Abstract Objective To assess the association between cardiorespiratory fitness (CRF) and outcomes in a cardiac rehabilitation (CR) cohort. Patients and Methods We conducted a retrospective study of ...5641 patients (4282 men 76% and 1359 women 24%; mean ± SD age, 60.0±10.3 years) with coronary artery disease who participated in CR between July 1, 1996, and February 28, 2009. Based on peak metabolic equivalents (METs), patients were classified as low fitness (LFit) (<5 METs), moderate fitness (5-8 METs), or high fitness (>8 METs). Results Baseline fitness predicted long-term mortality: relative to the LFit group, patients with moderate fitness had an adjusted hazard ratio of 0.54 (95% CI, 0.42-0.69), and those with high fitness a hazard ratio of 0.32 (95% CI, 0.24-0.44). Improvement in CRF at 12 weeks was associated with decreased overall mortality, with a 13% point reduction with each MET increase ( P <.001) and a 30% point reduction in those who started with LFit. At 1 year, each MET increase in CRF was associated with a 25% point reduction in overall mortality in the whole group ( P <.001). Conclusion In this study of contemporary CR patients, higher baseline fitness predicted lower mortality. The novel finding was that improvement in fitness during a CR program and improvements that persisted at 1 year were also associated with decreased mortality, most strongly in patients who start with LFit.
To determine whether acute kidney injury results in later long-term decline in kidney function we measured changes in kidney function over a 3-year period in adults undergoing coronary angiography ...who had serum creatinine measurements as part of their clinical care. Acute kidney injury was categorized by the magnitude of increase in serum creatinine (mild (50–99% or ≥0.3mg/dl) and moderate or severe (≥100%)) within 7 days of coronary angiography. Compared to patients without acute kidney injury, the adjusted odds of a sustained decline in kidney function at 3 months following angiography increased more than 4-fold for patients with mild to more than 17-fold for those with moderate or severe acute kidney injury. Among those with an estimated glomerular filtration rate after angiography less than 90ml/min per 1.73m2, the subsequent adjusted mean rate of decline in estimated glomerular filtration rate during long-term follow-up (all normalized to 1.73m2 per year) was 0.2ml/min in patients without acute kidney injury, 0.8ml/min following mild injury, and 2.8ml/min following moderate to severe acute kidney injury. Thus, acute kidney injury following coronary angiography is associated with a sustained loss and a larger rate of future decline in kidney function.
Although bilateral internal thoracic artery (BITA) grafting in coronary artery bypass grafting (CABG) is associated with low morbidity and good long-term results, controversy exists about the age ...after which BITA grafting is no longer beneficial. We sought to determine if such an age cutoff point exists.
The study cohort consisted of 5,601 consecutive patients from a cardiac surgery registry who underwent isolated CABG (1,038 19% BITA grafts, 4,029 72% single internal thoracic artery SITA grafts, 534 10% vein-only grafts) between 1995 and 2008. A Cox model was used to compare survival by use of bilateral, single, or no internal thoracic artery (ITA) grafts, adjusting for baseline clinical and demographic characteristics.
Mean follow-up was 7.1 years. Patients undergoing BITA grafting had the lowest 1-year mortality (2.4% versus 4.3% SITA grafting and 8.2% vein-only grafting; p < 0.0001). Relative to SITA grafting, a crude survival benefit of 54% existed for BITA grafting (hazard ratio HR 0.46; 95% confidence interval CI, 0.37 to 0.57; p < 0.0001) with worse survival for vein-only grafts (HR, 1.16; 95% CI, 0.99 to 1.37; p = 0.07). After adjustment, the benefit of BITA grafting was no longer statistically significant (HR, 0.87; 95% CI, 0.69 to 1.08; p = 0.2). However age may be an effect modifier: a spline analysis plotting HR (BITA grafting versus SITA grafting) against age suggested a potential survival advantage associated with BITA grafting in patients younger than 69.9 years.
Bilateral internal thoracic artery grafting is a reasonable revascularization strategy in suitable patients up to age 70 years. As benefits of arterial grafting become more obvious over time, a longer period of follow-up will be needed to confirm the advantage of a BITA grafting strategy. In the meantime the BITA grafting advantage for patients older than 70 years is not clear.
