How small is too small? A systematic review of center volume and outcome after cardiac transplantation

Background—The aim of this study was to assess the relationship between the volume of cardiac transplantation procedures performed in a center and the outcome after cardiac transplantation. Methods and Results—PubMed, Embase, and the Cochrane library were searched for articles on the volume–outcome relationship in cardiac transplantation. Ten studies were identified, and all adopted a different approach to data analysis and varied in adjustment for baseline characteristics. The number of patients in each study ranged from 798 to 14401, and observed 1-year mortality ranged from 12.6% to 34%. There was no association between the continuous variables of center volume and observed mortality. There was a weak association between the continuous variables of center volume and adjusted mortality up to 1 year and a stronger association at 5 years. When centers were grouped in volume categories, low-volume centers had the highest adjusted mortality, intermediate-volume centers had lower adjusted mortality, and high-volume centers had the lowest adjusted mortality but were not significantly better than intermediate-volume centers. Category limits were arbitrary and varied between studies. Conclusions—There is a relationship between center volume and mortality in heart transplantation. The existence of a minimum acceptable center volume or threshold is unproven. However, a level of 10 to 12 heart transplants per year corresponds to the upper limit of low-volume categories that may have relatively higher mortality. It is not known whether outcomes for patients treated in low-volume transplant centers would be improved by reorganizing centers to ensure volumes in excess of 10 to 12 heart transplants per year

Pharmacist intervention in primary care to improve outcomes in patients with left ventricular systolic dysfunction

<b>Background</b> Meta-analysis of small trials suggests that pharmacist-led collaborative review and revision of medical treatment may improve outcomes in heart failure.<p></p> <b>Methods and results</b> We studied patients with left ventricular systolic dysfunction in a cluster-randomized controlled, event driven, trial in primary care. We allocated 87 practices (1090 patients) to pharmacist intervention and 87 practices (1074 patients) to usual care. The intervention was delivered by non-specialist pharmacists working with family doctors to optimize medical treatment. The primary outcome was a composite of death or hospital admission for worsening heart failure. This trial is registered, number ISRCTN70118765. The median follow-up was 4.7 years. At baseline, 86% of patients in both groups were treated with an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. In patients not receiving one or other of these medications, or receiving less than the recommended dose, treatment was started, or the dose increased, in 33.1% of patients in the intervention group and in 18.5% of the usual care group [odds ratio (OR) 2.26, 95% CI 1.64–3.10; P< 0.001]. At baseline, 62% of each group were treated with a β-blocker and the proportions starting or having an increase in the dose were 17.9% in the intervention group and 11.1% in the usual care group (OR 1.76, 95% CI 1.31–2.35; P< 0.001). The primary outcome occurred in 35.8% of patients in the intervention group and 35.4% in the usual care group (hazard ratio 0.97, 95% CI 0.83–1.14; P = 0.72). There was no difference in any secondary outcome.<p></p> <b>Conclusion</b> A low-intensity, pharmacist-led collaborative intervention in primary care resulted in modest improvements in prescribing of disease-modifying medications but did not improve clinical outcomes in a population that was relatively well treated at baseline

"Real world" eligibility for sacubitril/valsartan in unselected heart failure patients: data from the Swedish Heart Failure Registry

