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

Aims: To examine determinants of access to treatment, outcomes, and hospital utilization in patients undergoing secundum atrial septal defect (ASD) closure in adulthood in England and Wales.

Methods and results: Large retrospective cohort study of all adult patients undergoing secundum ASD closures in England and Wales between 2000/01 and 2016/17. Data were from population-based official data sets covering congenital heart disease procedures, hospital episodes, and death registries. Out of 6541 index closures, 79.4% were transcatheter [median age 47 years, interquartile range (IQR) 34-61] and 20.6% were surgical (40 years, 28-52). The study cohort was predominantly female (66%), with socioethnic profile similar to the general population. Mortality in hospital was 0.2% and at 1 year 1.0% [95% confidence interval (CI) 0.8-1.2%]. Risk of death was lower for transcatheter repairs, adjusting for age, sex, year of procedure, comorbidities, and cardiac risk factors [in-hospital adjusted odds ratio 0.09, 95% CI 0.02-0.46; 1-year adjusted hazard ratio 0.5, 95% CI 0.3-0.9]. There was excess mortality 1 year after ASD closure compared with matched population data. Median (IQR) peri-procedural length of stay was 1.8 (1.4-2.5) and 7.3 (6.2-9.2) days for transcatheter and surgical closures, respectively. Hospital resource use for cardiac reasons started the year before repair (median two inpatient and two outpatient-only days) and decreased post-repair (zero inpatient and one outpatient days during the first 2 years).

Conclusion: This national study confirms that ASD closure in adults, by surgical or transcatheter methods, is provided independently of ethnic or socioeconomic differences, it is low (but not no) risk, and appears to reduce future cardiac hospitalization even in older ages.

Background: Individuals recovering from COVID-19 infection have reported experiencing symptoms of postural orthostatic tachycardia syndrome (POTS). These observations have raised concerns about COVID-19 as a significant precipitating factor in the development of post-viral POTS. Given the increasing number of POTS cases reported after COVID-19, we sought to examine the baseline characteristics of POTS patients before and after COVID-19.

Methods: We conducted an interrupted time series analysis on data obtained from the TriNetX database, which included a cohort of 65 141 065 patients aged 18 and older across 64 healthcare organizations. Monthly data on incidence rates (IR), incidence cases (IC), and prevalence cases (PC) of POTS were collected from January 2018 to June 2024, with March 1, 2020, defined as the cutoff date for pre- and post-COVID analysis.

Results: There was a significant increase in the IR of POTS post-COVID (p < 0.0001), with the IR increasing from 1.42/1000 000 to 20.3/1000 000 cases per person-year. Similarly, the monthly IC trend showed a significant rise from 4.21 to 22.66 cases (p < 0.001). The month-to-month prevalence showed an initial decline after COVID with a robust increase starting January 2023. Additionally, the prevalence of autonomic nervous system disorders and related comorbidities significantly decreased in the post-COVID cohort.

Conclusion: Our findings demonstrate a significant increase in the incidence of POTS following the COVID-19 pandemic, suggesting a potential association between COVID-19 infection and the development of post-viral POTS. Future research should explore the underlying mechanisms and treatment strategies for POTS in the context of post-COVID recovery.

Background: Mitral regurgitation (MR) is a prevalent valvular abnormality categorized as primary or secondary based on aetiology. Surgical intervention, particularly mitral valve repair, is often preferred over replacement due to its association with better outcomes. However, the benefits of repair versus replacement, especially in secondary MR, remain debated.

Objectives: This study aims to evaluate the long-term survival and reoperation rates in patients undergoing mitral valve repair compared to mitral valve replacement for MR in a cardiothoracic surgery unit in North-West England and in subgroups with degenerative and secondary aetiology.

Methods: We analysed 1 724 consecutive patients undergoing first-time mitral valve surgery (repair: n = 1 243; replacement: n = 481) between 2000-2021. Primary outcome was all-cause mortality. Genetic matching and overlap weighting were used to balance baseline characteristics.

