Coronary Heart Disease Database Research Articles

Temporal trends and predictors of emergency department visits and hospital readmissions in angina and no obstructive coronary artery disease (ANOCA): a population-based study of 85,573 adults

Abstract Background Chest pain in patients with angina and no obstructive coronary artery disease (ANOCA) is a diagnostic and treatment challenge, resulting in a significant burden on healthcare resources. With increasing recognition of ANOCA, it is uncertain if the healthcare resource utilization of patients with ANOCA has changed over time. We aimed to determine whether emergency department (ED) visits and hospital readmissions in patients with ANOCA has changed over time and their predictors. Methods A retrospective population-based cohort of patients who had their first cardiac angiography for a chest pain syndrome in Alberta between 2002 and 2020 were extracted from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) database. A temporal trend analysis was performed to investigate the proportion of ED visits and hospital readmissions in ANOCA and obstructive coronary artery disease (CAD). The predictors of ED visits and readmissions were also analyzed. Results In our analysis, 85,573 patients were included (26% ANOCA, 31% female, mean age 62.1 ± 12.0 years, 65% ED visit≥1, 30% readmission). The percentage of patients with ANOCA and obstructive CAD having an ED visit ranged between 26.3% to 30.7% and 47.7% to 53.1%, respectively. The percentage of patients with ANOCA and obstructive CAD having readmission declined slightly over time, from 6.5% to 3.8% in ANOCA and 24.8% to 15.3% in obstructive CAD. Obstructive CAD was found to be the most significant predictor of both ED visits (OR=1.933, 95% CI=1.837–2.034), and readmissions (HR=2.638, 95% CI=2.518–2.764), with congestive heart failure (OR=1.302, 95% CI=1.125–1.507) , peripheral artery disease (OR=1.291, 95% CI=1.116–1.494), cerebrovascular disease (OR=1.382, 95% CI=1.224–1.559), myocardial infarction (vs stable angina (SA): OR=1.233, 95% CI=1.172–1.297), and unstable angina (vs SA: OR=1.564, 95% CI=1.466-1.668–0.89) also contributing to ED visits, and diabetes (HR=1.276, 95% CI=1.229–1.323) and stable angina (vs MI: HR=0.746, 95% CI=0.719–0.774; vs UA: HR=0.895, 95% CI=0.857–0.934) contributing to readmissions. Conclusions Emergency department visits for patients with ANOCA have remained stable over time, with a slight decline in hospital readmissions. Patients with ANOCA had fewer ED visits and readmissions than obstructive CAD patients, and no sex differences were observed in the utilization of healthcare resources. This study suggests that education and follow-up interventions are still needed for patients with ANOCA.Comparison of baseline characteristicsED visits & Readmission Temporal Trends

The Impact of Cardiac Sparing Techniques on Major Cardiac Events for Patients Undergoing Breast Radiotherapy

