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

Background: Supraventricular ectopic activity (SVEA) is a marker of foci that may initiate atrial fibrillation (AF) and is associated with worse survival. The types and frequencies of SVEA for predicting postoperative AF (POAF), new-onset AF, and clinical outcomes in obstructive hypertrophic cardiomyopathy (oHCM) remain unknown.

Methods and results: Our study consecutively recruited 961 patients with oHCM. All patients underwent a 24-h Holter monitor before surgery. POAF incidence was 20.7% and increased with the burden of premature atrial contractions (PACs). Multivariable analysis showed that supraventricular tachycardia (SVT) was independently associated with POAF, with the model including SVT yielding the largest area under the curve (AUC) [0.710, 95% CI 0.670-0.750] for predicting POAF. During a median follow-up of 2.9 years, 12 deaths, 60 new-onset AF, and 139 composite endpoints were observed. A Spearman correlation indicated a linear relationship between the incidence of new-onset AF and composite endpoints with PAC frequency. The Kaplan-Meier survival curves demonstrated that patients with PACs >200 beats/day had significantly higher cumulative rates of new-onset AF [HR 3.13, (95% CI 1.74-5.62), P < 0.001] and composite endpoints [HR 2.00, (95% CI 1.30-3.06), P = 0.002] than their counterparts. Adding PACs >200 beats/day to the multivariable model significantly improved net reclassification improvement (NRI) and integrated discrimination improvement (IDI) for predicting new-onset AF (NRI = 0.264, IDI = 0.033) and composite endpoints (NRI = 0.233, IDI = 0.014).

Conclusion: The incidence of POAF was 20.7%, increasing with PACs severity. Furthermore, PACs burden was positively associated with a higher incidence of adverse events. Specially, PACs >200 beats/day may best predict a higher incidence of new-onset AF and worse survival.

Background: Major emergency abdominal surgery is associated with postoperative complications and high mortality. Long-term outcomes in patients with perioperative atrial fibrillation (POAF) have recently received increased attention, especially POAF in non-thoracic surgery.

Purpose: This study aimed to compare long-term AF related hospitalization and stroke in patients with POAF in relation to major emergency abdominal surgery and in patients with non-perioperative AF.

Methods and results: We crosslinked data from Danish nationwide registries and identified all patients who underwent major emergency abdominal surgery (2000-2018) and were diagnosed with POAF, and patients who developed AF in a non-perioperative setting. Patients with POAF were matched in a 1:5 ratio on age, sex, year of AF diagnosis, and oral anticoagulation (OAC) status at the beginning of follow-up with patients with non-perioperative AF. From discharge, we examined adjusted hazard ratios (HRs) of stroke using multivariable Cox regression analysis. The study population comprised 1041 (out of 42 021 who underwent major emergency abdominal surgery) patients with POAF and 5205 patients with non-perioperative AF. The median age was 78 years [interquartile range: 71-84] for those initiated on OAC therapy and 78 years [interquartile range: 71-85] for those not initiated on OAC therapy. During the first year of follow up, POAF was associated with similar rates of stroke as non-perioperative AF {patients initiated on OAC: HR 0.96 [95% confidence interval (CI) 0.52-1.77] and patients not initiated on OAC: HR 0.69 (95% CI 0.41-1.15)}.

Conclusion: POAF in relation to major emergency abdominal surgery was associated with similar rates of stroke as non-perioperative AF. These results suggest that POAF not only carry an acute burden but also a long-term burden in patients undergoing major emergency abdominal surgery.

Background: The prognosis for atrial fibrillation (AF) patients is based on data that is decades old. Given evolving standards of clinical practice, we sought to evaluate temporal trends in clinically important outcomes among patients with AF.

Methods and results: California's Department of Health Care Access and Information databases were used to identify adults aged ≥18 years with AF receiving hospital-based care in California. We compared three time-periods: 2005-2009, 2010-2014, and 2015-2019. International Classification of Diseases codes were used to identify chronic diseases and acute events. The outcomes were incident ischaemic stroke, intracranial haemorrhage, and overall mortality. We included 2 009 832 patients with AF (52.7% males, 70.7% Whites, and mean age of 75.0 years), divided in three cohorts: 2005-2009 (n = 738 954), 2010-2014 (n = 609 447), and 2015-2019 (n = 661 431). Each outcome became substantially less common with time: compared with 2005-2009, AF patients diagnosed in 2015-2019 experienced a 34% (adjusted hazard ratio [HR] 0.66, 95% confidence interval 0.64-0.69), 22% (HR 0.78, 0.75-0.82), and 24% (HR 0.76, 0.75-0.77) reduction in risk of incident ischaemic stroke, intracranial haemorrhage, and mortality, respectively. Between 2005-2009 and 2015-2019, patients aged ≥65 years experienced more reductions in each outcome compared with younger patients (P < 0.001 for all), and declines in each outcome were significantly lower for Hispanics and Blacks compared with white patients.

Conclusion: The risks of stroke, intracranial haemorrhage, and death have significantly declined among AF patients, although differences in the magnitude of improvement of these outcomes by demographic groups were observed. Commonly described estimates of the prognosis for AF patients should be updated to reflect contemporary care.