Purpose: PARADIGM-HF demonstrated the superiority of sacubitril/valsartan over enalapril in patients with heart failure and reduced ejection fraction (HF-REF). How widely applicable sacubitril/valsartan treatment is in unselected patients with HF-REF is not known. We examined eligibility of patients with HF-REF for treatment with sacubitril/valsartan, according to the criteria used in PARADIGM-HF, in the Swedish Heart Failure Registry (SwedeHF). Methods: Patients were considered potentially eligible if they were not hospitalized, had symptoms (NYHA class II–IV) and a reduced LVEF (≤ 40%), and were prescribed an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) at a dose equivalent to enalapril ≥ 10 mg daily. In these patients, we evaluated further eligibility according to the main additional PARADIGM-HF inclusion criteria. Results: Of 12,866 outpatients in NYHA functional class II–IV with an LVEF ≤ 40%, 9577 were prescribed at least 10 mg of enalapril (or equivalent) daily. Complete additional data were available for 3099 of these patients (32.4%) and of them 75.5% were potentially eligible for treatment with sacubitril/valsartan. The most common reason for ineligibility was a low natriuretic peptide level (n = 462, 14.9%). Only a small proportion of patients were ineligible due to low eGFR or serum potassium level. Because only 78% of patients were taking ≥ 10 mg enalapril or equivalent daily, only 58.9% of all patients (75.5% of 78%) were eligible for sacubitril/valsartan. Conclusions: Between 34 and 76% of symptomatic patients with HF-REF in a ‘real world’ population are eligible for treatment with sacubitril/valsartan, depending on background ACEI/ARB dose. The most common reason for ineligibility is a low natriuretic peptide level

Sex differences in incidence, mortality, and survival in individuals with stroke in Scotland, 1986 to 2005

<p><b>Background and Purpose:</b> The aim of this study was to examine the effect of sex across different age groups and over time for stroke incidence, 30-day case-fatality, and mortality.</p> <p><b>Methods:</b> All first hospitalizations for stroke in Scotland (1986 to 2005) were identified using linked morbidity and mortality data. Age-specific rate ratios (RRs) for comparing women with men for both incidence and mortality were modeled with adjustment for study year and socioeconomic deprivation. Logistic regression was used to model 30-day case-fatality.</p> <p><b>Results:</b> Women had a lower incidence of first hospitalization than men and size of effect varied with age (55 to 64 years, RR=0.65, 95% CI 0.63 to 0.66; 85 years, RR=0.94, 95% CI 0.91 to 0.96). Women aged 55 to 84 years had lower mortality than men and again size of effect varied with age (65 to 74 years, RR=0.79, 95% CI 0.76 to 0.81); 75 to 84 years, RR=0.94, 95% CI 0.92 to 0.95). Conversely, women aged 85 years had 15% higher stroke mortality than men (RR=1.15, 95% CI 1.12 to 1.18). Adjusted risk of death within 30 days was significantly higher in women than men, and this difference increased over the 20-year period in all age groups (adjusted OR in 55 to 64 year olds 1.23, 95% CI 1.14 to 1.33 in 1986 and 1.51, 95% CI 1.39 to 1.63 in 2005).</p> <p><b>Conclusions:</b> We observed lower rates of incidence and mortality in younger women than men. However, higher numbers of older women in the population mean that the absolute burden of stroke is greater in women. Short-term case-fatality is greater in women of all ages and, worryingly, these differences have increased from 1986 to 2005.</p&gt

Efficacy of pulmonary artery pressure monitoring in patients with chronic heart failure: a meta-analysis of three randomized controlled trials

Background and Aims: Adjustment of treatment based on remote monitoring of pulmonary artery (PA) pressure may reduce the risk of hospital admission for heart failure (HF). We have conducted a meta-analysis of large randomized trials investigating this question. Methods: A systematic literature search was performed for randomized clinical trials (RCTs) with PA pressure monitoring devices in patients with HF. The primary outcome of interest was the total number of HF hospitalizations. Other outcomes assessed were urgent visits leading to treatment with intravenous diuretics, all-cause mortality, and composites. Treatment effects are expressed as hazard ratios, and pooled effect estimates were obtained applying random effects meta-analyses. Results: Three eligible RCTs were identified that included 1898 outpatients in New York Heart Association functional class II-IV, either hospitalized for HF in the prior 12 months or with elevated plasma NT-proBNP concentrations. Mean follow-up was 14.7 months, 67.8% of the patients were men, and 65.8% had an ejection fraction ≤40%. Compared to patients in the control group, the hazard ratio (95% confidence interval) for total HF hospitalizations in those randomized to PA pressure monitoring was 0.70 (0.58-0.86) (p=0.0005). The corresponding hazard ratio for the composite of total HF hospitalizations, urgent visits and all-cause mortality was 0.75 (0.61-0.91; p=0.0037) and for all-cause mortality 0.92 (0.73-1.16). Subgroup analyses, including ejection fraction phenotype, revealed no evidence of heterogeneity in the treatment effect. Conclusions: The use of remote PA pressure monitoring to guide treatment of patients with HF reduces episodes of worsening HF and subsequent hospitalizations

