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

Background and aims: Hypertrophic cardiomyopathy (HCM) is characterized by unexplained left ventricular hypertrophy (LVH) ≥15 mm. The condition is often hereditary, and family screening is recommended to reduce the risk of adverse disease complications and premature death among relatives. Correct diagnosis of index patients is important to ensure that only relatives at risk of disease development are invited for family screening. To investigate whether patients with International Classification of Disease, Tenth Revision (ICD-10) codes for HCM (DI421) or hypertrophic obstructive cardiomyopathy (HOCM) (DI422) fulfilled recognized diagnostic criteria.

Methods: All patients with ICD-10 codes for HCM or HOCM at a Department of Cardiology were identified and had their diagnosis validated by a cardiac investigation or a review of their medical records and previous investigations.

Results: A total of 240 patients had ICD-10 codes for HCM/HOCM, of whom 202 (84%, 202/240) underwent re-examination, while 38 (16%, 38/240) had their hospital notes reviewed. A total of 76 patients (32%, n = 76/240) did not fulfil diagnostic criteria, of whom 39 (51%, n = 39/76) had normal (10 mm) or modest LV wall thickness (11-14 mm). The remaining 37 patients (49%, n = 37/76) had LVH ≥15 mm, which was well explained by uncontrolled hypertension (32%, n = 24/76), aortic valve stenosis (19%, n = 7/76), or wild-type amyloidosis (16%, n = 6/76).

Conclusion: One-third of patients with ICD-10 codes for HCM or HOCM did not fulfil recognized diagnostic criteria. Incorrect diagnosis of HCM may cause unnecessary family investigations, which may be associated with anxiety, and a waste of healthcare resources. This highlights the need for specialized cardiomyopathy services to ensure correct diagnosis and management of HCM.

Background: Weight loss is a poor prognostic factor in patients with chronic heart failure (HF). However, whether the same is true for hospitalized patients with HF is unknown, even though hospitalization is the first opportunity for many patients to be diagnosed with HF. This study aimed to investigate the prognostic value of weight loss in patients hospitalized for HF.

Methods and results: This was a post-hoc analysis of the FRAGILE-HF study, a prospective multi-center, observational study including 1332 hospitalized older (≥65 years) patients with HF. The primary outcome was all-cause death within two years of discharge. Self-reported body weight data 1 year prior to hospital admission were available for 1106 patients (83.0%) and were compared with their weight after decongestion therapy. The median weight change was -6.9% [-2.4 - -11.9] and 86.8% of the overall cohort experienced some weight loss. Whereas patients with weight loss ≥5%, which is a well-validated cut-off in chronic HF, had comparable mortality to those with less weight loss (P = 0.96 by log-rank test), patients with weight loss >12%, the lowest quartile value, had higher mortality than those with less weight loss (P = 0.024 for all-cause mortality, P = 0.028 for non-cardiovascular mortality, and P = 0.28 for cardiovascular mortality, respectively). In a Cox proportional hazard model, >12% weight loss was associated with high mortality after adjusting for known prognostic factors and history of malignancy (adjusted hazard ratio: 1.485 [1.070-2.062], P = 0.018).

Conclusion: Weight loss derived from patient-reported body weight 1 year before hospitalization was significantly associated with increased mortality after discharge, mainly due to non-cardiovascular etiology, in elderly patients hospitalized for HF.

Aims: We aimed to investigate temporal trends in all-cause mortality, heart failure (HF) hospitalization, and stroke from 1997 to 2018 in patients diagnosed with both HF and atrial fibrillation (AF).

