Heart failure (HF) often develops in patients with diabetes and is recognized for its role in inc... more Heart failure (HF) often develops in patients with diabetes and is recognized for its role in increased cardiovascular morbidity and mortality in this population. Most existing models predict risk in patients with prevalent rather than incident diabetes and fail to account for sex differences in HF risk factors. We derived sexspecific models in Ontario, Canada to predict HF at diabetes onset and externally validated these models in the U.K. RESEARCH DESIGN AND METHODS Retrospective cohort study using international population-based data. Our derivation cohort comprised all Ontario residents aged ‡18 years who were diagnosed with diabetes between 2009 and 2018. Our validation cohort comprised U.K. patients aged ‡35 years who were diagnosed with diabetes between 2007 and 2017. Primary outcome was incident HF. Sex-stratified multivariable Fine and Gray subdistribution hazard models were constructed, with death as a competing event. RESULTS A total of 348,027 Ontarians (45% women) and 54,483 U.K. residents (45% women) were included. At 1, 5, and 9 years, respectively, in the external validation cohort, the C-statistics were 0.81 (95% CI 0.79-0.84), 0.79 (0.77-0.80), and 0.78 (0.76-0.79) for the female-specific model; and 0.78 (0.75-0.80), 0.77 (0.76-0.79), and 0.77 (0.75-0.79) for the male-specific model. The models were well-calibrated. Age, rurality, hypertension duration, hemoglobin, HbA 1c , and cardiovascular diseases were common predictors in both sexes. Additionally, mood disorder and alcoholism (heavy drinker) were female-specific predictors, while income and liver disease were male-specific predictors. CONCLUSIONS Our findings highlight the importance of developing sex-specific models and represent an important step toward personalized lifestyle and pharmacologic prevention of future HF development. Over the last four decades, the number of adults with diabetes almost quadrupled worldwide (1). Having diabetes more than doubles an individual's risk of developing cardiovascular disease (CVD) (2), which is a leading cause of mortality (3) accounting for half of all deaths in patients with diabetes (4). Heart failure (HF) is an important sequela of diabetes through accelerated atherosclerosis and other direct cellular
ardiac surgery is a growing field, with 2 million procedures currently being performed globally e... more ardiac surgery is a growing field, with 2 million procedures currently being performed globally each year. 1 The last 2 decades have seen important advances in surgical and perioperative care and in improved patient survival. 2-4 On the other hand, as patients presenting for surgery become increasingly older and frail, they shift their goals and priorities toward how surgery might affect personal freedom and mobility, rather than longevity alone. 5-9 New or residual impairments after surgery are of particular concern to patients and clinicians alike, but the quality and standard of cardiac care has long been assessed by traditional "tombstone" measures such as mortality and major adverse cardiovascular events. 5,8,10-12 Patient-centred care represents a priority area for modern medical practice and research, and the facilitation of shared surgical decision-making could be improved by incorporating patient perspectives and patient-derived data. 13-15 Our group has recently derived "disability-free survival" as a patient-defined outcome through a large-scale survey of more than 3000 patients with cardiovascular diseases. 16 According to patient preferences and values, disability was defined as the composite of stroke, recurrent nonelective hospital admissions and admission to a nursing home. 16 Before this outcome measure could be meaningfully used to inform patient-centred decision-making, its epidemiology and impact need to be described first at the population level. We therefore conducted the current study to evaluate disability-free survival after major cardiac surgery in a population-based cohort. Methods Design and study population We conducted a population-based, retrospective cohort study in Ontario, Canada. We included adults residing in Ontario
Purpose of review Patients with multivessel coronary artery disease (CAD) may undergo revasculari... more Purpose of review Patients with multivessel coronary artery disease (CAD) may undergo revascularization by either percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG). This review will discuss the use of polygenic risk scores for risk-stratification of patients with multivessel CAD in order to guide the choice of revascularization. Recent findings A 57-single nucleotide polymorphism (SNP)-polygenic risk score can accurately risk-stratify patients with CAD and identify those who will receive greater benefit from statin therapy. The most recent genomic studies reveal 243 different SNPs are now significantly associated with CAD. Randomized clinical trials comparing PCI vs. CABG (FREEDOM, SYNTAX, NOBLE, EXCEL) have uncovered factors related to CAD severity (diabetes, SYNTAX score) are critical determinants of outcomes after revascularization. Summary There is a need to discover predictors of outcomes after PCI vs. CABG to improve clinical decision-making in multivessel CAD. High polygenic risk score is associated with increased CAD severity and better outcomes with statin therapy. Randomized clinical trials indicate CAD severity is associated with better outcomes after CABG compared with PCI. Accordingly, polygenic risk score could also be associated with better outcomes after CABG vs. PCI and used to optimize revascularization for patients with multivessel CAD.
