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

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 cardiovascular disease in patients with diabetes, which are freely available on the ESC website (https://www.escardio.org/Guidelines). The document also underwent external review, including international experts from within and beyond Europe and ESC partner organizations, including the Interamerican Society of Cardiology, the Asian Pacific Society of Cardiology, and the Asean Federation of Cardiology.

Background: Health-related quality of life (HRQoL) for patients following myocardial infarction (MI) is frequently impaired. We investigated the association of baseline and changes in HRQoL with mortality following MI.

Methods and results: Nationwide longitudinal study of 9474 patients admitted to 77 hospitals in England as part of the Evaluation of the Methods and Management of Acute Coronary Events study. Self-reported HRQoL was collected using EuroQol EQ-5D-3L during hospitalization and at 1, 6, and 12 months following discharge. The data was analysed using flexible parametric and multilevel survival models. Of 9474 individuals with MI, 2360 (25%) were women and 2135 (22.5%) died during the 9-year follow-up period. HRQoL improved over 12 months (baseline mean, mean increase: EQ-5D 0.76, 0.003 per month; EQ-VAS 69.0, 0.5 per month). At baseline, better HRQoL was inversely associated with mortality [Hazard ratio (HR) 0.55, 95% CI 0.47-0.63], and problems with self-care (HR 1.73, 1.56-1.92), mobility (1.65, 1.50-1.81), usual activities (1.34, 1.23-1.47), and pain/discomfort (1.34, 1.22-1.46) were associated with increased mortality. Deterioration in mobility, pain/discomfort, usual activities, and self-care over 12 months were associated with increased mortality (HR 1.43, 95% CI 1.31-1.58; 1.21, 1.11-1.32; 1.20, 1.10-1.32; 1.44, 1.30-1.59, respectively).

Conclusion: After MI, poor HRQoL at baseline, its dimensions, and deterioration over time are associated with an increased risk of mortality. Measuring HRQoL in routine clinical practice after MI could identify at-risk groups for interventions to improve prognosis.

Introduction: The European Society of Cardiology (ESC) and the American College of Cardiology/American Heart Association (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 and results: A systematic review of 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. Among the 76 included guidelines, the average citation-per-year was 344 (ISI) and 681 (Scholar). Forty-nine per cent 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 the lowest performance for the domains of systematic search of evidence, use of pre-defined 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. ACC/AHA guidelines followed more rigorous development methods compared with 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.

Background and aims: 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 Angina with Non-Obstructive Coronary Arteries (ANOCA) has largely been inferred, as there is limited quantitative data. To compare the journey of patients with ANOCA vs. obstructive CAD, particularly in relation to (i) clinical presentation, and (ii) diagnostic assessment, (iii) 12 month patient-reported outcome measures, and (iv) 3-year composite major adverse cardiovascular events.

Methods and results: A total of 2285 ANOCA and 4087 obstructive CAD consecutive patients were included from the CADOSA (Coronary Angiogram Database of South Australia) registry between 2012 and 2018. At presentation for elective invasive angiography, the chest pain features and non-invasive ischaemic 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).

Conclusion: Although the pre-angiography journey (symptoms and non-invasive ischaemic 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: There are currently no specialized risk scoring systems for critically ill patients with coronary heart disease (CHD). Arterial stiffness, as measured by estimated pulse wave velocity (ePWV), has emerged as a potential indicator of mortality or adverse cardiovascular events in individuals with CHD. This study aimed to evaluate the association between ePWV and all-cause mortality among critically ill patients with CHD beyond traditional risk scores.

Methods and results: This study included 11 001 participants with CHD from the Medical Information Mart for Intensive Care IV, with a 1-year follow-up. The primary endpoint was 1-year all-cause mortality, and the secondary endpoint was in-hospital mortality. Elevated ePWV was significantly associated with higher risks of in-hospital [odds ratio 1.15, 95% confidence interval (CI) 1.12-1.17, P < 0.001] and 1-year (hazard ratio 1.21, 95% CI 1.20-1.23, P < 0.001) mortality. These associations remained consistent when adjusted for traditional risk scores and potential confounders. When ePWV was integrated into traditional risk scoring models (Oxford Acute Severity of Illness Score, Sequential Organ Failure Assessment score, Acute Physiology Score III, Systemic Inflammatory Response Syndrome score, Simplified Acute Physiology Score II, and Logistic Organ Dysfunction System score), the predictive accuracy (area under the curve: 64.55-70.56, 64.32-72.51, 72.35-75.80, 55.58-67.68, 71.27-73.53, and 67.24-73.40, P < 0.001) and reclassification (net reclassification index: 0.230, 0.268, 0.257, 0.255, 0.221, and 0.254; integrated discrimination improvement: 0.049, 0.072, 0.054, 0.068, 0.037, and 0.061, P < 0.001) of these models significantly improved for 1-year mortality. Similar results were also found for in-hospital mortality.