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

Methods and results: 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 March 2022. Multivariable Cox regression and competing risk analyses were performed to assess the impact of AF on MACE and non-fatal outcomes respectively. Our cohort comprised 145 293 COVID-19 patients (median age 67.4 years old; 49.7% males): new-AF, n = 5140 (3.5%); prior-AF, n = 23 204 (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 rehospitalization rates for ischaemic stroke, cardiac failure, and AF, but not venous thromboembolism, were significantly higher in these patients. Both new-AF and prior-AF patients had higher rehospitalization rates for ischaemic stroke compared to no-AF patients, independent of CHA2DS2VASc.

Conclusion: 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: Dual antiplatelet therapy with P2Y12 inhibitors (P2Y12i) and aspirin following acute myocardial infarction (AMI) prevents future ischaemic events. People with atrial fibrillation (AF) also require oral anticoagulants (OAC), increasing bleeding risk. Guidelines recommend post-discharge prescribing of direct OAC with clopidogrel and discontinuation of P2Y12i after 12 months, but little is known about use in clinical practice.

Aim: To describe post-discharge use of OACs and P2Y12i in people with AF and a history of OAC use hospitalized for AMI.

Methods and results: We identified 1330 people hospitalized for AMI with a diagnosis of AF and history of OAC use in New South Wales, Australia, July 2018-June 2020. We identified three aspects of post-discharge antithrombotic medicine use with possible safety implications: (1) not being dispensed OACs; (2) dispensing OAC and P2Y12i combinations associated with increased bleeding (involving warfarin, ticagrelor, or prasugrel); and (3) P2Y12i use longer than 12 months.After discharge, 74.3% of people were dispensed an OAC, 45.4% were dispensed a P2Y12i, and 35.8% were dispensed both. People with comorbid heart failure or cancer were less likely to receive OACs. Only 11.2% of people who dispensed both an OAC and P2Y12i received combinations associated with increased bleeding; this was more common among people with chronic kidney disease or prior warfarin or statin use. A total of 44.6% of people dispensed both medicines continued P2Y12i for over 12 months; this was more common in people who received a revascularization or lived in areas of social disadvantage.

Conclusion: We identified potential gaps in pharmacotherapy, including underuse of recommended therapies at discharge, use of combinations associated with increased bleeding, and P2Y12i use beyond 12 months. Prescribing vigilance across both hospital and community care is required.

Background: A virtual ward (VW) supports patients who would otherwise need hospitalization by providing acute care, remote monitoring, investigations, and treatment at home. By March 2024, the VW programme had treated 10 950 patients across six speciality VWs, including heart failure (HF). This evaluation presents the economic assessment of the Liverpool HF VW.

Method and results: A comprehensive economic cost comparison model was developed by the York Health Economics Consortium (University of York) to compare the costs of the VW to standard hospital inpatient care [standard care (SC)]. The model included direct VW costs and additional costs across the care pathway. Costs and resource use for 648 patients admitted to the HF VW were calculated for 30 days post-discharge and total cohort costs were extrapolated to a full year. Primary outcomes included costs related to length of stay, readmissions, and NHS 111 contact. The total cost for the HF VW pathway, including set-up costs, was £467 524. This results in an incremental net cost benefit of £735 512 compared with the total SC cost of £1 203 036, indicating a substantial net cost benefit of £1135 per patient per episode (PPPE). This advantage remains despite initial setup expenses and ongoing costs such as home visits, virtual consultations, point-of-care testing, and home monitoring equipment.

Conclusion: Our HF VW model offers a substantial net cost benefit, driven by reduced hospital stays, fewer emergency department visits, and lower readmission rates. The study highlights the importance of considering system-wide impacts and continuous monitoring of VWs as they develop.

Background: Ischaemic heart disease (IHD) is a major cause of heart failure (HF), a condition expected to increasingly affect global health and economics. This study evaluates the global burden, trends, and disparities of HF linked to IHD, aiming to inform health policy development.

Methods and results: Data from the Global Burden of Disease Study 2021 (GBD2021) are analysed using joinpoint regression, decomposition analysis, and Bayesian age-period-cohort analysis (BAPC). Health disparities are assessed through the Socio-demographic Index (SDI) via the Slope Index of Inequality and the Concentration Index, with future trends projected from 2022 to 2045. In 2021, global HF cases due to IHD were over 19.16 million, with an age-standardized prevalence rate (ASPR) of 228.31 per 100 000 [95% Uncertainty Interval (UI), 188.18-279.55] and age-standardized years lived with disability (ASYLDs) rate of 20.43 per 100 000 [95% UI, 13.55-28.7]. In 2021, there was a 2.87% increase in ASPR and ASYLDs compared with 1990, primarily driven by population growth and aging. Significant reductions in global ASPR and ASYLDs disparities are observed, though the disease burden has intensified in countries with lower SDI levels. Projections indicate that by 2045, while the prevalence and years lived with disability for HF caused by IHD will increase, the ASPR and ASYLDs are expected to decrease.

