use in population with CVD was an estimated €352.2 million (95% CI: €272.8, €431.7), 93% of which was due to use of secondary care services.

Conclusion: We identified substantially increased use of healthcare services attributable to CVD in Ireland. Continued efforts aimed at CVD primary prevention and management are required.