Conclusions: Estimated pulse wave velocity is a strong independent predictor of both short- and long-term mortality in critically ill patients with CHD. Importantly, integrating ePWV into traditional risk scores significantly boosts the predictive accuracy for 1-year and in-hospital all-cause mortality.

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 acute coronary syndromes, 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 (IASC), the Pan-African Society of Cardiology (PASCAR), the Asian Pacific Society of Cardiology (APSC), and the ASEAN Federation of Cardiology (AFC).

Background: Despite continuous advances in post-resuscitation management, the outcome after out-of-hospital cardiac arrest (OHCA) is limited. To improve the outcome, interdisciplinary cardiac arrest centres (CACs) have been established in recent years, but survival remains low, and treatment strategies vary considerably in clinical and geographical aspects. Here we analysed a strategy of in-hospital post-resuscitation management while evaluating the outcome.

Methods: A broad spectrum of pre- and in-hospital parameters of 545 resuscitated patients admitted to the Cardiac Arrest Center of the University Hospital of Marburg between January 2018 and December 2022 were retrospectively analysed. Inclusion criteria were ≥18 years, resuscitation by emergency medical services, and non-traumatic cause of OHCA.

Results: In the overall patient cohort, the survival rate to hospital discharge was 39.8% (n = 217/545), which is 50.7% higher than in the EuReCa-TWO registry. A total of 77.2% of the survivors had CPC status 1 or 2 (favourable neurological outcome) before and after therapy. A standardized 'therapy bundle' for in-hospital post-resuscitation management was applied to 445 patients who survived the initial treatment in the emergency department. In addition to basic care (standardized antimicrobial therapy, adequate anticoagulation, targeted sedation, early enteral, and parenteral nutrition), it includes early whole-body CT (n = 391; 87.9%), invasive coronary diagnostics (n = 322; 72.4%), targeted temperature management (n = 293; 65.8%), and if indicated, mechanical circulatory support (n = 145; 32.6%), and appropriate neurological diagnostics.

Conclusions: Early goal-directed post-resuscitation management in a well-established and highly frequented CAC leads to significantly higher survival rates. However, our results underline the need for a broader standardization in post-resuscitation management to ultimately improve the outcome.

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 revascularization and clinical outcomes for admissions with acute coronary syndrome (ACS).

Methods and results: We included hospital admissions in England for types of ACS 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 revascularization. Of 428 700 admissions with ACS, 212 015 (48.8%) received revascularization within 30 days. Women, black ethnicity, multimorbid, and frail patients were less likely to undergo revascularization. South Asian ethnicities had higher [hazard ratio (HR) = 1.15, 95% confidence interval (CI) 1.14-1.17] revascularization 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%-ST-elevation myocardial infarction (STEMI); 24.9% vs. 18.7%-non-ST-elevation myocardial infarction (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: Bifurcation lesions are associated with higher rates of major adverse cardiac events (MACE).

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

Methods and results: From the ULTRA-BIFURCAT registry, we compared intravascular ultrasound (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, and stent thrombosis was the primary endpoint. Subgroup analyses were performed for unprotected left main (ULM) and non-ULM disease. 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 [hazard ratio (HR) 0.62, 95% confidence internal (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 a reduction in all-MI (HR 0.32, 95% CI 0.16-0.64) in the ULM population and with lower stent thrombosis (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.

Conclusion: In a real-world scenario, IVUS guidance during drug eluting stent (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.

Background: The burden of ischaemic 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 and results: This study used data from the Global Burden of Disease (GBD) 2021 database to analyse 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, disability-adjusted life years (DALYs), years lived with disability, and years of life lost. Joinpoint regression and Auto-Regressive Integrated Moving Average modelling were used to assess trends and project future burden through 2035. 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 with 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 sociodemographic index 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.