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

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 and results: A nationally-linked cohort of STEMI patients (January 2005-March 2019) were obtained from the UK Myocardial Infarction National Audit Project and UK national Hospital Episode Statistics Admitted Patient Care registries. We used the composite opportunity-based quality indicator to measure overall care quality. Survival outcomes were assessed using Cox proportional hazard models and Kaplan-Meier and cumulative survival curves. In total, 6787 STEMI indexed admissions with cancer were identified. Of those, 4340 (63.9%) patients received optimum care, 1320 (19.5%) intermediate care, and 1127(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 [hazard ratio (HR) 7.0, 95% confidence interval (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, 1 year, and 5 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.

Aims: To define and characterize polypharmacy in people with heart failure.

Methods and results: The PULSE dataset is a bespoke single centre, retrospective, longitudinal, observational cohort database of patients hospitalized for heart failure, capturing data from the first heart failure admission through to death or end of data collection, including all subsequent admissions. First admission with heart failure was used to define baseline polypharmacy. There were 660 patients included in the dataset, 55.6% male, mean age 76.1 (±SD 12.3). Median number of medications on admission was 9 (25th-75th centile 7-12) and on discharge 10 (25th-75th centile 8-13). Polypharmacy prevalence was 87.3% on admission, increasing at discharge to 95.1% (P < 0.001). Mean medication complexity index score increased from 28.5 (±SD 14.9) at admission to 31.8 (±14.1) at discharge (P < 0.001). Number of medications on admission increased with increasing age (P < 0.001), higher Charlson Co-morbidity Index (P < 0.001), numerically more co-morbidities (P < 0.001), higher Clinical Frailty Scale (P < 0.001), longer length of stay (P = 0.03), worse New York Heart Association class of symptoms (P = 0.04), and a diagnosis of heart failure with preserved ejection fraction compared with heart failure with reduced ejection fraction (P = 0.002). Cardiovascular medications contributed 50% of medications. Prescribing of heart failure medications reduced with increased polypharmacy.

Conclusion: Polypharmacy is common on first admission to hospital for people with heart failure. More medications at admission are associated with increasing age, co-morbidity, and frailty. People with polypharmacy are more likely to have a heart failure with preserved ejection fraction diagnosis, have worse symptoms and a longer hospital stay.

ESC Guidelines provide best practice, evidence-based recommendations for diagnosing and treating patients with cardiovascular diseases. It is not always possible for best practices to be followed, however, particularly in low-resource settings. To address this issue, a set of guideline-related documents were created to identify key priorities for users in these settings. The documents highlight the related recommendations and describe key strategies for clinicians to approach implementation of these recommendations or discuss alternatives which are in line with the intention of the recommendations, if not having all of the same advantages. The suggestions cannot be used as exact substitutes for the original recommendations in the guidelines, which have not been altered and continue to reflect best practice. This document on key priorities for low-resource settings was developed by the task force chairs and other members of the task force who produced the 2023 ESC Guidelines for the management of cardiomyopathies, which are freely available on the ESC website (https://www.escardio.org/Guidelines). This document also underwent external review including international experts from within and beyond Europe and ESC partner organizations, including the Interamerican Society of Cardiology, the Pan-African Society of Cardiology, the Asian Pacific Society of Cardiology, and the ASEAN Federation of Cardiology.

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 trial. ABSI was calculated using waist circumference, 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, 3319 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.

Aims: While advancements in care may improve the clinical course of atrial fibrillation (AF), data on trends in lost lifetime after developing cardiovascular complications are sparse.