What This Article Tells Us That Is New • In a retrospective study of 5,127 patients undergoing no... more What This Article Tells Us That Is New • In a retrospective study of 5,127 patients undergoing noncardiac surgery, an increased risk of postoperative acute kidney injury (defined as more than 50% or 0.3 mg/dl increase in serum creatinine concentration) was found when intraoperative mean arterial pressure was less than 60 mmHg for more than 20 min and less than 55 mmHg for more than 10 min
Acute postoperative myocardial ischemia (PMI) after cardiac surgery is an infrequent event that c... more Acute postoperative myocardial ischemia (PMI) after cardiac surgery is an infrequent event that can evolve rapidly and become a potentially life-threatening complication. Multiple factors are associated with acute PMI after cardiac surgery and may vary by the type of surgical procedure performed. Although the criteria defining nonprocedural myocardial ischemia are well established, there are no universally accepted criteria for the diagnosis of acute PMI. In addition, current evidence on the management of acute PMI after cardiac surgery is sparse and generally of low methodological quality. Once acute PMI is suspected, prompt diagnosis and treatment are imperative, and options range from conservative strategies to percutaneous coronary intervention and redo coronary artery bypass grafting. In this document, a multidisciplinary group including experts in cardiac surgery, cardiology, anesthesiology, and postoperative care summarizes the existing evidence on diagnosis and treatment of acute PMI and provides clinical guidance.
American Heart Journal Plus: Cardiology Research And Practice, 2022
Study objective: A multi-institutional interdisciplinary team was created to develop a research g... more Study objective: A multi-institutional interdisciplinary team was created to develop a research group focused on leveraging artificial intelligence and informatics for cardio-oncology patients. Cardio-oncology is an emerging medical field dedicated to prevention, screening, and management of adverse cardiovascular effects of cancer/ cancer therapies. Cardiovascular disease is a leading cause of death in cancer survivors. Cardiovascular risk in these patients is higher than in the general population. However, prediction and prevention of adverse cardiovascular events in individuals with a history of cancer/cancer treatment is challenging. Thus, establishing an interdisciplinary team to create cardiovascular risk stratification clinical decision aids for integration into electronic health records for oncology patients was considered crucial. Design/setting/participants: Core team members from the Medical College of Wisconsin (MCW), University of Wisconsin-Milwaukee (UWM), and Milwaukee School of Engineering (MSOE), and additional members from Cleveland Clinic, Mayo Clinic, and other institutions have joined forces to apply high-performance computing in cardio-oncology. Results: The team is comprised of clinicians and researchers from relevant complementary and synergistic fields relevant to this work. The team has built an epidemiological cohort of ~5000 cancer survivors that will serve as a database for interdisciplinary multi-institutional artificial intelligence projects. Conclusion: Lessons learned from establishing this team, as well as initial findings from the epidemiology cohort, are presented. Barriers have been broken down to form a multi-institutional interdisciplinary team for health informatics research in cardio-oncology. A database of cancer survivors has been created collaboratively by the team and provides initial insight into cardiovascular outcomes and comorbidities in this population.
Heart failure (HF) often develops in patients with diabetes and is recognized for its role in inc... more Heart failure (HF) often develops in patients with diabetes and is recognized for its role in increased cardiovascular morbidity and mortality in this population. Most existing models predict risk in patients with prevalent rather than incident diabetes and fail to account for sex differences in HF risk factors. We derived sexspecific models in Ontario, Canada to predict HF at diabetes onset and externally validated these models in the U.K. RESEARCH DESIGN AND METHODS Retrospective cohort study using international population-based data. Our derivation cohort comprised all Ontario residents aged ‡18 years who were diagnosed with diabetes between 2009 and 2018. Our validation cohort comprised U.K. patients aged ‡35 years who were diagnosed with diabetes between 2007 and 2017. Primary outcome was incident HF. Sex-stratified multivariable Fine and Gray subdistribution hazard models were constructed, with death as a competing event. RESULTS A total of 348,027 Ontarians (45% women) and 54,483 U.K. residents (45% women) were included. At 1, 5, and 9 years, respectively, in the external validation cohort, the C-statistics were 0.81 (95% CI 0.79-0.84), 0.79 (0.77-0.80), and 0.78 (0.76-0.79) for the female-specific model; and 0.78 (0.75-0.80), 0.77 (0.76-0.79), and 0.77 (0.75-0.79) for the male-specific model. The models were well-calibrated. Age, rurality, hypertension duration, hemoglobin, HbA 1c , and cardiovascular diseases were common predictors in both sexes. Additionally, mood disorder and alcoholism (heavy drinker) were female-specific predictors, while income and liver disease were male-specific predictors. CONCLUSIONS Our findings highlight the importance of developing sex-specific models and represent an important step toward personalized lifestyle and pharmacologic prevention of future HF development. Over the last four decades, the number of adults with diabetes almost quadrupled worldwide (1). Having diabetes more than doubles an individual's risk of developing cardiovascular disease (CVD) (2), which is a leading cause of mortality (3) accounting for half of all deaths in patients with diabetes (4). Heart failure (HF) is an important sequela of diabetes through accelerated atherosclerosis and other direct cellular