Heart failure and socioeconomic status: accumulating evidence of inequality

Aims Socioeconomic status (SES) is a powerful predictor of incident coronary disease and adverse cardiovascular outcomes. Understanding the impact of SES on heart failure (HF) development and subsequent outcomes may help to develop effective and equitable prevention, detection, and treatment strategies Methods and results A systematic literature review of electronic databases including PubMed, EMBASE, CINAHL, and the Cochrane Library, restricted to human subjects, was carried out. The principal outcomes were incidence, prevalence, hospitalizations, mortality, and treatment of HF. Socioeconomic measures included education, occupation, employment relations, social class, income, housing characteristics, and composite and area level indicators. Additional studies were identified from bibliographies of relevant articles and reviews. Twenty-eight studies were identified. Lower SES was associated with increased incidence of HF, either in the community or presenting to hospital. The adjusted risk of developing HF was increased by ∼30–50% in most reports. Readmission rates following hospitalization were likewise greater in more deprived patients. Although fewer studies examined mortality, lower SES was associated with poorer survival. Evidence defining the equity of medical treatment of patients with HF was scarce and conflicting. Conclusions Socioeconomic deprivation is a powerful independent predictor of HF development and adverse outcomes. However, the precise mechanisms accounting for this risk remain elusive. Heart failure represents the endpoint of numerous different pathophysiological processes and ‘chains of events’, each modifiable throughout the disease trajectories. The interaction between SES and HF is accordingly complex. Disentangling the many and varied life course processes is challenging. A better understanding of these issues may help attenuate the health inequalities so clearly evident among patients with HF

129 prescribing multiple classes of evidence based pharmacotherapy in the community is associated with lower mortality

Background Prescribing of evidence based therapies (EBTs) reduces mortality in patients with cardiovascular disease. We aimed to describe the association between the prescription of EBTs for a first diagnosis of myocardial infarction (MI), angina or peripheral arterial disease (PAD) and mortality at 1 year.<p></p> Methods We conducted a retrospective cohort study using a linked database of primary and secondary care records covering 238 064 individuals (6% of the Scottish population). We identified patients with a first diagnosis of MI, angina, or PAD defined as a first hospitalisation or first recording of the diagnosis in primary or secondary care. We extracted data on the prescription of EBTs from primary care. Patients who died within the first 30 days were excluded. EBTs included ACE inhibitor/Angiotensin receptor blockers (ARBs), β-blockers, statins and antiplatelet agents; patients were categorised as prescribed no EBTs, one drug, two drugs and≥three drugs prescribed. Multivariable logistic regression was used to examine whether prescribing multiple classes of EBTs was associated with improving mortality.<p></p> Result Between 1997 and 2005, 4305 patients with a first diagnosis of MI, 7210 with angina, and 3385 with PAD had survived within 30 days after their first diagnosis. In comparison to those who were not prescribed EBTs, MI patients prescribed one drug were not significantly less likely to die (OR 1.05 95% CI 0.74 to 1.51); however patients prescribed two drugs (OR 0.56 95% CI 0.38 to 0.83) or ≥three drugs (OR 0.64 95% CI 0.46 to 0.90) were significantly less likely to die following a first diagnosis of MI (p=0.002). Similar trends were seen with angina—one drug (OR 0.86 95% CI 0.63 to 1.16), two drugs (OR 0.58 95% CI 0.40 to 0.0.84) and ≥three drugs (OR 0.44, 95% CI 0.28 to 0.67) (p=0.001). There was no significant corresponding association in those with PAD—one drug (OR 0.80, 95% CI 0.54 to 1.19), two drugs (OR 0.70, 95% CI 0.38 to 1.27) and ≥three drugs (OR 0.68, 95% CI 0.23 to 1.98) (p=0.49).<p></p> Conclusions The prescription of multiple classes of EBTs is associated with lower mortality in patients with a first diagnosis of MI and angina but not PAD. The greater number of drugs prescribed the greater the associated reduction in mortality. This fact was clearly observed in angina patients. These data highlight the need to ensure all patients receive appropriate EBTs.<p></p&gt