Methods and results: In this nationwide registry-based matched cohort study (1 January 2000-31 December 2022), we followed patients with ischaemic stroke, gastrointestinal bleeding, intracranial bleeding, heart failure (HF), and myocardial infarction (MI) after AF and matched referents with AF. We estimated the average loss of life expectancy as the difference in restricted mean survival time between patients with AF with and without a complication and compared the loss between 2000-10 and 2011-22. We followed 27 809 patients with ischaemic stroke, 28 938 with gastrointestinal bleeding, 7710 with intracranial bleeding, 50 914 with HF, and 14 141 with MI and their matched referents. The loss of lifetime improved for ischaemic stroke [-2.1 vs. -1.8 years; difference 4.0 months, 95% confidence interval (CI) 2.4-5.6; P < 0.001]. We found no evidence of trends for gastrointestinal (-1.7 vs. -1.8 years; difference -0.8 months, 95% CI -2.5 to 0.8; P = 0.32) or intracranial bleeding (-3.3 vs. -3.1 years; difference 1.6 months, 95% CI -1.3 to 4.6; P = 0.28). The loss of lifetime improved for HF (-2.1 vs. -1.9 years; difference 2.4 months, 95% CI 0.9-3.8; P = 0.001) and MI (-1.6 vs. -1.1 years; difference 5.9 months, 95% CI 3.3-8.5; P < 0.001).

Conclusion: Among patients with AF, the loss of expected lifetime after incident ischaemic stroke, HF, and MI improved modestly over the past two decades but not after gastrointestinal or intracranial bleeding. These findings support the development and evaluation of interventions that prevent and reduce severity of complications after AF, particularly for bleeding.

Aim: 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 and results: Data on the incidence, prevalence, deaths, and disability-adjusted life years (DALYs) of PAH and PAH-HF were analysed 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. 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 with 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 HF 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.

Conclusion: 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.

Introduction: Quality registries may involve specific inclusion criteria, detailed investigations, or selected hospitals and practitioners, which are not random. Whether the care and outcomes in quality registries are generalizable to the broader population is not well known. We here examine care indicators and outcomes in heart failure (HF) patients enrolled vs. non-enrolled in Swedish Heart Failure (SwedeHF) quality registry.

Methods and results: Observational study of 90-day survivors after a HF in Stockholm (2012-2021). We linked health records from the Stockholm Creatinine Measurements project with SwedeHF. Participants enrolled in SwedeHF were compared to those non-enrolled, focusing on settings of care, use of guideline-recommended therapies, treatment adherence, dose titration, persistence, and outcomes. Analyses considered stratification by settings of management (primary care, cardiology-outpatient, and cardiology-inpatient care). We identified 48 374 incident HF cases of which 4878 (10%) were enrolled in SwedeHF within 90 days. Enrolled participants were younger, more often men and had fewer comorbidities than non-enrolled. Enrolled participants were more likely to initiate, persist and adhere to, and achieve higher dosages of guideline-recommended HF therapies (P < 0.05 for all). Enrolled participants were less likely to experience a major cardiovascular event [CV death, nonfatal myocardial infarction or stroke; HR 0.92, 95% confidence interval (CI) 0.86-0.99] and all-cause death (HR 0.87, 95% CI 0.82-0.92), but had similar rates of HF hospitalization (HR 1.03, 95% CI 0.94-1.15) compared to non-enrolled ones. Findings were similar across settings of management.

Conclusion: Enrollment in the SwedeHF registry occurred in a minority of patients, and was associated with better adherence to guideline-recommended HF therapies and fewer major cardiovascular events and lower mortality. The generalizability of these HF registry findings to all HF patients was, however, limited.

Introduction: Adequate inclusion and representation of patients in clinical studies is critical for the generalizability of research findings. The aim of this analysis was to determine inclusion and reporting by age, sex, and ethnicity in clinical studies of high-risk medical devices (orthopaedic, diabetes, and cardiovascular) approved in the European Union.

Methods: This is an analysis of data from three co-ordinated systematic reviews of clinical evidence for high-risk medical devices. This analysis includes 641 studies, reporting on more than 1.9 million patients treated with high-risk orthopaedic, diabetes, and cardiovascular medical devices. The main outcomes were the proportions of studies providing data on the age, sex, and ethnicity of participants, and the performance of stratified analyses based on these factors.