The Canadian Patient Experience Survey—Inpatient Care is a validated measure for adult inpatient experience. Linking surveys with administrative data can examine the experience of patients in ...specific demographic or clinical groups.
We examined survey responses obtained over a 4-year period from patients who underwent coronary artery bypass graft and/or valve replacement in Alberta. The 56-question telephone survey was administered within 6 weeks of discharge. Surveys were linked with administrative records to identify the Canadian Classification of Intervention procedure codes, which were in scope. Responses to each question were reported as percentage in “top box,” where “top box” represents the most positive answer choice (eg, “always” and “yes”).
From April 2014 to March 2018, 1082 surveys were completed by patients who underwent coronary artery bypass graft and/or valve replacement. Respondents were predominantly male (73.8%), with a mean age of 64.7 ± 11.9 years. Overall, 73.3% of respondents rated their hospital care as 9 or 10 out of 10 (best), and 86.2% would “definitely recommend” the hospital to friends/family members. Top performing questions pertained to having a discussion about help needed after discharge (96.6% responding “yes”) and receiving written discharge information (93.2% responding “yes”). Lack of quietness of the hospital environment at night (34.8% responding “always”) and lack of staff sufficiently describing side effects of new medications (44.9% responding “always”) were identified as potential areas for improvement.
Our results provide patient-reported experiences about inpatient cardiac care in Alberta hospitals. The findings could inform quality improvement initiatives that are patient-centred.
Le Sondage sur les expériences d’hospitalisation des patients canadiens est un outil valide de mesure de l’expérience des patients adultes hospitalisés. Le couplage des sondages aux données administratives peut permettre d’examiner l’expérience des patients de groupes démographiques ou cliniques particuliers.
Nous avons examiné les réponses obtenues au sondage sur une période de 4 ans auprès de patients qui avaient subi un pontage aortocoronarien ou un remplacement valvulaire, ou les deux, en Alberta. Nous avons fait passer un sondage téléphonique de 56 questions dans les 6 semaines après la sortie de l’hôpital. Les sondages ont été couplés aux dossiers administratifs pour trouver les codes d’interventions de la Classification canadienne des interventions en santé, qui en faisaient partie. Les réponses à chacune des questions étaient exprimées en pourcentage dans la « catégorie supérieure », c’est-à-dire que la « catégorie supérieure » représente le choix le plus positif de réponse (par exemple « toujours » et « oui »).
D’avril 2014 à mars 2018, les patients qui avaient subi un pontage aortocoronarien ou un remplacement valvulaire, ou les deux, ont rempli 1082 sondages. Les répondants étaient surtout des hommes (73,8 %), dont l’âge moyen était de 64,7 ± 11,9 ans. Dans l’ensemble, 73,3 % des répondants ont accordé à leurs soins hospitaliers une cote de 9 ou de 10 sur 10 (la plus élevée), et 86,2 % « recommanderaient certainement » l’hôpital à leurs amis et aux membres de leur famille. Les questions qui ont eu la meilleure cote concernaient le fait d’avoir une discussion sur l’aide nécessaire après la sortie de l’hôpital (96,6 % ont répondu « oui ») et de recevoir des renseignements écrits à la sortie de l’hôpital (93,2 % ont répondu « oui »). Le manque de tranquillité de l’environnement hospitalier durant la nuit (34,8 % ont répondu « toujours ») et le manque de personnel pour décrire adéquatement les effets secondaires des nouveaux médicaments (44,9 % ont répondu « toujours ») ont été considérés comme les points à améliorer.
Nos résultats fournissent les expériences rapportées par les patients sur les soins en cardiologie aux patients hospitalisés dans les hôpitaux de l’Alberta. Les résultats pourraient influencer les initiatives sur l’amélioration de la qualité de manière à ce qu’elles soient axées sur le patient.
Chronic total occlusions (CTO) occur in nearly 20% of coronary angiograms. CTO revascularization, either by percutaneous coronary intervention (PCI) or coronary artery bypass grafting surgery (CABG), ...is infrequently performed, approximately one-third of cases. Long-term outcomes are unknown. The objective of the study was to determine whether early CTO revascularization of patients, either by CABG or PCI, was associated with improved clinical outcomes.