Results: Median follow-up was 7.1 years. In the matched cohort, mitral valve replacement was associated with higher rates of blood transfusion (29% vs 22%), longer ICU stays, and more strokes (3.7% vs 0.4%). While 90-day mortality did not differ significantly between groups, long-term follow-up showed a survival advantage for repair (HR: 1.32, 95% CI: 1.08-1.63). Although repair had higher reoperation rates (4.3% vs 2.1%), the composite of death or reoperation did not differ significantly. In degenerative MR subgroup, repair showed superior long-term survival, whereas in secondary MR, no significant survival difference was observed between strategies.

Conclusions: Among patients suitable for either surgical strategy, mitral valve repair showed better long-term survival compared to replacement, particularly in degenerative MR. However, this advantage was not observed in secondary MR.

Background: Heart failure (HF) presents a significant global health challenge due to its rising prevalence and impact on disability.

Aims: This study aims to comprehensively analyze the global burden of HF and its underlying causes.

Methods: Using data from the Global Burden of Disease Study 2021, we analyzed the prevalence and Years Lived with Disability (YLD) of HF, examining its implications across diverse demographics and geographic regions.

Results: In 2021, approximately 55.5 million (95% UI 49.0-63.8) people worldwide were affected by HF, a significant increase from 25.4 million (95% UI 22.3-29.2) in 1990. The age-standardized prevalence rate per 100 000 people was 676.7 (95% UI 598.7-776.8) overall, with males experiencing a higher rate at 760.8 (95% UI 673.2-874.7) compared to females at 604.0 (95% UI 535.0-692.3). The age-standardized prevalence YLD rates increased by 5.5% (95% CI 2.7-8.5) and 5.9% (95% CI 2.9-9.0) during this period. Ischemic heart disease emerged as the primary cause of HF, with an age-standardized prevalence rate of 228.3 (95% UI 118.2-279.6), followed by hypertensive heart disease at 148.3 (95% UI 117.3-186.3), and cardiomyopathy/myocarditis at 62.0 (95% UI 51.2-73.2). Noteworthy, countries in the high Socio-Demographic Index (SDI) quintile exhibited higher HF prevalence rates but maintained stable trends. In contrast, countries in lower SDI quintiles, while initially experiencing lower prevalence rates, showed increased age-standardized HF prevalence and YLD rates over the same period.

Conclusions: HF emerges as a significant and growing public health challenge globally, influenced by distinct socioeconomic gradients.

Aims: In light of recent advances in imaging techniques, molecular understanding and therapeutic options in hypertrophic cardiomyopathy (HCM), we performed a systematic review of current guidelines for the diagnosis and management of HCM in order to identify consensus and discrepant areas in the clinical practice guidelines.

Methods and results: We systematically reviewed the English language guidelines and recommendations for the management of HCM in adults. MEDLINE and EMBASE databases were searched for guidelines published in the last 10 years. Following a systematic search, three guidelines on the diagnosis and management of HCM were identified, all of which were robustly developed (AGREE rigour of development score ≥50%). These guidelines were authored by the major European (ESC; 2023), American (AHA/ACC/AMSSM/HRS/PACES/SCMR; 2024) and Japanese (JCS/JHFS; 2018) cardiovascular societies. There was broad consensus on echocardiographic recommendations, the medical and invasive management of HCM, the application of genetic testing and family screening, and exercise and reproductive recommendations in HCM. There were areas of variability in the definition and diagnostic criteria for HCM, cardiovascular magnetic resonance (CMR) imaging recommendations and assessment of sudden cardiac death (SCD) risk and prevention strategies. Due to the JCS/JHFS guideline being older, there are no recommendations on the use of cardiac myosin ATPase inhibitors.

Conclusion: Contemporary guidelines for HCM achieve consensus across a broad range of criteria and recommendations concerning diagnosis and management. However, variations in the approach towards risk assessment for SCD exist between the guidelines. There are also more subtle differences concerning diagnostic criteria and the utility of late gadolinium enhancement for risk stratification, which will likely evolve as the evidence-base broadens.