In radiotherapy, studies with historical estimates have shown a linear relationship between cardiac dose and risk of major cardiac events with no safe dose threshold. This study investigates the relationship between cardiac dose and event rates for patients undergoing breast radiotherapy with modern heart-sparing techniques, where substantially lower cardiac doses are achieved. From 2008 to 2018, all patients undergoing curative whole breast or chest wall radiotherapy at a tertiary care center were included. In this study, the deep-inspiration breath hold (DIBH) technique was implemented in 2013 as the standard of care for left-sided patients. Cardiacdosimetricdata from the clinical treatment plan was extracted and matched to patients from the ongoing, prospectively collected Alberta Provincial Project for Outcome Assessment in Coronary Heart disease (APPROACH) database that experienced a major adverse cardiac event (MACE). MACE was defined as myocardial infarction, hospitalization for unstable angina, hospitalization for heart failure,or clinically indicated coronary revascularization.For all the left- and right-sided patients, the population event rates, the median time to event, and the average (± standard deviation) of the mean heart physical dose is reported. The proportion of left- and right-sided patients experiencing a major cardiac event were tested for independence using a two-sample z-test for proportions. A student's t-test was used to measure significance for mean heart dose. An alpha of 0.05 was used to indicate significance for both tests. A total of 4893 patients received breast radiotherapy with 2429 left-sided, 2429 right-sided, and 35 synchronous bilateral. For all patients, Table 1 describes laterality, treatment characteristics, and prescription. The median (range) age at the time of first radiotherapy treatment was 59 (23-94). Of these patients with contours available, 96 left-sided (3.9%) and 69 right-sided (2.8%) patients experienced a MACE (p = 0.03) with a mean heart dose of 1.4 (±0.7)Gyand 0.5 (±0.2)Gy, in the event cohorts respectively (p < 0.001). The mean time to event was 4.7 (±3.2) years and 4.8 (±3.0) years for left- and right-sided patients, respectively (p = 0.83). For the left-sided cohort treated with DIBH, the mean heart dose is 1.0 (±0.8)Gy. In the era of modern radiotherapy and cardiac-sparing techniques, mean heart dose and corresponding event rates are stillsignificantlyhigher for left-sided patients than right-sided patients. Future work will aim to test whether there is a safe threshold for cardiac dose in the context of these results.

Temporal Trends of the Prevalence of Angina With No Obstructive Coronary Artery Disease (ANOCA).

Angina with no obstructive coronary artery disease (ANOCA) is a common entity. There is still under-recognition of this condition, but it is unclear if the referral patterns for chest pain diagnosis have changed. We aimed to determine if the prevalence of patients diagnosed with ANOCA by means of coronary angiography has changed over time. A population-based cohort of patients who had their first coronary angiogram for a chest pain syndrome in Alberta from 1995 to 2020 was extracted retrospectively from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) database. A temporal trend analysis was performed to compare patients with ANOCA vs obstructive coronary artery disease (CAD), and the predictors of ANOCA were investigated. In our analysis, 121,066 patients were included (26% ANOCA, 31% female, overall mean age 62 years). The percentages of ANOCA vs obstructive CAD ranged from 24.2% to 26.7% in all patients (P < 0.001), from 19.4% to 21.4% in patients with acute coronary syndromes (P= 0.002), and from 30.6% to 37.5% in patients with stable angina (P < 0.001). Independent predictors of ANOCA were female sex (odds ratio [OR] 3.34, 95% confidence interval [CI] 3.05-3.66), younger age (OR 0.96, 95% CI 0.95-0.96), history of atrial fibrillation (OR 2.18, 95% CI 1.73-2.73), and stable angina (vs myocardial infarction: OR 0.25, 95% CI 0.23-0.28; vs unstable angina: OR 0.79, 95% CI 0.70-0.89). Traditional cardiovascular risk factors were associated with obstructive CAD. There remained a high prevalence of ANOCA detected during invasive coronary angiography, which remained stable over time. This study demonstrates an opportunity to exclude obstructive CAD with less invasive testing, particularly in women.

TEMPORAL TRENDS OF THE PREVALENCE OF ISCHEMIA WITH NON-OBSTRUCTIVE CORONARY ARTERY DISEASE (INOCA) IN ALBERTA, CANADA

TEMPORAL TRENDS OF THE PREVALENCE OF ISCHEMIA WITH NON-OBSTRUCTIVE CORONARY ARTERY DISEASE (INOCA) IN ALBERTA, CANADA

Sexual Activity After Acute Coronary Syndrome: A Qualitative Approach to Patient and Partner Experiences.