European Heart Journal - Quality of Care and Clinical Outcomes, Jun 13, 2023
Background ST-segment myocardial infarction (STEMI) is typically associated with increased age, b... more Background ST-segment myocardial infarction (STEMI) is typically associated with increased age, but there is an important group of patients who suffer from STEMI under the age of 50 who are not well characterized in studies. Methods and results We analysed results from Myocardial Ischemia National Audit Project (MINAP) from the United Kingdom (UK) between 2010 and 2017 and the National Inpatient Sample (NIS) from the United States of America (USA) between 2010 and 2018. After exclusion criteria, there were 32 719 STEMI patients aged ≤50 from MINAP, and 238 952 patients’ ≤50 from the NIS. We analysed temporal trends in demographics, management, and mortality. The proportion of females increased, 15.6% (2010–2012) to 17.6% (2016–2017) (UK) and 22.8% (2010–2012) to 23.1% (2016–2018) (USA). The proportion of white patients decreased, from 86.7% (2010) to 79.1% (2017) (UK) and 72.1% (2010) to 67.1% (2017) (USA). Invasive coronary angiography (ICA) rates increased in UK (2010–2012: 89.0%, 2016–2017: 94.3%), while decreased in USA (2010–2012: 88.9%, 2016–2018: 86.2% (USA). After adjusting for baseline characteristics and management strategies, there was no difference in all-cause mortality in the UK in 2016–2017 compared to 2010–2012 (OR:1.21, 95% CI:0.60–2.40), but there was a decrease in the USA in 2016–2018 compared to 2010–2012 (OR: 0.84, 95% CI: 0.79–0.90). Conclusion The demographics of young STEMI patients have temporally changed in the UK and USA, with increased proportions of females and ethnic minorities. There was a significant increase in the frequency of diabetes mellitus over the respective time periods in both countries.
Trials suggest patients with ST-elevation myocardial infarction (STEMI) without ‘standard modifia... more Trials suggest patients with ST-elevation myocardial infarction (STEMI) without ‘standard modifiable cardiovascular risk factors’ (SMuRFs) have poorer outcomes, but the role of ethnicity has not been investigated. We analyzed 118,177 STEMI patients using the Myocardial Ischaemia National Audit Project (MINAP) registry. Clinical characteristics and outcomes were analyzed using hierarchical logistic regression models; patients with ≥1 SMuRF (n = 88,055) were compared with ‘SMuRFless’ patients (n = 30,122), with subgroup analysis comparing outcomes of White and Ethnic minority patients. SMuRFless patients had higher incidence of major adverse cardiovascular events (MACE) (odds ratio, OR: 1.09, 95% CI 1.02–1.16) and in-hospital mortality (OR: 1.09, 95% CI 1.01–1.18) after adjusting for demographics, Killip classification, cardiac arrest, and comorbidities. When additionally adjusting for invasive coronary angiography (ICA) and revascularisation (percutaneous coronary intervention (PCI) or coronary artery bypass grafts surgery (CABG)), results for in-hospital mortality were no longer significant (OR 1.05, 95% CI .97–1.13). There were no significant differences in outcomes according to ethnicity. Ethnic minority patients were more likely to undergo revascularisation with ≥1 SMuRF (88 vs 80%, P < .001) or SMuRFless (87 vs 77%, P < .001. Ethnic minority patients were more likely undergo ICA and revascularisation regardless of SMuRF status.
European Heart Journal - Quality of Care and Clinical Outcomes, Mar 15, 2023
AimsTo assess processes of care and clinical outcomes in cancer patients with ST elevation myocar... more AimsTo assess processes of care and clinical outcomes in cancer patients with ST elevation myocardial infarction (STEMI) according to cancer type.Methods and resultsThis is a national population-based study of patients admitted with STEMI in the UK between January 2005 and March 2019. Data were obtained from the National Heart Attack Myocardial Infarction National Audit Project (MINAP) registry and the Hospital Episode Statistics registry. We identified 353 448 STEMI-indexed admissions between 2005 and 2019. Of those, 8581 (2.4%) had active cancer. Prostate cancer (29% of STEMI patients with cancer) was the most common cancer followed by haematologic malignancies (14%) and lung cancer (13%). Cancer patients were less likely to receive invasive coronary revascularization (60.0% vs. 71.6%, P < 0.001] and had higher in-hospital death [odd ratio (OR) 1.39, 95% confidence interval (CI) 1.25–1.54] and bleeding (OR 1.23, 95% CI 1.03–1.46). Cancer patients had higher mortality at 30 days (HR 2.39, 95% CI 2.19–2.62) and 1 year (HR 3.73, 95% CI 3.58–3.89). Lung cancer was the cancer associated with the highest risk of death in the hospital (OR 1.75, 95% CI 1.39–2.22) and at 1 year (OR 8.08, 95% CI 7.44–8.78). Colon cancer (OR 1.98, 95% CI 1.24–3.14) was the main cancer associated with major bleeding. All common cancer types were associated with higher mortality at 1 year. Cardiovascular death (62%) was the main cause of death in the first 30 days, while cancer (52%) was the main cause of death within 1 year.ConclusionSTEMI patients with cancer have a higher risk of short- and long-term mortality, particularly lung cancer. Colon cancer is the main cancer associated with major bleeding. Cardiovascular disease was the main cause of death in the first month, whereas cancer was the main cause of death within 1 year.