Background: Atrial fibrillation (AF) is common in COVID-19 patients. The impact of AF on major-adverse-cardiovascular-events (MACE defined as all-cause mortality, myocardial infarction, ischemic stroke, cardiac failure or coronary revascularisation), recurrent AF admission and venous thromboembolism in hospitalised COVID-19 patients is unclear.

Methods: Patients admitted with COVID-19 (1-January-2020 to 30-September-2021) were identified from the New South Wales Admitted-Patient-Data-Collection database, stratified by AF status (no-AF vs prior-AF or new-AF during index COVID-19 admission) and followed-up until 31-Mar-2022. Multivariable Cox regression and competing risk analyses were performed to assess the impact of AF on MACE and non-fatal outcomes respectively.

Results: Our cohort comprised 145293 COVID-19 patients (median age 67.4yo; 49.7% males): new-AF, n=5140 (3.5%); prior-AF, n=23204 (16.0%). During a median follow-up of 9-months, prior-AF and new-AF patients had significantly higher MACE events (44.7% vs 36.2% vs 18.0%) and all-cause mortality (36.0% vs 28.7% vs 15.2%) compared to no-AF patients (both logrank P<0.001). After adjusting for age, gender, intensive-care-unit admission, referral source and comorbidities, compared to no-AF, new-AF and prior-AF groups were independently associated with MACE (adjusted hazard ratio[aHR]=1.15, 95% confidence interval[CI]=1.09-1.20; aHR=1.36, 95%CI=1.33-1.40 respectively). Competing risk analyses showed rehospitalisation rates for ischemic stroke, cardiac failure and AF, but not venous thromboembolism, were significantly higher in these patients. Both new-AF and prior-AF patients had higher rehospitalisation rates for ischemic stroke compared to no-AF patients, independent of CHA2DS2VASc.

Conclusions: COVID-19 patients with AF are at high risk of adverse clinical outcomes. Such patients may need increased surveillance and consideration for early anticoagulation.

Background: Contemporary studies demonstrate that non-ST-segment elevation myocardial infarction (NSTEMI) processes of care vary according to sex. Little is known regarding variation in practice between geographical areas and centres.

Methods: We identified 305 014 NSTEMI admissions in the United Kingdom (UK) Myocardial Ischaemia National Audit Project (MINAP), 2010-17, including female sex (110 209). Hierarchical, multivariate logistic regression models were fitted, assessing for differences in primary outcomes according to sex. Risk-standardized mortality rates (RSMR) were calculated for individual hospitals to illustrate the correlation with variables of interest. 'Heat maps' were plotted to show regional and sex-based variation in the opportunity-based quality indicator score (surrogate for optimal processes of care).

Results: Women presented older (77 years vs. 69 years, P < 0.001) and were more often Caucasian (93% vs. 91%, P < 0.001). Women were less frequently managed with an invasive coronary angiogram (58% vs. 75%, P < 0.001) or percutaneous coronary intervention (35% vs. 49%, P < 0.001). In our hospital-clustered analysis, we show a positive correlation between the RSMR and the increasing proportion of women treated for NSTEMI (R2 = 0.17, P < 0.001). There was a clear negative correlation between the proportion of women who had an optimum OBQI score during their admission and RSMR (R2 = 0.22, P < 0.001), with a weaker correlation in men (R2 = 0.08, P < 0.001). Heat maps according to the Clinical Commissioning Group (CCG) demonstrate significant regional variation in the OBQI score, with women receiving poorer quality care throughout the UK.

Conclusion: There was a significant variation in the management of patients with NSTEMI according to sex, with widespread geographical variation. Structural changes are required to enable improved care for women.

Aims: Mechanical complications (MCs) are rare but potentially fatal sequelae of acute myocardial infarction (AMI). Surgery, though challenging, is considered the treatment of choice. The authors sought to study the early and long-term results of patients undergoing surgical treatment for post-AMI MCs.