Prior psychiatric hospitalization is associated with excess mortality in patients hospitalized with non-cardiac chest pain: a data linkage study based on the full Scottish population (1991-2006)

AIMS: Non-cardiac chest pain (NCCP) is considered a benign condition. We investigate case-fatality following an incident hospitalization for NCCP and determine whether previous psychiatric hospitalization is associated with short-term mortality. METHODS AND RESULTS: This was a population-based retrospective cohort study of 159 888 patients discharged from hospital in Scotland (1991-2006) following a first NCCP hospitalization, using routinely collected morbidity and mortality data. All-cause and cardiovascular disease (CVD) mortality at 1 year following hospitalization was examined. A total of 3514 (4.4%) men and 3136 (3.9%) women with a first NCCP hospitalization had a psychiatric hospitalization in the 10 years preceding incident NCCP hospitalization. Those with a previous psychiatric hospitalization were younger and more socioeconomically deprived (SED). Overall, crude case fatality at 1 year was 4.4% in men and 3.7% in women. This was higher in patients with a previous psychiatric hospitalization compared with those without (overall: men 6.3 vs. 4.3%; women: 5.3 vs. 3.6%), in all age groups and all SED quintiles. Following adjustment (year of NCCP hospitalization, SED, co-morbid diabetes, and hypertension), the hazard of all-cause and CVD-specific death at 1 year was higher in men and women with a previous psychiatric hospitalization than without, with effect modification according to age group. CONCLUSION: Non-cardiac chest pain is not an entirely benign condition. Individuals with a hospital discharge diagnosis of NCCP who have a previous psychiatric hospitalization have a greater risk of death, all-cause, and CVD-specific, at 1 year, than those without. A NCCP hospitalization is an opportunity to engage, and where appropriate, intervene to modify cardiovascular risk in this difficult-to-reach and high-risk group

Primary care burden and treatment of patients with heart failure and chronic obstructive pulmonary disease in Scotland

Aims: Heart failure (HF) and chronic obstructive pulmonary disease (COPD) frequently coexist and present major challenges to healthcare providers. The epidemiology, consultation rate, and treatment of patients with HF and COPD in primary care are ill-defined. Methods and results: This was an analysis of cross-sectional data from 61 primary care practices (377 439 patients) participating in the Scottish Continuous Morbidity Recording scheme. The prevalence of COPD in patients with HF increased from 19.8% in 1999 to 23.8% in 2004. In 2004, the prevalence was similar in men and women (24.8% vs. 22.9%, P = 0.09), increased with age up to 75 years, and increased with greater socioeconomic deprivation (most deprived 31.3% vs. least deprived 18.6%, P = 0.01). Contact rates for HF or COPD in those with both conditions were greater than disease-specific contact rates in patients with either condition alone. Although overall beta-blocker prescribing increased over time; the adjusted odds of beta-blocker prescription in patients with COPD was low and failed to improve [odds ratio 0.30 (0.28–0.32), P < 0.001]. In 2004, only 18% of individuals with HF and COPD were prescribed beta-blockers vs. 41% in those without COPD. Conclusion: Chronic obstructive pulmonary disease is a frequent comorbidity in patients with HF and represents a significant healthcare burden to primary care. Although beta-blocker prescribing in the community has increased, less than a fifth of patients with HF and COPD received beta-blockers