BackgroundLittle is known about how best to support both patients and their partners in the reengagement of sexual activity (SA) after acute coronary syndrome (ACS), with sparse direct data from the partner on their needs and concerns in the area of SA support.ObjectivesWe undertook a qualitative study to address this gap in the literature through 3 objectives from a patient and partner perspective: (1) to characterize the experience of reengaging in SA post ACS, (2) to identify needs and priorities in the area of SA support post ACS, and (3) to determine whether cardiac rehabilitation (CR) could be an acceptable point of intervention for SA support.MethodsSemistructured qualitative interviews were conducted with 6 male patients who were post ACS and their partners (age range, 47–81 years). Patients were criterion sampled from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease database. Inductive thematic data analysis was conducted.ResultsFour themes were identified: “importance,” “support received,” “on their own,” and “wanting support.” Couples reaffirmed the importance of SA pre and post ACS, reported SA support as currently insufficient but articulated ways it could be improved, and reported CR as a current source of SA support but thought there could be room for improvement on the content and delivery of such information.ConclusionsThis study illustrates the potential value of promoting SA support for both patients who are post ACS and their partners and reports that SA support provided at CR would be viewed as important, needed, and acceptable.

Automated Referral to Cardiac Rehabilitation After Coronary Artery Bypass Grafting Is Associated With Modest Improvement in Program Completion

BackgroundCardiac 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. MethodsAll 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. ResultsA 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). ConclusionAutomated 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.

Automated Referral to Cardiac Rehabilitation following Coronary Artery Bypass Grafting is associated with limited improvements in program completion: a large cohort study

IntroductionCardiac Rehabilitation (CR) reduces residual cardiovascular risk among patients who have received coronary artery bypass grafting (CABG) surgery. However, many patients do not attend and some are never referred. It is unclear whether automated referral is associated with improved CR completion rates.&#x0D; Objectives and ApproachGeographically inclusive databases were linked to assess the impact of automated referral on rates of referral to and completion of CR post-CABG. Automated referral to CR post-CABG was instituted in Calgary on July 1, 2007. All subjects receiving CABG in Calgary between January 1, 1996 and March 31, 2016 were enrolled in the study. The Alberta Provincial Project for Outcome Assessment in Coronary Heart disease (APPROACH) database, TotalCardiology-Rehabilitation (TC-R) database, and provincial vital statistics were linked using the unique Provincial Health Number available for each patient. The association between CR referral, completion, and survival was assessed using proportional hazard models.&#x0D; ResultsThere were 28,100 patients referred to the CR program, of which 26,411 were linked to the APPROACH database for a 93.99\% linkage rate. After excluding patients who did not receive CABG, a total of 8,118 patients were identified as the study population [mean age 66.2 (SD 10.2) years, 18.9\% female] during the study period: 5,103 prior to implementation of automated referral, and 3,015 post-automation. Rates of referral increased from 39.5\% prior to automation to 75.0\% post-automation (p&#x0D; Conclusion/ImplicationsAutomated referral to CR is associated with increased referral rates but less dramatic increases in CR completion rates post-CABG. Given the significant improvement in survival associated with CR completion, further work is needed to improve CR referral, and more importantly, CR completion rates.

Factors Associated With Cardiorespiratory Fitness at Completion of Cardiac Rehabilitation: Identification of Specific Patient Features Requiring Attention

BackgroundWe aimed to determine and compare predictors of postcardiac rehabilitation (CR) cardiorespiratory fitness (CRF), improvements in a large cohort of subjects with varying baseline CRF levels completing CR for ischemic heart disease and to refine prediction models further by baseline CRF. MethodsThe Alberta Provincial Project for Outcomes Assessment in Coronary Heart disease (APPROACH) and TotalCardiology (TotalCardiology, Inc, Calgary, Alberta, Canada) databases were used retrospectively to obtain information on 10,732 (1955 [18.2%] female; mean age 60.4, standard deviation [SD] 10.5 years) subjects who completed the 12-week comprehensive CR program between 1996 and 2016. Peak metabolic equivalents (METs) were determined at program start and completion and identified patients at baseline with low fitness (L-Fit) (< 5 METs), moderate fitness (M-Fit, 5-8 METs), or high fitness (H-Fit, > 8 METs). Multivariable linear regression models were developed to predict METs at completion of the program. ResultsAcross all fitness groups, mean baseline METs was the strongest predictor of CRF at completion of CR. Other factors—including sex, age, current smoking status, obesity, and diabetes—were highly predictive of post-CR CRF (all P < 0.05). Compared with H-fit patients, coronary artery bypass graft and chronic obstructive pulmonary disease in L-Fit patients, and cerebrovascular disease in M-Fit patients had an additional negative effect on the overall model variance in post-CR CRF. ConclusionExpected CRF at the end of CR is highly predictable, with several key patient factors being clear determinants of CRF. Although most identified patient factors are not modifiable, our analysis highlights populations that may require extra attention over the course of CR to attain maximal benefit.