Methods and results: From Danish nationwide registers, we identified 152 059 patients with new-onset HF between 1997 and 2018. Patients were grouped according to year of new-onset HF and AF-status: Prevalent AF (n = 34 734), New-onset AF (n = 12 691), and No AF (n = 104 634). Median age decreased from 76 to 73 years between 1997 and 2018. The proportion of patients with prevalent or new-onset AF increased from 24.7% (n = 9256) to 35.8% (n = 14 970). Five-year risk of all-cause mortality went from 69.1% [confidence interval (CI): 67.9-70.2%] to 51.3% (CI: 49.9-52.7%), 62.3% (CI: 60.5-64.4%) to 43.0% (CI: 40.5-45.5%), and 61.9% (CI: 61.3-62.4%) to 36.7% (CI: 35.9-37.6%) for the Prevalent AF, New-onset AF, and No AF-group, respectively. Minimal changes were observed in the risk of HF-hospitalization. Five-year stroke risk decreased from 8.5% (CI: 7.8-9.1%) to 5.0% (CI: 4.4-5.5%) for the prevalent AF group, 8.2% (CI: 7.2-9.2%) to 4.6% (CI: 3.7-5.5%) for new-onset AF, and 6.3% (CI: 6.1-6.6%) to 4.9% (CI: 4.6-5.3%) for the No AF group. Simultaneously, anticoagulant therapy increased for patients with prevalent (from 42.7 to 93.1%) and new-onset AF (from 41.9 to 92.5%).

Conclusion: From 1997 to 2018, we observed an increase in patients with HF and co-existing AF. Mortality decreased for all patients, regardless of AF-status. Anticoagulation therapy increased, and stroke risk for patients with AF was reduced to a similar level as patients without AF in 2013-2018.

Dilated cardiomyopathy (DCM) is extensively discussed in numerous expert consensus documents and international guidelines, with differing recommendations. To support clinicians in daily practice and decision-making, we conducted a systematic review of key guidelines and recommendations concerning the diagnosis and clinical management of DCM. Our research encompassed MEDLINE and EMBASE databases for relevant articles published, as well as the websites of relevant scientific societies. We identified two guidelines and one scientific statement that met stringent criteria, thereby qualifying them for detailed systematic analysis. Our review revealed consensus on several key aspects: the definition of DCM, the use of B-type natriuretic peptides and high-sensitivity troponin in laboratory testing, the essential role of multimodality cardiovascular imaging for initial diagnosis, genetic counselling, and the management of advanced disease. Nonetheless, notable areas of variation included the formation of multidisciplinary management teams, the role of cascade genetic testing, pathways for arrhythmic risk stratification, and the criteria for prophylactic defibrillator implantation. Significant evidence gaps persist, particularly regarding the clinical trajectory of genetic, non-genetic and gene-elusive forms of DCM, the use of cardiovascular magnetic resonance in phenotype-negative family members with genotype-positive probands, and the development of potential aetiology-oriented therapies. Addressing these gaps could enhance clinical outcomes and inform future research directions and guideline development.

Aims: This study aimed to investigate the relationship between visceral adipose tissue (VAT), measured using a body shape index (ABSI), and outcomes in patients with heart failure with preserved ejection fraction (HFpEF).

Methods: ABSI data and cardiovascular outcomes were obtained from the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial. ABSI was calculated using waist circumference (WC), body mass index, and height. ABSI values were categorized into tertiles for analysis (≤0.078, 0.078-0.084, and > 0.084).

Results: In total, 3 319 patients with HFpEF were enrolled during a mean follow-up period of 3.9 years. ABSI was positively associated with a high risk of cardiovascular events in patients with HFpEF after multivariate adjustment. In the highest tertile, higher risks of all-cause mortality (hazard ratio [HR]: 1.464, 95% confidence interval [CI]: 1.150-1.864), cardiovascular death (HR: 1.685, 95% CI: 1.241-2.289), myocardial infarction (MI) (HR: 1.778, 95% CI: 1.088-2.904), and major adverse cardiovascular events (MACEs) (HR: 1.430, 95% CI: 1.123-1.822]) were noted. Patients with previous or current high ABSI had poorer long-term prognoses, with increased risks of all-cause mortality (HR: 1.635, 95% CI: 1.116-2.396), cardiovascular death (HR: 1.724, 95% CI: 1.071-2.775), MI (HR: 2.021, 95% CI: 0.878-4.653), and MACEs (HR: 1.653, 95% CI: 1.117-2.447).

Conclusion: ABSI was independently associated with long-term prognosis in patients with HFpEF, and a history of high ABSI was associated with a poorer prognosis later in life, underscoring the importance of reducing VAT in HFpEF. Trial registration: The trial was registered at ClinicalTrials.gov (NCT00094302).

