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

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.

Aims: It is not well known if sex differences in the use and results of aortic valve replacement (AVR) are changing. The aim of the study is to assess the time trends in the differences by sex in the utilization of AVR procedures in hospitals and in the community.

Methods and results: Retrospective observational analysis using data from the Spanish National Hospitalizations Administrative Database. All hospitalizations between 2016 and 2021 with a main diagnosis of aortic stenosis (International Classification of Diseases-10 codes: I35.0 and I35.2) were included. Time trends in hospitalization, AVRs, and hospital outcomes were analysed. Crude utilization and population-standardized rates were calculated. During the study period, 64 384 hospitalizations in 55 983 patients (55.5% men) with 36 915 (65.9%) AVR were recorded. Of these, 15 563 (42.2%) were transcatheters and 21 432 (58.0%) were surgical. At the hospital level, transcatheter procedures were more frequently performed in women (32.3% vs. 24.2%, P < 0.001), and surgical in men (42.9% vs. 32.5%, P < 0.001) but at the population level, surgical and transcatheter aortic valve replacements (TAVRs) were used more frequently in men (12.6 surgical and 8.0 transcatheter per 100 000 population) vs. women (6.4 and 5.8, respectively; P < 0.001 for both comparisons). Transcatheter procedures shifted from 17.3% in 2016 to 38.0% in 2021, overtaking surgical procedures in 2018 for women and 2021 for men.

Conclusions: TAVR has displaced surgical aortic valve replacement (SAVR) as the most frequent AVR procedure in Spain by 2020. This occurred earlier in women, who, despite the greater weight of their age group in the older population, received fewer AVRs, both SAVR and TAVR.

Aims: The objective of this prospective cohort study on the incidence of metabolic diseases and risk factors in Shunde (Speed-Shunde cohort) was to evaluate the incidence of cardiovascular-kidney-metabolic (CKM) syndrome and metabolic-associated multimorbidity, such as diabetes, hypertension, dyslipidaemia, and metabolic dysfunction-associated steatotic liver disease in Shunde, Foshan, Guangdong, China. Additionally, the study sought to identify the potential determinants that may impact the development of these conditions and the potential consequences that may result.

Methods and results: In the Speed-Shunde cohort, data were gathered via questionnaires, physical measurements, and laboratory analyses encompassing demographic data, behavioural tendencies, anthropometric assessments, controlled attenuation parameters, and liver stiffness measurement utilizing vibration-controlled transient elastography, as well as serum and urine detection (such as oral 75 g glucose tolerance tests, haemoglobin A1c levels, lipid profiles, liver and renal function tests, urinary microalbumin, and creatinine levels). The baseline data were gathered from October 2021 to September 2022 from over 10 000 Chinese community-based adults and the follow-up surveys would be conducted every 2 or 3 years. Blood and urine samples were obtained and stored for future omics data acquisition. Initial analyses revealed the prevalence and risk factors associated with metabolic-associated multimorbidity.

Conclusions: The Speed-Shunde cohort study is a longitudinal community-based cohort with comprehensive CKM health and metabolic-associated multimorbidity assessment. It will provide valuable insights into these conditions' development, progression, and interrelationships, potentially informing future prevention and treatment strategies.

Aims: The long-term outcomes of out of hospital cardiac arrest (OHCA) survivors are not well known.

Methods and results: Using the Myocardial Ischaemia National Audit Project (MINAP) registry, linked to Office for National Statistics mortality data, we analysed 661 326 England, Wales, and Northern Ireland acute myocardial infarction (AMI) patients; 14 127 (2%) suffered OHCA and survived beyond 30 days of hospitalization. Patients dying within 30 days of admission were excluded. Mean follow-up for the patients included was 1500 days. Cox regression models were fitted, adjusting for demographics and management strategy. OHCA survivors were younger (in years) {64 [interquartile range (IQR) 54-72] vs. 70 (IQR 59-80), P < 0.001}, more often underwent invasive coronary angiography (88% vs. 71%, P < 0.001) and percutaneous coronary intervention (72% vs. 45%, P < 0.001). Overall, the risk of mortality for OHCA patients that survived past 30 days was lower than patients that did not suffer cardiac arrest [adjusted hazard ratio (HR) 0.91; 95% CI; 0.87-0.95, P < 0.001]. 'Excellent care' according to the mean opportunity-based quality indicator (OBQI) score compared to 'Poor care', predicted a reduced risk of long-term mortality post-OHCA for all patients (HR: 0.77, CI; 0.76-0.78, P < 0.001), more for STEMI patients (HR: 0.73, CI; 0.71-0.75, P < 0.001), but less significantly in NSTEMI patients (HR: 0.79, CI; 0.78-0.81, P < 0.001).

Conclusion: OHCA patients remain at significant risk of mortality in-hospital. However, if surviving over 30 days post-arrest, OHCA survivors have good longer-term survival up to 10 years compared to the general AMI population. Higher-quality inpatient care appears to improve long-term survival in all OHCA patients, more so in STEMI.