One thousand six hundred twenty-four patients from the Canadian CTO registry were followed for at least 9.75 years. Revascularization was performed according to routine clinical practice. Patients were grouped according to CTO revascularization status (PCI or CABG of CTO vessel, CTO revasc) or no CTO revasc (medical therapy only, or PCI/CABG of non-CTO vessels only), within 3 months of initial angiogram. Patients were followed for mortality, revascularization procedures (PCI and CABG), and hospitalizations for acute coronary syndromes and heart failure.
Early CTO revasc was performed in 28.2% of patients (17.5% CABG, 10.7% PCI). The CTO revasc group was younger, with more males and generally fewer comorbidities. There was a significantly lower mortality probability at 10 years in the CTO revascularization group (22.7% 95% CI, 19.0%-26.9%) compared with the no CTO revasc group (36.6% 95% CI, 33.8%-39.5%). At 10 years, revascularization rates (14.0% versus 22.8%) and acute coronary syndrome hospitalization rates (10.0% versus 16.6%) were significantly lower in the CTO revasc group. Baseline-adjusted analysis showed CTO revasc was associated with significantly lower all-cause mortality (hazard ratio, 0.67 95% CI, 0.54-0.84). In both landmark and time varying analyses, association with lower mortality was particularly robust for CTO revascularization by CABG (hazard ratio 0.56 and 0.60, respectively), with a marginally significant result for PCI in the time varying analysis (hazard ratio 0.711 95% CI, 0.51-0.998).
Early CTO revascularization was associated with significantly lower all-cause mortality, revascularization rates, and hospitalization for acute coronary syndrome at 10 years, and mainly driven by outcomes in patients with CABG.
Because alcohol and drug use disorders (SUDs) can influence quality of care, we compared patients with and without SUDs on frequency of catheterization, revascularization, and in-hospital mortality ...after acute myocardial infarction (AMI).
This study employed hospital discharge data identifying all adult AMI admissions (ICD-9-CM code 410) between April 1996 and December 2001. Patients were classified as having an SUD if they had alcohol and/or drug (not nicotine) abuse or dependence using a validated ICD-9-CM coding definition. Catheterization and revascularization data were obtained by linkage with a clinically-detailed cardiac registry. Analyses (controlling for comorbidities and disease severity) compared patients with and without SUDs for post-MI catheterization, revascularization, and in-hospital mortality.
Of 7,876 AMI unique patient admissions, 2.6% had an SUD. In adjusted analyses mortality was significantly higher among those with an SUD (odds ratio (OR) 2.02; 95%CI: 1.10-3.69), while there was a trend toward lower catheterization rates among those with an SUD (OR 0.75; 95%CI: 0.55-1.01). Among the subset of AMI admissions who underwent catheterization, the adjusted hazard ratio for one-year revascularization was 0.85 (95%CI: 0.65-1.11) with an SUD compared to without.
Alcohol and drug use disorders are associated with significantly higher in-hospital mortality following AMI in adults of all ages, and may also be associated with decreased access to catheterization and revascularization. This higher mortality in the face of poorer access to procedures suggests that these individuals may be under-treated following AMI. Targeted efforts are required to explore the interplay of patient and provider factors that underlie this finding.
This study was designed to examine the use of cardiovascular medications and outcomes in patients with heart failure (HF) and renal dysfunction.
Renal insufficiency is associated with poorer outcomes ...in patients with HF, but the mechanisms are uncertain. In particular, the degree of therapeutic nihilism in these patients, and whether it is appropriate, is unclear.
This was a prospective cohort study with a one-year follow-up.
In 6,427 patients with cardiologist-diagnosed HF and angiographically proven coronary artery disease (mean age 69 years; 65% men; one-year mortality, 10%), 39% had creatinine clearances <60 ml/min. Patients with renal insufficiency were less likely to be prescribed angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, statins, or aspirin (all p < 0.001). However, users of aspirin (odds ratio OR 0.69, 95% confidence interval CI 0.57 to 0.85), statins (OR 0.79, 95% CI 0.64 to 0.97), and beta-blockers (OR 0.75, 95% CI 0.62 to 0.90) were less likely to die in the subsequent 12 months than nonusers, irrespective of renal function (all OR adjusted for covariates including atherosclerotic burden and ejection fraction). Although ACE inhibitor users with creatinine clearances ≥60 ml/min had lower 12-month mortality (OR 0.72, 95% CI 0.48 to 0.99), ACE inhibitor users with clearances <60 ml/min did not (OR 1.21, 95% CI 0.97 to 1.51).