Background Guidelines recommend that hospitalized patients newly diagnosed with HF be referred to... more Background Guidelines recommend that hospitalized patients newly diagnosed with HF be referred to an outpatient HF clinic (HFC) within 2 weeks of discharge. Our study aims were (i) to assess the current literary landscape on the impact of patient sex on HFC referral and outcomes and (ii) to provide a qualitative overview of possible considerations for the impact of sex on referral patterns and HF characteristics including aetiology, symptom severity, investigations undertaken and pharmacologic therapy. Methods and results We conducted a scoping review using the Arksey and O'Malley framework and searched Medline, EMBASE, PsychINFO, Cochrane Library, Ageline databases and grey literature. Eligible articles included index HF hospitalizations or presentations to the Emergency Department (ED), a description of the HFC referral of patients not previously followed by an HF specialist and sex-specific analysis. Of the 11 372 potential studies, 8 met the inclusion criteria. These studies reported on a total of 11 484 participants, with sample sizes ranging between 168 and 3909 (25.6%-50.7% female). The included studies were divided into two groups: (i) those outlining the referral process to an HFC and (ii) studies which include patients newly enrolled in an HFC. Of the studies in Group 1, males (51%-82.4%) were more frequently referred to an HFC compared with females (29%-78.1%). Studies in Group 2 enrolled a higher proportion of males (62%-74% vs. 26%-38%). One study identified independent predictors of HFC referral which included male sex, younger age, and the presence of systolic dysfunction, the latter two more often found in males. Two studies, one from each group reported a higher mortality amongst males compared with females, whereas another study from Group 2 reported a higher hospitalization rate amongst females following HFC assessment. Conclusions Males were more likely than females to be referred to HFCs after hospitalization and visits to the Emergency Department, however heterogeneity across studies precluded a robust assessment of sex-based differences in outcomes. This highlights the need for more comprehensive longitudinal data on HF patients discharged from the acute care setting to better understand the role of sex on patient outcomes.
ObjectiveCongestive acute kidney injury (c-AKI) refers to AKI in the presence of right ventricula... more ObjectiveCongestive acute kidney injury (c-AKI) refers to AKI in the presence of right ventricular failure (RVF) and is a highly morbid complication of cardiac surgery. However, treatment has traditionally been reactive rather than proactive due to limited modalities to predict this complication. The objective of this study was to investigate the ability of insulin-like growth-factor binding protein 7 (IGFBP7), to predict c-AKI, AKI and RVF in patients undergoing cardiac surgery, as compared to N-terminal prohormone B-type natriuretic peptide (NT-pro-BNP) and pulmonary artery pulsatility index (PAPi).MethodsThis prospective nested case–control study consisted of 350 adult patients who underwent elective cardiac surgery. The outcomes were c-AKI, AKI and RVF. Unadjusted and adjusted conditional logistic regression models and areas under the receiver operating characteristic curve (AUC) were used to assess the predictive performance of each marker.ResultsFor the prediction of c-AKI, th...
Heart failure (HF) often develops in patients with diabetes and is recognized for its role in inc... more Heart failure (HF) often develops in patients with diabetes and is recognized for its role in increased cardiovascular morbidity and mortality in this population. Most existing models predict risk in patients with prevalent rather than incident diabetes and fail to account for sex differences in HF risk factors. We derived sexspecific models in Ontario, Canada to predict HF at diabetes onset and externally validated these models in the U.K. RESEARCH DESIGN AND METHODS Retrospective cohort study using international population-based data. Our derivation cohort comprised all Ontario residents aged ‡18 years who were diagnosed with diabetes between 2009 and 2018. Our validation cohort comprised U.K. patients aged ‡35 years who were diagnosed with diabetes between 2007 and 2017. Primary outcome was incident HF. Sex-stratified multivariable Fine and Gray subdistribution hazard models were constructed, with death as a competing event. RESULTS A total of 348,027 Ontarians (45% women) and 54,483 U.K. residents (45% women) were included. At 1, 5, and 9 years, respectively, in the external validation cohort, the C-statistics were 0.81 (95% CI 0.79-0.84), 0.79 (0.77-0.80), and 0.78 (0.76-0.79) for the female-specific model; and 0.78 (0.75-0.80), 0.77 (0.76-0.79), and 0.77 (0.75-0.79) for the male-specific model. The models were well-calibrated. Age, rurality, hypertension duration, hemoglobin, HbA 1c , and cardiovascular diseases were common predictors in both sexes. Additionally, mood disorder and alcoholism (heavy drinker) were female-specific predictors, while income and liver disease were male-specific predictors. CONCLUSIONS Our findings highlight the importance of developing sex-specific models and represent an important step toward personalized lifestyle and pharmacologic prevention of future HF development. Over the last four decades, the number of adults with diabetes almost quadrupled worldwide (1). Having diabetes more than doubles an individual's risk of developing cardiovascular disease (CVD) (2), which is a leading cause of mortality (3) accounting for half of all deaths in patients with diabetes (4). Heart failure (HF) is an important sequela of diabetes through accelerated atherosclerosis and other direct cellular