Background: Myocardial injury is prevalent among patients hospitalized for COVID-19. However, the role of COVID-19 vaccines in modifying the risk of myocardial injury is unknown.

Aims: To assess the role of vaccines in modifying the risk of myocardial injury in COVID-19.

Methods and results: We enrolled COVID-19 patients admitted from March 2021 to February 2022 with known vaccination status and ≥1 assessment of hs-cTnI within 30 days from the admission. The primary endpoint was the occurrence of myocardial injury (hs-cTnI levels >99th percentile upper reference limit). A total of 1019 patients were included (mean age: 67.7 ± 14.8 years, 60.8% male, and 34.5% vaccinated against COVID-19). Myocardial injury occurred in 145 (14.2%) patients. At multivariate logistic regression analysis, advanced age, chronic kidney disease, and hypertension, but not vaccination status, were independent predictors of myocardial injury. In the analysis according to age tertiles distribution, myocardial injury occurred more frequently in the III tertile (≥76 years) compared with other tertiles (I tertile: ≤60 years; II tertile: 61-75 years) (P < 0.001). Moreover, in the III tertile, vaccination was protective against myocardial injury [odds ratio (OR): 0.57, 95% confidence interval (CI): 0.34-0.94; P = 0.03], while a previous history of coronary artery disease was an independent positive predictor. In contrast, in the I tertile, chronic kidney disease (OR: 6.94, 95% CI: 1.31-36.79, P = 0.02) and vaccination (OR: 4.44, 95% CI: 1.28-15.34, P = 0.02) were independent positive predictors of myocardial injury.

Conclusion: In patients ≥76 years, COVID-19 vaccines were protective for the occurrence of myocardial injury, while in patients ≤60 years, myocardial injury was associated with previous COVID-19 vaccination. Further studies are warranted to clarify the underlying mechanisms.

Aims: We aim to examine the association between long-term cumulative health status and subsequent mortality among patients with acute heart failure (HF).

Methods and results: Based on a national prospective cohort study of patients hospitalized for HF, we measured health status by Kansas City Cardiomyopathy Questionnaire (KCCQ)-12 at four time points, i.e. admission and 1, 6 and 12 months after discharge. Cumulative health status was interpreted by cumulative KCCQ-12 score and cumulative times of good health status. Outcomes included subsequent all-cause and cardiovascular mortality. Multivariable Cox proportional hazard models were performed to examine the association between cumulative health status and subsequent mortality. Totally, 2328 patients {36.7% women with median age 66 [interquartile range (IQR): 56-75] years} were included, and the median follow-up was 4.34 (IQR: 3.93-4.96) years. Compared with quartile 4, the lowest quartile 1 had the highest hazard ratio (HR) for all-cause mortality [2.96; 95% confidence interval (CI): 2.26-3.87], followed by quartile 2 (1.79; 95% CI: 1.37-2.34) and quartile 3 (1.62; 95% CI: 1.23-2.12). Patients with zero times of good health status had the highest risk of all-cause mortality (HR: 2.41, 95% CI: 1.69-3.46) compared with patients with four times of good health status. Similar associations persisted for cardiovascular mortality.

Conclusion: A greater burden of cumulative health status indicated worse survival among patients hospitalized for HF. Repeated KCCQ measurements could be helpful to monitor long-term health status and identify patients vulnerable to death.

Aims: Recent trials have shown that low-dose colchicine (0.5 mg once daily) reduces major cardiovascular events in patients with acute and chronic coronary syndromes. We aimed to estimate the cost-effectiveness of low-dose colchicine therapy in patients with chronic coronary disease when added to standard background therapy.

Methods and results: This Markov cohort cost-effectiveness model used estimates of therapy effectiveness, transition probabilities, costs, and quality of life obtained from the Low-Dose Colchicine 2 trial, as well as meta-analyses and public sources. In this trial, low-dose colchicine was added to standard of care and compared with placebo. The main outcomes were cardiovascular events, including myocardial infarction, stroke, and coronary revascularization, quality-adjusted life year (QALY), the cost per QALY gained (incremental cost-effectiveness ratio), and net monetary benefit. In the model, low-dose colchicine therapy yielded 0.04 additional QALYs compared with standard of care at an incremental cost of €455 from a societal perspective and €729 from a healthcare perspective, resulting in a cost per QALY gained of €12 176/QALY from a societal perspective and €19 499/QALY from a healthcare perspective. Net monetary benefit was €1414 from a societal perspective and €1140 from a healthcare perspective. Low-dose colchicine has a 96 and 94% chance of being cost-effective, from a societal and a healthcare perspective, respectively, when using a willingness to pay of €50 000/QALY. Net monetary benefit would decrease below zero when annual low-dose colchicine costs would exceed an annual cost of €221 per patient.

Conclusion: Adding low-dose colchicine to standard of care in patients with chronic coronary disease is cost-effective according to commonly accepted thresholds in Europe and Australia and compares favourably in cost-effectiveness to other drugs used in chronic coronary disease.