Aims: This study aimed to assess the educational inequalities in cardiovascular disease (CVD), coronary heart disease (CHD) and stroke among four generations, and to analyze the mediating role of healthy lifestyles and metabolic factors.

Methods: This prospective cohort study included 447 227 participants from UK Biobank, with a mean age of 56.10 (8.08) years, divided into four generations born in 1930s, 1940s, 1950s, and 1960s. Cox regression models and the relative index of inequality (RII) were employed to estimate educational inequality on CVD, CHD and stroke. Counterfactual mediation analysis was utilized to estimate the mediating effects of healthy lifestyles and metabolic factors.

Results: After a median of 13.39 years follow-up, 81 470 cases of CVD were documented. In the fully adjusted model, compared to participants with college education, participants with primary school or below had HRs (95%Cl) for CVD of 1.03 (0.96, 1.11), 1.05 (1.03, 1.08), 1.15 (1.10, 1.20), and 1.37 (1.25, 1.51) in 1930s, 1940s, 1950s, and 1960s, respectively. RII (95%Cl) in CVD increased from 1.04 (0.94,1.14) in the 1930s to 1.35(1.22,1.49) in the 1960s. Across all generations, the proportion mediated by healthy lifestyles and metabolic factors on CVD was 13.36% to 21.72% and 30.65% to 40.70%, respectively. Similar results were observed for CHD and stroke.

Conclusion: Educational inequalities in CVD incidence persisted across generations, with potentially greater disparities in 1960s. Implementing effective interventions for healthy lifestyle and metabolic factors that target the less educated population may help reduce these health disparities.

Background: While current evidence suggests that the clinical outcomes of ST-elevation myocardial infarction (STEMI) are worse among patients with cancer, it is unknown what role the quality of care received during admission plays. We aimed to evaluate the association between care quality and patient survival after discharge.

Methods: A nationally-linked cohort of STEMI patients (January 2005-March 2019) were obtained from the UK Myocardial Infarction National Audit Project (MINAP) and UK national Hospital Episode Statistics Admitted Patient Care (HES APC) registries. We used the composite opportunity-based quality indicator (OBQI) to measure overall care quality. Survival outcomes were assessed using Cox proportional hazard models and Kaplan-Meier and cumulative survival curves.

Results: In total, 6 787 STEMI indexed admissions with cancer were identified. Of those, 4 340 (63.9%) patients received optimum care, 1 320 (19.5%) intermediate care, and 1 127(25.2%) low care quality. Patients with low care quality were older (optimum quality median (IQR) = 72.8 (65.1, 79.6), intermediate quality 75.5 (67.9, 82.1), low quality 78.2 (69.2, 84.7)) and more frequently women (optimum quality 21.6%, intermediate quality 27.3%, low quality 35.5%). Compared to patients with optimum care, patients with low care quality had a higher risk of death at 30 days (HR 7.0, 95% CI 5.7-8.7), 1 year (HR 4.0, 95% CI 3.6-4.4), and 5 years (HR 2.6, 95% CI 2.4-2.8). Relative survival analysis revealed that the number of patients who would survive nationally if they received optimal care is 84 (95% CI 67-102), 508 (95% CI 468-548), and 1096 (95% CI 1034-1158) at 30 days, one year, and five years respectively. The association between care quality and survival was more profound in the Northwest and Northeast regions.

Conclusion: Quality of care is closely associated with short- and long-term survival among STEMI patients with cancer. Improving quality of care may save hundreds to thousands of lives in the shorter and longer term.

Background: In patients undergoing invasive coronary angiography for the investigation of angina, the management pathways for obstructive coronary artery disease (CAD) are well described, whereas the clinical and diagnostic journey of patients with ANOCA has largely been inferred, as there is limited quantitative data.

Objectives: To compare the journey of patients with ANOCA versus Obstructive CAD, particularly in relation to (i) clinical presentation and (ii) diagnostic assessment, (iii) 12 month patient-reported outcome measures (PROMs) and (iv) three year composite MACE.

Methods: A total of 2,285 ANOCA and 4,087 Obstructive CAD consecutive patients were included from the CADOSA (Coronary Angiogram Database of South Australia) registry between 2012-2018.