Results: The majority (>90%) of studies in all three device categories (orthopaedics, diabetes, and cardiovascular) provided data on the age and sex of participants, but only a minority (<10%) provided information on ethnicity. Female patients comprised over half of the patients in the included orthopaedic and diabetes device studies, but <40% of patients in the included cardiovascular device studies (P < 0.001). A minority of studies performed analyses stratified by age (14.6%) or sex (10.4%), although those were more frequently reported in randomized studies.

Conclusions: Almost all studies in this analysis provided demographic data on age and sex, but only a small minority had analysed whether these factors had any impact on device performance. Very few studies provided information on the ethnicity of study participants. Cardiovascular device studies enrolled a lower proportion of female patients in comparison to orthopaedic and diabetes device studies.

Study registration: Cardiovascular device systematic review: PROSPERO (CRD42022308593). Diabetes device systematic review: PROSPERO (CRD42022366871). Orthopaedic device systematic review: open science framework (https://osf.io/6gmyx).

Aims: The lack of standardized definitions for heart failure outcome measures limits the ability to reliably assess the effectiveness of heart failure therapies. The European Unified Registries for Heart Care Evaluation and Randomised Trials (EuroHeart) aimed to produce a catalogue of internationally endorsed data definitions for heart failure outcome measures.

Methods and results: Following the EuroHeart methods for the development of cardiovascular data standards, a working group was formed of representatives from the European Society of Cardiology Heart Failure Association and other leading heart failure experts. A systematic review of observational and randomized clinical trials identified current outcome measures, which was supplemented by clinical practice guidelines and existing registries for contemporary definitions. A modified Delphi process was employed to gain consensus for variable inclusion and whether collection should be mandatory (Level 1) or optional (Level 2) within EuroHeart. In addition, a set of complementary outcome measures were identified by the working group as of scientific and clinical importance for longitudinal monitoring for people with heart failure. Five Level 1 and two Level 2 outcome measures were selected and defined, alongside five complementary monitoring outcomes for patients with heart failure.

Conclusion: We present a structured, hierarchical catalogue of internationally endorsed heart failure outcome measures. This will facilitate quality improvement, high quality observational research, registry-based trials, and post-market surveillance of medical devices.

Background and aims: The Academic Research Consortium for High Bleeding Risk criteria (ARC-HBR) are recommended by guidelines for bleeding risk assessment in ST-elevation myocardial infarction (STEMI). The aim of this study was to identify possible other risk factors and adjust the original ARC-HBR criteria for confounders.

Methods and results: All consecutive STEMI patients managed in a Finnish tertiary hospital between 2016 and 2022 were identified using a database search. Data collection was done by reviewing electronic patient records. Bleeding risk was assessed according to the ARC-HBR criteria. The primary endpoint was non-access site bleeding academic research consortium (BARC) type 3 or 5 bleeding during 1-year follow-up. A total of 1548 STEMI patients were analysed. HBR criteria was fulfilled in 661 (42.7%). Multivariable competing risk analysis identified only 4 individual ARC-HBR criteria as independent risk factors for bleeding. Smoking status was identified as a novel bleeding risk factor. Current and former smokers had increased bleeding risk compared with never smokers [hazard ratio (HR) 3.01, 95% confidence interval (CI) 1.62-5.61 and HR 1.99, CI 1.19-3.34]. In those not meeting any ARC-HBR criteria, cumulative BARC 3 or 5 incidence of current smoking was 3.40% and intracranial haemorrhage (ICH) 1.36%. Thus, exceeding ARC-HBR definition for a major criterion. In the non-HBR group the prevalence of current smoking was 40.4% (n = 358).

Conclusion: Current and former smoking predicts major bleeding complications after STEMI. Current smoking is highly prevalent among those classified as non-HBR according to the ARC-HBR criteria.