Heart failure (HF) often develops in patients with diabetes and is recognized for its role in inc... more Heart failure (HF) often develops in patients with diabetes and is recognized for its role in increased cardiovascular morbidity and mortality in this population. Most existing models predict risk in patients with prevalent rather than incident diabetes and fail to account for sex differences in HF risk factors. We derived sexspecific models in Ontario, Canada to predict HF at diabetes onset and externally validated these models in the U.K. RESEARCH DESIGN AND METHODS Retrospective cohort study using international population-based data. Our derivation cohort comprised all Ontario residents aged ‡18 years who were diagnosed with diabetes between 2009 and 2018. Our validation cohort comprised U.K. patients aged ‡35 years who were diagnosed with diabetes between 2007 and 2017. Primary outcome was incident HF. Sex-stratified multivariable Fine and Gray subdistribution hazard models were constructed, with death as a competing event. RESULTS A total of 348,027 Ontarians (45% women) and 54,483 U.K. residents (45% women) were included. At 1, 5, and 9 years, respectively, in the external validation cohort, the C-statistics were 0.81 (95% CI 0.79-0.84), 0.79 (0.77-0.80), and 0.78 (0.76-0.79) for the female-specific model; and 0.78 (0.75-0.80), 0.77 (0.76-0.79), and 0.77 (0.75-0.79) for the male-specific model. The models were well-calibrated. Age, rurality, hypertension duration, hemoglobin, HbA 1c , and cardiovascular diseases were common predictors in both sexes. Additionally, mood disorder and alcoholism (heavy drinker) were female-specific predictors, while income and liver disease were male-specific predictors. CONCLUSIONS Our findings highlight the importance of developing sex-specific models and represent an important step toward personalized lifestyle and pharmacologic prevention of future HF development. Over the last four decades, the number of adults with diabetes almost quadrupled worldwide (1). Having diabetes more than doubles an individual's risk of developing cardiovascular disease (CVD) (2), which is a leading cause of mortality (3) accounting for half of all deaths in patients with diabetes (4). Heart failure (HF) is an important sequela of diabetes through accelerated atherosclerosis and other direct cellular
ardiac surgery is a growing field, with 2 million procedures currently being performed globally e... more ardiac surgery is a growing field, with 2 million procedures currently being performed globally each year. 1 The last 2 decades have seen important advances in surgical and perioperative care and in improved patient survival. 2-4 On the other hand, as patients presenting for surgery become increasingly older and frail, they shift their goals and priorities toward how surgery might affect personal freedom and mobility, rather than longevity alone. 5-9 New or residual impairments after surgery are of particular concern to patients and clinicians alike, but the quality and standard of cardiac care has long been assessed by traditional "tombstone" measures such as mortality and major adverse cardiovascular events. 5,8,10-12 Patient-centred care represents a priority area for modern medical practice and research, and the facilitation of shared surgical decision-making could be improved by incorporating patient perspectives and patient-derived data. 13-15 Our group has recently derived "disability-free survival" as a patient-defined outcome through a large-scale survey of more than 3000 patients with cardiovascular diseases. 16 According to patient preferences and values, disability was defined as the composite of stroke, recurrent nonelective hospital admissions and admission to a nursing home. 16 Before this outcome measure could be meaningfully used to inform patient-centred decision-making, its epidemiology and impact need to be described first at the population level. We therefore conducted the current study to evaluate disability-free survival after major cardiac surgery in a population-based cohort. Methods Design and study population We conducted a population-based, retrospective cohort study in Ontario, Canada. We included adults residing in Ontario
Purpose of review Patients with multivessel coronary artery disease (CAD) may undergo revasculari... more Purpose of review Patients with multivessel coronary artery disease (CAD) may undergo revascularization by either percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG). This review will discuss the use of polygenic risk scores for risk-stratification of patients with multivessel CAD in order to guide the choice of revascularization. Recent findings A 57-single nucleotide polymorphism (SNP)-polygenic risk score can accurately risk-stratify patients with CAD and identify those who will receive greater benefit from statin therapy. The most recent genomic studies reveal 243 different SNPs are now significantly associated with CAD. Randomized clinical trials comparing PCI vs. CABG (FREEDOM, SYNTAX, NOBLE, EXCEL) have uncovered factors related to CAD severity (diabetes, SYNTAX score) are critical determinants of outcomes after revascularization. Summary There is a need to discover predictors of outcomes after PCI vs. CABG to improve clinical decision-making in multivessel CAD. High polygenic risk score is associated with increased CAD severity and better outcomes with statin therapy. Randomized clinical trials indicate CAD severity is associated with better outcomes after CABG compared with PCI. Accordingly, polygenic risk score could also be associated with better outcomes after CABG vs. PCI and used to optimize revascularization for patients with multivessel CAD.