Results: At presentation for elective invasive angiography, the chest pain features and non-invasive ischemic markers were indistinguishable between patients with Obstructive CAD and ANOCA, although the latter were younger (67±11 vs. 61 ± 11 years, p<0.001), more likely to be female (27% vs. 58%, p<0.001) and have fewer traditional cardiac risk factors. However, following angiography (compared to those with Obstructive CAD) patients with ANOCA were less likely to attain a cardiac discharge diagnosis (100% vs. 22%) or receive anti-anginal therapy (76% vs. 57%), despite the same prevalence of persistent angina (weekly angina: 10% vs 11% over 12 months).

Conclusions: Although the pre-angiography journey (symptoms & non-invasive ischemic investigations) of patients with Obstructive CAD and ANOCA is indistinguishable, the post-angiography journey is portrayed by a vast diagnostic and treatment gap in those with ANOCA, which needs to be addressed.

Background and aims: Direct (medical and non-medical) and indirect (production losses and informal care) costs of cardiovascular disease (CVD) have been captured in two previous United Kingdom (UK) cost-of-illness studies, but the areas of long-term care and medical device costs were neglected. We aimed to quantify the economic burden of CVD in the UK from a societal perspective between fiscal years 2019/20 to 2021/22.

Methods: Mixed-methods study in a prevalence-based retrospective review of economic costs focused on the public sector. Top-down costing was applied to the following areas: inpatient hospital care, outpatient specialist care, emergency care, primary care, medications, medical devices, long-term care, production losses to morbidity, and production losses to mortality. Bottom-up costing was used by applying the marginal effects of having a cardiovascular disease on several parameters using survey data from the Survey on Health, Aging, and Retirement in Europe to estimate informal care costs.

Results: The modelling performed shows that the total costs of CVD in the UK in 2021/22 were £29.021 billion (bn), with direct costs of £16.620 bn and indirect costs of £12.402 bn. The breakdown of direct costs for the UK were inpatient care (£6.732 bn), long-term care (£4.649 bn), medications (£1.940 bn), primary care (£1.556 bn), outpatient care (£1.011 bn), emergency care (£327.6 million (mn)), and medical devices (£404.4 mn). The breakdown of indirect costs for the UK were informal care costs (£6.377 bn), production losses to mortality (£4.544 bn), and production losses to morbidity (£1.481 bn).

Conclusion: There is a significant economic burden of CVD in the UK, with the highest direct cost resulting from inpatient care and the highest indirect cost resulting from informal care.

Background: Pulmonary arterial hypertension (PAH) and PAH-related heart failure (PAH-HF) have undergone significant epidemiological changes since 1990. However, large-scale studies are scarce. This study evaluates global epidemiologic trends from 1990 to 2021 and projects them to 2050 to inform public health policies.

Methods: Data on the incidence, prevalence, deaths, and disability-adjusted life years (DALYs) of PAH and PAH-HF were analyzed using models like joinpoint regression, bayesian age-period-cohort and decomposition analysis. Trends were reported by sex, age group, and geographic region, with projections extending to 2050.

Results: In 2021, the global age-standardized incidence rate (ASIR), prevalence rate (ASPR), mortality rate (ASMR), and DALY rate (ASDR) for PAH were 0.52, 2.28, 0.27, and 8.24 per 100 000 population, respectively. Compared to 1990, ASIR and ASPR increased, while ASDR and ASMR declined. Females showed higher burdens in nearly all outcomes. In 2021, Zambia and Switzerland had the highest ASIR and ASPR of PAH, while Mongolia recorded the highest ASMR and ASDR. For PAH-HF, the number of prevalent cases and years lived with disability from 1990 to 2021, though most heart failure subtypes showed declines in ASPR. Decomposition analysis attributed increases in PAH incidence, prevalence, and DALYs primarily to population growth, while aging primarily drove increases in deaths. Future projections suggest continued growth in ASIR but declines in other burden indicators after 2021.

Conclusions: From 1990 to 2021, the global burden of PAH and PAH-HF increased, with significant gender disparities. These results provide valuable guidance for healthcare strategies and resource allocation.