Kidney Function, ACE-Inhibitor/Angiotensin Receptor Blocker Use, and Survival Following Hospitalization for Heart Failure: A Cohort Study

Background:Angiotensin-converting enzyme inhibitors/angiotensin receptor blocker (ACE-I/ARB) improve outcomes in patients with heart failure and reduced left-ventricular (LV) systolic function. However, these medications can cause a rise in serum creatinine and their benefits in patients with HF accompanied by kidney disease are less certain.Objective:To characterize associations between estimated glomerular filtration rate (eGFR), patterns of ACE-Is and ARBs use, and 1-year survival following hospitalization for heart failure (HF).Design:We formed a retrospective cohort study of patients admitted with HF and followed HF medication prescriptions using the pharmaceutical information network, stratified by discharge eGFR.Setting:Cardiology services in 3 centers in Southern Alberta, Canada.Patients:The study cohort included patients admitted to hospital with a clinical diagnosis of HF.Measurements:eGFR was determined from inpatient laboratory data prior to discharge. Outpatient prescription data prior to and following the index hospitalization was obtained using the Pharmaceutical Information Network of Alberta and survival was determined from provincial vital statistics.Methods:Characteristics of the HF cohort were obtained from the Admissions Module of the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) database. Multivariable Cox proportional hazards models were used to evaluate the association between time-varying ACE-I/ARB use, and mortality, and to test whether eGFR modified this association.Results:Totally, 1404 patients were included. Within the first 3 months following discharge, ACE-I/ARBs were used in 71%, 67%, 62%, and 52% for those with eGFR > 90, 45-89, 30-44, and < 30 mL/min/1.73 m2, respectively, with differences in use persisting after 1 year of follow-up. Patients with eGFR < 45 mL/min/1.73 m2 had significantly lower rates of ACE-I/ARB use following hospitalization. In adjusted models, ACE-I/ARB use following discharge was associated with 25% lower risk of mortality (Hazard Ratio [HR]: 0.75, 95% confidence interval [CI]: 0.61-0.92; P < 0.01), without evidence that this association differed by eGFR (P = 0.75).Limitations:LV function measurements were not available for the cohort. Due to the observation design of the study, treatment-selection bias may be present.Conclusion:Patients with HF and reduced eGFR at time of hospital discharge were less likely to receive ACE-I/ARB despite these medications being associated with lower mortality independent of eGFR. These findings demonstrate the need for further research on strategies for safe use of ACE-I and ARB in patients with HF and kidney disease.

No modifying effect of nutritional status on statins therapy in relation to all-cause death in older patients with coronary artery disease.