Conclusion: The global burden of HF due to IHD remains a significant concern. Urgent improvements in the allocation of medical resources and the implementation of effective prevention and management strategies are necessary to address this issue.

Aims: Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in selected patients with heart failure (HF) and electrical dyssynchrony. This treatment receives class IA recommendations in European Society of Cardiology (ESC) guidelines. However, despite these strong recommendations, CRT implantation practice varies greatly in Europe. The purpose of the sub-analysis of CRT Survey II data was to describe how countries' health per capita expenditure affects CRT implantation practice.

Methods and results: Between 2015 and 2016, two ESC associations, European Heart Rhythm Association and Heart Failure Association, conducted the CRT Survey II, a survey of CRT implantations in 11 088 patients in 42 ESC member states. We analysed CRT patient selection and guideline adherence in those countries according to high or low health expenditure per capita. There were 21 high health expenditure countries (n = 6844 patients) and 21 (n = 3852) with low health expenditure. The countries with the lowest health expenditure were more likely to implant CRT in patients who had strong guideline recommendations for implantation, younger patients and those recently hospitalized for HF or with symptomatic HF (67% vs. 58%, P < 0.001). The ratio of CRT-Pacemaker (CRT-P) to CRT-Defibrillator (CRT-D) was similar in both spending groups, as was the percentage of CRT implantation in women.

Conclusion: CRT Survey II has demonstrated a non-uniform delivery of healthcare. Countries with low health expenditure per capita appear to be reserving CRT therapy for younger patients, those with class IA indication and patients with more severe symptoms of heart failure.

Background: Significant knowledge gaps remain regarding the heterogeneity of heart failure (HF) phenotypes, particularly among patients with preserved or mildly reduced left ventricular ejection fraction (HFp/mrEF). Our aim was to identify HF subtypes within the HFp/mrEF population.

Methods: K-prototypes clustering algorithm was used to identify different HF phenotypes in a cohort of 2570 patients diagnosed with heart failure with mildly reduced ejection fraction or heart failure with preserved left ventricular ejection fraction. This algorithm employs the k-means algorithm for quantitative variables and k-modes for qualitative variables.

Results: We identified three distinct phenotypic clusters: Cluster A (n = 850, 33.1%), characterized by a predominance of women with low comorbidity burden; Cluster B (n = 830, 32.3%), mainly women with diabetes mellitus and high comorbidity; and Cluster C (n = 890, 34.5%), primarily men with a history of active smoking and respiratory comorbidities. Significant differences were observed in baseline characteristics and 1-year mortality rates across the clusters: 18% for Cluster A, 33% for Cluster B, and 26.4% for Cluster C (P < 0.001). Cluster B had the shortest median time to death (90 days), followed by Clusters C (99 days) and A (144 days) (P < 0.001). Stratified Cox regression analysis identified age, cancer, respiratory failure, and laboratory parameters as predictors of mortality.

Conclusion: Cluster analysis identified three distinct phenotypes within the HFp/mrEF population, highlighting significant heterogeneity in clinical profiles and prognostic implications. Women were classified into two distinct phenotypes: low-risk women and diabetic women with high mortality rates, while men had a more uniform profile with a higher prevalence of respiratory disease.

Introduction: Hypertrophic cardiomyopathy (HCM) is the most prevalent inherited cardiac disease. The impact of HCM on quality of life (QoL) and societal costs remains poorly understood. This prospective multi-centre burden of disease study estimated QoL and societal costs of genotyped HCM patients and genotype-positive phenotype-negative (G+/P-) subjects.

Methods and results: Participants were categorized into three groups based on genotype and phenotype: (i) G+/P- [left ventricular (LV) wall thickness <13 mm], (ii) non-obstructive HCM [nHCM, LV outflow tract (LVOT) gradient <30 mmHg], and (iii) obstructive HCM (oHCM, LVOT gradient ≥30 mmHg). We assessed QoL with EQ-5D-5L and Kansas City Cardiomyopathy Questionnaires (KCCQ). Societal costs were measured using medical consumption (Medical Consumption Questionnaire) and productivity cost (iMTA Productivity Cost Questionnaire) questionnaires. We performed subanalyses within three age groups: <40, 40-59, and ≥60 years. From three Dutch hospitals, 506 subjects were enrolled (84 G+/P-, 313 nHCM, 109 oHCM; median age 59 years, 39% female). HCM (both nHCM and oHCM) patients reported reduced QoL vs. G+/P- subjects (KCCQ: 88 vs. 98, EQ-5D-5L: 0.88 vs. 0.96; both P < 0.001). oHCM patients reported lower KCCQ scores than nHCM patients (83 vs. 89, P = 0.036). Societal costs were significantly higher in HCM patients (€19,035/year vs. €7385/year) compared with G+/P- controls, mainly explained by higher healthcare costs and productivity losses. Being symptomatic and of younger age (<60 years) particularly led to decreased QoL and increased costs.

Conclusion: HCM is associated with decreased QoL and increased societal costs, especially in younger and symptomatic patients. oHCM patients were more frequently symptomatic than nHCM patients. This study highlights the substantial disease burden of HCM and can aid in assessing new therapy cost-effectiveness for HCM in the future.