What This Article Tells Us That Is New • In a retrospective study of 5,127 patients undergoing no... more What This Article Tells Us That Is New • In a retrospective study of 5,127 patients undergoing noncardiac surgery, an increased risk of postoperative acute kidney injury (defined as more than 50% or 0.3 mg/dl increase in serum creatinine concentration) was found when intraoperative mean arterial pressure was less than 60 mmHg for more than 20 min and less than 55 mmHg for more than 10 min
Acute postoperative myocardial ischemia (PMI) after cardiac surgery is an infrequent event that c... more Acute postoperative myocardial ischemia (PMI) after cardiac surgery is an infrequent event that can evolve rapidly and become a potentially life-threatening complication. Multiple factors are associated with acute PMI after cardiac surgery and may vary by the type of surgical procedure performed. Although the criteria defining nonprocedural myocardial ischemia are well established, there are no universally accepted criteria for the diagnosis of acute PMI. In addition, current evidence on the management of acute PMI after cardiac surgery is sparse and generally of low methodological quality. Once acute PMI is suspected, prompt diagnosis and treatment are imperative, and options range from conservative strategies to percutaneous coronary intervention and redo coronary artery bypass grafting. In this document, a multidisciplinary group including experts in cardiac surgery, cardiology, anesthesiology, and postoperative care summarizes the existing evidence on diagnosis and treatment of acute PMI and provides clinical guidance.
American Heart Journal Plus: Cardiology Research And Practice, 2022
Study objective: A multi-institutional interdisciplinary team was created to develop a research g... more Study objective: A multi-institutional interdisciplinary team was created to develop a research group focused on leveraging artificial intelligence and informatics for cardio-oncology patients. Cardio-oncology is an emerging medical field dedicated to prevention, screening, and management of adverse cardiovascular effects of cancer/ cancer therapies. Cardiovascular disease is a leading cause of death in cancer survivors. Cardiovascular risk in these patients is higher than in the general population. However, prediction and prevention of adverse cardiovascular events in individuals with a history of cancer/cancer treatment is challenging. Thus, establishing an interdisciplinary team to create cardiovascular risk stratification clinical decision aids for integration into electronic health records for oncology patients was considered crucial. Design/setting/participants: Core team members from the Medical College of Wisconsin (MCW), University of Wisconsin-Milwaukee (UWM), and Milwaukee School of Engineering (MSOE), and additional members from Cleveland Clinic, Mayo Clinic, and other institutions have joined forces to apply high-performance computing in cardio-oncology. Results: The team is comprised of clinicians and researchers from relevant complementary and synergistic fields relevant to this work. The team has built an epidemiological cohort of ~5000 cancer survivors that will serve as a database for interdisciplinary multi-institutional artificial intelligence projects. Conclusion: Lessons learned from establishing this team, as well as initial findings from the epidemiology cohort, are presented. Barriers have been broken down to form a multi-institutional interdisciplinary team for health informatics research in cardio-oncology. A database of cancer survivors has been created collaboratively by the team and provides initial insight into cardiovascular outcomes and comorbidities in this population.
Heart failure (HF) often develops in patients with diabetes and is recognized for its role in inc... more Heart failure (HF) often develops in patients with diabetes and is recognized for its role in increased cardiovascular morbidity and mortality in this population. Most existing models predict risk in patients with prevalent rather than incident diabetes and fail to account for sex differences in HF risk factors. We derived sexspecific models in Ontario, Canada to predict HF at diabetes onset and externally validated these models in the U.K. RESEARCH DESIGN AND METHODS Retrospective cohort study using international population-based data. Our derivation cohort comprised all Ontario residents aged ‡18 years who were diagnosed with diabetes between 2009 and 2018. Our validation cohort comprised U.K. patients aged ‡35 years who were diagnosed with diabetes between 2007 and 2017. Primary outcome was incident HF. Sex-stratified multivariable Fine and Gray subdistribution hazard models were constructed, with death as a competing event. RESULTS A total of 348,027 Ontarians (45% women) and 54,483 U.K. residents (45% women) were included. At 1, 5, and 9 years, respectively, in the external validation cohort, the C-statistics were 0.81 (95% CI 0.79-0.84), 0.79 (0.77-0.80), and 0.78 (0.76-0.79) for the female-specific model; and 0.78 (0.75-0.80), 0.77 (0.76-0.79), and 0.77 (0.75-0.79) for the male-specific model. The models were well-calibrated. Age, rurality, hypertension duration, hemoglobin, HbA 1c , and cardiovascular diseases were common predictors in both sexes. Additionally, mood disorder and alcoholism (heavy drinker) were female-specific predictors, while income and liver disease were male-specific predictors. CONCLUSIONS Our findings highlight the importance of developing sex-specific models and represent an important step toward personalized lifestyle and pharmacologic prevention of future HF development. Over the last four decades, the number of adults with diabetes almost quadrupled worldwide (1). Having diabetes more than doubles an individual's risk of developing cardiovascular disease (CVD) (2), which is a leading cause of mortality (3) accounting for half of all deaths in patients with diabetes (4). Heart failure (HF) is an important sequela of diabetes through accelerated atherosclerosis and other direct cellular