Statins therapy in the secondary prevention of coronary artery disease (CAD) is associated with a lower risk of adverse cardiovascular events. However, little is known regarding the association of elderly patients with nutritional risk on statin therapy. To investigate whether older patients with CAD who were at nutritional risk gain similar survival benefit from statins therapy as their counterparts without nutritional risk. We conducted a retrospective hospital-based cohort study among 1705 patients with CAD who were older than 65years of age, using coronary heart disease database from 2008 to 2012. Nutritional status of included patients was gauged using the geriatric nutritional risk index. After stratification by nutritional status, the hazard of all-cause death was compared between those with or without statins therapy. Of the 1705 patients included in the study (mean age 72 years; 73% male), all-cause death occurred in 146 (9.2%) patients with statins use and in 33 (26.2%) patients without statins use. The rate of all-cause death was higher in patients not receiving statins irrespective of nutritional status. After adjustments for potential confounders, the HR with statins use was 0.33 (95% CI 0.20-0.55) in patients without nutritional risk and 0.47 (95% CI 0.22-1.00) in patients with nutritional risk. No interaction effect was detected between nutritional status and statins use in relation to all-cause death (P value for interaction effect 0.516). Despite of the patient's nutritional status, statins therapy as a secondary prevention in elderly CAD patients was associated with decreased risk of all-cause death.

PREDICTING CARDIORESPIRATORY FITNESS IMPROVEMENT AT CARDIAC REHABILITATION COMPLETION: PATIENT FACTORS THAT DESERVE SPECIAL ATTENTION

Cardiorespiratory fitness (CRF) has recently been proposed as a vital sign. Improvements in CRF achieved over the course of a cardiac rehabilitation (CR) program are strongly predictive of survival in patients with coronary artery disease (CAD). However, not all CR participants achieve equivalent gains in exercise capacity. Our objective was to determine predictors of post-CR CRF in a large, well described cohort of subjects completing CR. All subjects who completed the 12-week, comprehensive CR program at TotalCardiology-Rehabilitation between 1996 and 2016 were included. Baseline data including demographics, comorbidities, ejection fraction, and CAD severity were obtained from the program database and supplemented by The Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) database. Subjects underwent a graded exercise test at program start and completion to determine peak metabolic equivalents (METs). A multivariable linear regression model with bootstrapping to refine estimates was developed to predict METs at program completion. A total of 10537 (1909 (18.1%) female; mean age 60.3 (SD 10.5) years) subjects had sufficient data for inclusion. Subjects had a high burden of comorbidities: 1993 (18.9%) had diabetes, 6406 (60.8%) had hypertension and 2343 (22.2%) were current smokers; nearly a fifth were over 70 years old (2026, 19.2%). Mean baseline METs achieved for the whole cohort was 7.6 (SD 2.0), this improved to 8.5 (SD 2.1) METs by 12 weeks. A multivariable regression model including baseline METs, sex, demographics, and co-morbidities was highly predictive of METs achieved at program completion (R2=0.8067; Table; figure). In particular, female sex, advanced age, current smoking status, South Asian ethnicity, and obesity were highly predictive of worse 12 week CRF. Expected CRF at the end of CR is highly predictable, with several key patient factors being clear determinants. While most identified patient factors are not modifiable, our analysis highlights populations that may require extra attention over the course of CR to attain maximal benefit.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Validity of Canadian discharge abstract data for hypertension and diabetes from 2002 to 2013.

Surveillance using coded administrative health data has shown that the prevalence of hypertension and diabetes in Canada increased substantially between 1998 to 2008. These findings require an assumption that the validity of hypertension and diabetes coding is stable over time. We tested this assumption by examining temporal trends in the validity of coding for hypertension and diabetes in the Canadian hospital Discharge Abstract Database. We used the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) database, a clinical registry, as the reference standard to evaluate the validity of the Discharge Abstract Database in recording hypertension and diabetes in Alberta. The APPROACH database contains data for all Alberta residents who have undergone cardiac catheterization and includes prospective ascertainment of comorbid conditions before each procedure. We linked patient data between the 2 databases for 2002 to 2013 using patient provincial health number. Temporal trends in sensitivity, specificity, positive predictive value, negative predictive value and Cohen κ were calculated for both hypertension and diabetes in the Discharge Abstract Database. We matched 63 483 patients between the APPROACH database and the Discharge Abstract Database. The validity of the Discharge Abstract Database for hypertension and diabetes remained mostly consistent over time. Between 2002 and 2013, sensitivity, specificity, positive predictive value and negative predictive value ranged from 66% to 87% for hypertension and from 81% to 98% for diabetes; the corresponding κ scores ranged from 0.50 to 0.62 and from 0.80 to 0.89. No significant differences in the validity of coding were found across age, sex or hospital location subgroups. The validity of coding for hypertension and diabetes in the Discharge Abstract Database remained fairly consistent between 2002 and 2013. Our findings support the use of the Discharge Abstract Database for hypertension and diabetes surveillance in hospital settings.