Methods and results: Patients who underwent surgical treatment for post-infarction MCs between 2001 through 2019 in 27 centres worldwide were retrieved from the database of the CAUTION study. In-hospital and long-term mortality were the primary outcomes. Cox proportional hazards regression models were used to determine independent factors associated with overall mortality. The study included 720 patients. The median age was 70.0 [62.0-77.0] years, with a male predominance (64.6%). The most common MC encountered was ventricular septal rupture (VSR) (59.4%). Cardiogenic shock was seen on presentation in 56.1% of patients. In-hospital mortality rate was 37.4%; in more than 50% of cases, the cause of death was low cardiac output syndrome (LCOS). Late mortality occurred in 133 patients, with a median follow-up of 4.4 [1.0-8.6] years. Overall survival at 1, 5, and 10 years was 54.0, 48.1, and 41.0%, respectively. Older age (P < 0.001) and post-operative LCOS (P < 0.001) were independent predictors of overall mortality. For hospital survivors, 10-year survival was 65.7% and was significantly higher for patients with VSR than those with papillary muscle rupture (long-rank P = 0.022).

Conclusion: Contemporary data from a multicentre cohort study show that surgical treatment for post-AMI MCs continues to be associated with high in-hospital mortality rates. However, long-term survival in patients surviving the immediate post-operative period is encouraging.

The management of acute myocarditis (AM) is addressed in multiple clinical guidelines. We systematically reviewed current guidelines developed by national and international medical organizations on the management of AM to aid clinical practice. Publications in MEDLINE, EMBASE and Cochrane were identified between 1 January 2013 and 12 April 2024. Additionally, the websites of relevant organizations and the Guidelines International Network, Guideline Central, and NHS knowledge and library hub were reviewed. Two reviewers independently screened titles and abstracts, two reviewers assessed the rigour of guideline development, and one reviewer extracted the recommendations. Two of the three guidelines identified showed good rigour of development. Those rigorously developed agreed on the definition of AM, sampling serum troponin as part of the workflow for AM, testing for B-type natriuretic peptides in heart failure, key diagnostic imaging in the form of cardiovascular magnetic resonance, coronary angiography to exclude significant coronary disease, indications for endomyocardial biopsy (EMB), and indications for immunosuppression and advanced treatment options. Discrepancies exist in sampling creatine kinase-myocardial bound as a marker of myocardial injury, indications for EMB, and indications for immunosuppression and treatment of uncomplicated AM. Evidence is lacking for the use of 18F-Fluorodeoxyglucose Positron Emission Tomography for myocardial imaging, exercise restriction, follow-up measures, and genetic testing, and there are few high-quality randomized trials to support treatment recommendations. Recommendations for management of AM in the guidelines have largely been developed from expert opinion rather than trial data.

Background: There is limited information on the prognostic impact of new onset versus preexistent atrial fibrillation (AF) in hospitalized patients with cancer.

Objectives: We sought to determine the clinical impact of new onset AF (NOAF) compared with preexistent AF in hospitalized patients with cancer.

Methods: All patients with cancer hospitalized over the course of 1 year with clinically manifest new or preexistent AF were enrolled in the Memorial Sloan Kettering Cancer Center AF registry. The relationship of NOAF to the primary composite outcome of all cause death, cardiovascular (CV) rehospitalization, or cerebrovascular event (CVE), as well as secondary CV endpoints, were analysed using proportional hazards regression. Where applicable, the competing risk of death was accounted for using methodology described by Fine and Gray.

Results: Among 606 patients included in the analysis, 313 (51.7%) had NOAF and 293 (48.3%) had preexistent AF. Patients with NOAF were younger and had less frequent prior history of CV disease compared with patients with preexistent AF. At follow-up, patients with NOAF had a higher adjusted hazard for the primary composite outcome versus patients with prior AF (hazard ratio [HR] 1.64, 95% confidence interval [CI] 1.27, 2.13, P = 0.002), as well as the secondary CV composite outcome of clinical AF recurrence, CV death, CV rehospitalization, or CVE (HR 2.17, 95% CI 1.57, 2.99, P < 0.0001).

Conclusions: In hospitalized patients with cancer and electrocardiographically manifest new versus preexistent AF, NOAF was associated with a higher risk for the primary composite outcome of all-cause death, CV rehospitalization, or CVE.