European Heart Journal - Quality of Care and Clinical Outcomes, Jun 13, 2023
Background ST-segment myocardial infarction (STEMI) is typically associated with increased age, b... more Background ST-segment myocardial infarction (STEMI) is typically associated with increased age, but there is an important group of patients who suffer from STEMI under the age of 50 who are not well characterized in studies. Methods and results We analysed results from Myocardial Ischemia National Audit Project (MINAP) from the United Kingdom (UK) between 2010 and 2017 and the National Inpatient Sample (NIS) from the United States of America (USA) between 2010 and 2018. After exclusion criteria, there were 32 719 STEMI patients aged ≤50 from MINAP, and 238 952 patients’ ≤50 from the NIS. We analysed temporal trends in demographics, management, and mortality. The proportion of females increased, 15.6% (2010–2012) to 17.6% (2016–2017) (UK) and 22.8% (2010–2012) to 23.1% (2016–2018) (USA). The proportion of white patients decreased, from 86.7% (2010) to 79.1% (2017) (UK) and 72.1% (2010) to 67.1% (2017) (USA). Invasive coronary angiography (ICA) rates increased in UK (2010–2012: 89.0%, 2016–2017: 94.3%), while decreased in USA (2010–2012: 88.9%, 2016–2018: 86.2% (USA). After adjusting for baseline characteristics and management strategies, there was no difference in all-cause mortality in the UK in 2016–2017 compared to 2010–2012 (OR:1.21, 95% CI:0.60–2.40), but there was a decrease in the USA in 2016–2018 compared to 2010–2012 (OR: 0.84, 95% CI: 0.79–0.90). Conclusion The demographics of young STEMI patients have temporally changed in the UK and USA, with increased proportions of females and ethnic minorities. There was a significant increase in the frequency of diabetes mellitus over the respective time periods in both countries.
Trials suggest patients with ST-elevation myocardial infarction (STEMI) without ‘standard modifia... more Trials suggest patients with ST-elevation myocardial infarction (STEMI) without ‘standard modifiable cardiovascular risk factors’ (SMuRFs) have poorer outcomes, but the role of ethnicity has not been investigated. We analyzed 118,177 STEMI patients using the Myocardial Ischaemia National Audit Project (MINAP) registry. Clinical characteristics and outcomes were analyzed using hierarchical logistic regression models; patients with ≥1 SMuRF (n = 88,055) were compared with ‘SMuRFless’ patients (n = 30,122), with subgroup analysis comparing outcomes of White and Ethnic minority patients. SMuRFless patients had higher incidence of major adverse cardiovascular events (MACE) (odds ratio, OR: 1.09, 95% CI 1.02–1.16) and in-hospital mortality (OR: 1.09, 95% CI 1.01–1.18) after adjusting for demographics, Killip classification, cardiac arrest, and comorbidities. When additionally adjusting for invasive coronary angiography (ICA) and revascularisation (percutaneous coronary intervention (PCI) or coronary artery bypass grafts surgery (CABG)), results for in-hospital mortality were no longer significant (OR 1.05, 95% CI .97–1.13). There were no significant differences in outcomes according to ethnicity. Ethnic minority patients were more likely to undergo revascularisation with ≥1 SMuRF (88 vs 80%, P < .001) or SMuRFless (87 vs 77%, P < .001. Ethnic minority patients were more likely undergo ICA and revascularisation regardless of SMuRF status.
European Heart Journal - Quality of Care and Clinical Outcomes, Mar 15, 2023
AimsTo assess processes of care and clinical outcomes in cancer patients with ST elevation myocar... more AimsTo assess processes of care and clinical outcomes in cancer patients with ST elevation myocardial infarction (STEMI) according to cancer type.Methods and resultsThis is a national population-based study of patients admitted with STEMI in the UK between January 2005 and March 2019. Data were obtained from the National Heart Attack Myocardial Infarction National Audit Project (MINAP) registry and the Hospital Episode Statistics registry. We identified 353 448 STEMI-indexed admissions between 2005 and 2019. Of those, 8581 (2.4%) had active cancer. Prostate cancer (29% of STEMI patients with cancer) was the most common cancer followed by haematologic malignancies (14%) and lung cancer (13%). Cancer patients were less likely to receive invasive coronary revascularization (60.0% vs. 71.6%, P < 0.001] and had higher in-hospital death [odd ratio (OR) 1.39, 95% confidence interval (CI) 1.25–1.54] and bleeding (OR 1.23, 95% CI 1.03–1.46). Cancer patients had higher mortality at 30 days (HR 2.39, 95% CI 2.19–2.62) and 1 year (HR 3.73, 95% CI 3.58–3.89). Lung cancer was the cancer associated with the highest risk of death in the hospital (OR 1.75, 95% CI 1.39–2.22) and at 1 year (OR 8.08, 95% CI 7.44–8.78). Colon cancer (OR 1.98, 95% CI 1.24–3.14) was the main cancer associated with major bleeding. All common cancer types were associated with higher mortality at 1 year. Cardiovascular death (62%) was the main cause of death in the first 30 days, while cancer (52%) was the main cause of death within 1 year.ConclusionSTEMI patients with cancer have a higher risk of short- and long-term mortality, particularly lung cancer. Colon cancer is the main cancer associated with major bleeding. Cardiovascular disease was the main cause of death in the first month, whereas cancer was the main cause of death within 1 year.