Female Sex Is Associated With Extended Length of Hospital Stay Following CABG Surgery in Patients With Severe Obesity

Female Sex Is Associated With Extended Length of Hospital Stay Following CABG Surgery in Patients With Severe Obesity

A Predictive Study of the Dynamic Development of the P-Wave Terminal Force in Lead V1 in the Electrocardiogram in Relation to Long-Term Prognosis in Non-ST-Segment Elevation Acute Coronary Syndrome Patients during Hospitalization.

Changes in the ECG indicator PtfV1 reflect left atrial pressure and left ventricular diastolic function in NSTE-ACS patients during hospitalization. The value of PtfV1 in the evaluation of long-term prognosis in NSTE-ACS is still not clear. The purpose of this study was to investigate the relationship between the dynamic changes in P-wave terminal force in lead V1(PtfV1) in the ECG of non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients during hospitalization and the long-term major adverse cardiovascular events (MACEs) of patients. A total of 595 patients who received coronary angiography and were confirmed as NSTE-ACS in the coronary heart disease database of Department of Cardiology of West China Hospital were continuously included. The PtfV1 and other clinical data at admission and discharge were collected and dynamically observed. The end events of follow-up observation were MACEs. Follow-up was performed on 595 patients for 24.71 ± 1.95 months. There were 127 PtfV1(+) and 468 PtfV1(-) at admission, and the incidences of MACEs were 14.2% and 11.1%, respectively (P = 0.731). Compared with patients with persistent PtfV1(-) ECG at admission and discharge, 53 patients with persistent PtfV1(+) ECG at admission and discharge had increased risk for MACEs (HR: 2.221, 95% CI: 1.072-4.601, P = 0.032); 94 patients with new PtfV1(+) ECG at discharge also had significantly increased risk for MACEs (HR: 2.993, 95% CI: 1.660-5.397, P = 0.000). NSTE-ACS patients with persistent PtfV1(+) ECG indicators at admission and discharge and new PtfV1(+) at discharge had significantly increased risk of MACEs.

ANTICOAGULATION AND ANTIPLATELET PATTERNS IN PATIENTS WITH ATRIAL FIBRILLATION POST-PERCUTANEOUS CORONARY INTERVENTION

Guidelines recommend the use of triple antithrombotic therapy (TAT), defined as ASA, clopidogrel, and warfarin, in patients with non-valvular atrial fibrillation (NVAF) who undergo percutaneous coronary intervention with stent implantation (PCI). This is based on observational data, expert opinion, and standard of care. The objective of this study was to characterize the use of anticoagulant and antiplatelet therapy at discharge in patients with NVAF post-PCI at our institution, and to identify determinants of the most commonly utilized regimens. A retrospective chart review was conducted at the Mazankowski Alberta Heart Institute from January 1, 2011 to December 31, 2013. Adult inpatients with NVAF and a CHADS2 score ≥1 who received PCI were included. Patients with mechanical devices requiring anticoagulation or who underwent cardiac surgery during hospitalization were excluded. Patients were identified using the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) database and medical records. The primary outcome was the proportion of patients discharged on TAT. A total of 108 patients were screened with 74 patients included. The median age was 73 years and 73% were male. The majority of patients had dyslipidemia (70%) and hypertension (60%). The median CHADS2 and HASBLED scores were 2 and 3, respectively. Nine patients (12.2%) had a previous gastrointestinal bleed (GIB). Table 1 summarizes the discharge therapy results. Male patients were more likely to receive TAT in a multivariate logistic regression analysis. No patients with a previous GIB received TAT. Positive predictors in a multivariate logistic regression analysis for use of DAT included female sex and previous GIB. Despite a guideline-based indication, less than half of patients received TAT. Non-evidence based combinations of NOACs and ticagrelor were used in one-fifth of patients. Other than consideration of GIB, the rationale for using DAT in place of TAT was unclear. Further studies are needed to elucidate variance from guideline-based therapy.