Renal insufficiency is common in patients with HF and coronary artery disease, and these patients have more advanced coronary atherosclerosis. Patients with renal insufficiency are less likely to be prescribed efficacious therapies, but have better outcomes if they receive these medications.
Methods: Prospective cohort study using APPROACH which collects clinical and angiographic data on all patients undergoing an angiogram in Alberta to determine trends in cause-specific mortality based ...on death certificates for patients > 20 years who underwent PCI from 2005-2013.
Cardiac rehabilitation (CR) is a guideline-indicated modality for reducing residual cardiovascular risk among patients undergoing coronary artery bypass grafting (CABG) surgery. However, many ...referred patients do not initiate or complete a CR program; even more patients are never even referred.
All post-CABG patients in Calgary, Alberta, Canada, from January 1, 1996, to March 31, 2016, were included. Data were obtained from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease and TotalCardiology Rehabilitation databases. Automated referral to CR at discharge after CABG was instituted on July 1, 2007. We used interrupted time series analysis to evaluate the impact of automated referral on CR referral and completion rates and studied the association of these CR process markers with mortality.
A total of 8,118 patients underwent CABG surgery during the study period: 5,103 before automation and 3,015 after automation. Automation increased referral rates from 39.5% to 75.0% (P < 0.001). Automated referral was associated with a 7.2% increase in CR completion in the overall population (33.3% vs 26.1%; P < 0.001). In adjusted models, CR referral alone was not associated with reduced mortality (hazard ratio HR 0.84, 95% CI 0.64-1.11), but CR completion was (HR 0.43, 95% CI 0.31-0.61).
Automated referral in post-CABG patients resulted in modest improvement in CR program completion. Therefore, even when CR referral is automated to include all eligible patients, additional strategies to support CR program enrollment and completion remain necessary to achieve the desired health benefits.
La réadaptation cardiaque (RC) est une modalité recommandée dans les lignes directrices afin de diminuer le risque cardiovasculaire résiduel chez les patients qui ont subi un pontage aortocoronarien (PAC). Toutefois, bon nombre des patients orientés en RC ne commencent ou ne terminent pas le programme qui leur est proposé, et encore plus de patients ne sont jamais orientés en RC.
Tous les patients ayant subi un PAC à Calgary, en Alberta (Canada) entre le 1er janvier 1996 et le 31 mars 2016 ont été inclus dans l’étude. Les données sont tirées des bases de données de l’Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease et de la clinique TotalCardiology Rehabilitation. Depuis le 1er juillet 2007, les patients ayant subi un PAC sont systématiquement orientés vers un service de RC à leur sortie de l’hôpital. Nous avons utilisé une analyse des séries chronologiques interrompues pour évaluer l’incidence de cette orientation systématique vers un service de RC et les taux d’achèvement du programme de RC, et nous avons examiné l’association entre ces marqueurs du processus de RC et la mortalité.
Au total, 8 118 patients ont subi un PAC durant la période étudiée : 5 103 patients avant l’orientation systématique vers un programme de RC et 3 015, après. Après l’adoption de l’orientation systématique, le taux d’orientation des patients est passé de 39,5 % à 75,0 % (p < 0,001). L’orientation systématique a été associée à une hausse de 7,2 % de l’achèvement d’un programme de RC dans l’ensemble de la population (33,3 % vs 26,1 %; p < 0,001). Dans les modèles ajustés, l’orientation vers un programme de RC seule n’a pas été associée à une baisse de la mortalité (rapport des risques instantanés RRI de 0,84; IC à 95 % : de 0,64 à 1,11), mais l’achèvement d’un tel programme l’a été (RRI de 0,43; IC à 95 % : de 0,31 à 0,61).
L’orientation systématique des patients ayant subi un PAC a entraîné une hausse modeste des taux d’achèvement d’un programme de RC. En conséquence, même lorsqu’une orientation systématique vers un programme de RC est instaurée afin d’inclure tous les patients admissibles, la mise en œuvre d’autres stratégies pour favoriser l’adhésion à un programme de RC et l’achèvement d’un tel programme s’impose afin d’obtenir les résultats escomptés en matière de santé.
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