Background Guidelines recommend that hospitalized patients newly diagnosed with HF be referred to... more Background Guidelines recommend that hospitalized patients newly diagnosed with HF be referred to an outpatient HF clinic (HFC) within 2 weeks of discharge. Our study aims were (i) to assess the current literary landscape on the impact of patient sex on HFC referral and outcomes and (ii) to provide a qualitative overview of possible considerations for the impact of sex on referral patterns and HF characteristics including aetiology, symptom severity, investigations undertaken and pharmacologic therapy. Methods and results We conducted a scoping review using the Arksey and O'Malley framework and searched Medline, EMBASE, PsychINFO, Cochrane Library, Ageline databases and grey literature. Eligible articles included index HF hospitalizations or presentations to the Emergency Department (ED), a description of the HFC referral of patients not previously followed by an HF specialist and sex-specific analysis. Of the 11 372 potential studies, 8 met the inclusion criteria. These studies reported on a total of 11 484 participants, with sample sizes ranging between 168 and 3909 (25.6%-50.7% female). The included studies were divided into two groups: (i) those outlining the referral process to an HFC and (ii) studies which include patients newly enrolled in an HFC. Of the studies in Group 1, males (51%-82.4%) were more frequently referred to an HFC compared with females (29%-78.1%). Studies in Group 2 enrolled a higher proportion of males (62%-74% vs. 26%-38%). One study identified independent predictors of HFC referral which included male sex, younger age, and the presence of systolic dysfunction, the latter two more often found in males. Two studies, one from each group reported a higher mortality amongst males compared with females, whereas another study from Group 2 reported a higher hospitalization rate amongst females following HFC assessment. Conclusions Males were more likely than females to be referred to HFCs after hospitalization and visits to the Emergency Department, however heterogeneity across studies precluded a robust assessment of sex-based differences in outcomes. This highlights the need for more comprehensive longitudinal data on HF patients discharged from the acute care setting to better understand the role of sex on patient outcomes.
ObjectiveCongestive acute kidney injury (c-AKI) refers to AKI in the presence of right ventricula... more ObjectiveCongestive acute kidney injury (c-AKI) refers to AKI in the presence of right ventricular failure (RVF) and is a highly morbid complication of cardiac surgery. However, treatment has traditionally been reactive rather than proactive due to limited modalities to predict this complication. The objective of this study was to investigate the ability of insulin-like growth-factor binding protein 7 (IGFBP7), to predict c-AKI, AKI and RVF in patients undergoing cardiac surgery, as compared to N-terminal prohormone B-type natriuretic peptide (NT-pro-BNP) and pulmonary artery pulsatility index (PAPi).MethodsThis prospective nested case–control study consisted of 350 adult patients who underwent elective cardiac surgery. The outcomes were c-AKI, AKI and RVF. Unadjusted and adjusted conditional logistic regression models and areas under the receiver operating characteristic curve (AUC) were used to assess the predictive performance of each marker.ResultsFor the prediction of c-AKI, th...
Heart failure (HF) often develops in patients with diabetes and is recognized for its role in inc... more Heart failure (HF) often develops in patients with diabetes and is recognized for its role in increased cardiovascular morbidity and mortality in this population. Most existing models predict risk in patients with prevalent rather than incident diabetes and fail to account for sex differences in HF risk factors. We derived sexspecific models in Ontario, Canada to predict HF at diabetes onset and externally validated these models in the U.K. RESEARCH DESIGN AND METHODS Retrospective cohort study using international population-based data. Our derivation cohort comprised all Ontario residents aged ‡18 years who were diagnosed with diabetes between 2009 and 2018. Our validation cohort comprised U.K. patients aged ‡35 years who were diagnosed with diabetes between 2007 and 2017. Primary outcome was incident HF. Sex-stratified multivariable Fine and Gray subdistribution hazard models were constructed, with death as a competing event. RESULTS A total of 348,027 Ontarians (45% women) and 54,483 U.K. residents (45% women) were included. At 1, 5, and 9 years, respectively, in the external validation cohort, the C-statistics were 0.81 (95% CI 0.79-0.84), 0.79 (0.77-0.80), and 0.78 (0.76-0.79) for the female-specific model; and 0.78 (0.75-0.80), 0.77 (0.76-0.79), and 0.77 (0.75-0.79) for the male-specific model. The models were well-calibrated. Age, rurality, hypertension duration, hemoglobin, HbA 1c , and cardiovascular diseases were common predictors in both sexes. Additionally, mood disorder and alcoholism (heavy drinker) were female-specific predictors, while income and liver disease were male-specific predictors. CONCLUSIONS Our findings highlight the importance of developing sex-specific models and represent an important step toward personalized lifestyle and pharmacologic prevention of future HF development. Over the last four decades, the number of adults with diabetes almost quadrupled worldwide (1). Having diabetes more than doubles an individual's risk of developing cardiovascular disease (CVD) (2), which is a leading cause of mortality (3) accounting for half of all deaths in patients with diabetes (4). Heart failure (HF) is an important sequela of diabetes through accelerated atherosclerosis and other direct cellular
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Papers by Louise Sun