TYPE 2 MI IN SOUTHERN ALBERTA: A DESCRIPTIVE ANALYSIS

The concept of type 2 myocardial infarction (MI), or myocardial necrosis due to supply-demand mismatch, was introduced in 2007, causing contention and confusion for many clinicians. We aimed to gather data on a large, unselected population of patients with type 2 MI and to evaluate investigation, management and prognosis. All patients with a positive troponin over a 2-year period in the Calgary Health Region were identified. Chart review was performed and patients with explicit ACS diagnoses excluded, leaving only patients with troponin elevations presumably associated with type 2 MI. Follow up data were obtained through the use of the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) database and its linkage to the Alberta Bureau of Vital Statistics. From January 1, 2007 to December 31, 2008, 998 patients with a presumptive diagnosis of type 2 MI were identified, with the majority admitted to general practice or internal medicine services. Infrequent symptoms were recorded, with the most common symptom being shortness of breath. Despite the troponin elevation, ECG was not performed in 6%, and 1/3 did not have subsequent ECGs after an initial assessment. The most common ECG change identified was T wave changes (24.1%), with ST depression in 13.7% and ST elevation observed in 5.6% of diagnosed type 2 MI. Echocardiograms were performed in only 23.2%, CT PE in 6.2%, and nuclear myocardial perfusion imaging in 0.05%. No patient underwent cardiac catheterization. Evidence-based therapy was prescribed infrequently, with only 25.5% given ASA and 16.7% statin. Outcomes were poor, as demonstrated in the Table. Readmission rates were high at 13.5% at 30-days and 35.2% at 1-year. In this large unselected cohort of patients with presumptive diagnoses of type 2 MI, ECG changes were common, and investigations to rule out type 1 MI or ongoing underlying ischemia were uncommon. Outcomes for these patients were poor and readmission rates high. Further research is required to determine appropriate management of this important group of patients.

CHD@ZJU: a knowledgebase providing network-based research platform on coronary heart disease.

Coronary heart disease (CHD), the leading cause of global morbidity and mortality in adults, has been reported to be associated with hundreds of genes. A comprehensive understanding of the CHD-related genes and their corresponding interactions is essential to advance the translational research on CHD. Accordingly, we construct this knowledgebase, CHD@ZJU, which records CHD-related information (genes, pathways, drugs and references) collected from different resources and through text-mining method followed by manual confirmation. In current release, CHD@ZJU contains 660 CHD-related genes, 45 common pathways and 1405 drugs accompanied with >8000 supporting references. Almost half of the genes collected in CHD@ZJU were novel to other publicly available CHD databases. Additionally, CHD@ZJU incorporated the protein–protein interactions to investigate the cross-talk within the pathways from a multi-layer network view. These functions offered by CHD@ZJU would allow researchers to dissect the molecular mechanism of CHD in a systematic manner and therefore facilitate the research on CHD-related multi-target therapeutic discovery.Database URL: http://tcm.zju.edu.cn/chd/

Abstract 19311: Obesity is Associated with Increased Rates of Revascularization in Coronary Artery Bypass Grafting Patients: A Large Cohort Study

Introduction: While excess mass has been demonstrated to be associated with improved survival in subjects with coronary artery disease (CAD), other potential outcomes have not been considered. The objective of this study was to assess the relationship between obesity and repeat revascularization in subjects who have undergone coronary artery bypass grafting (CABG). METHODS: The Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease database was used to obtain information on subjects who underwent CABG between 1995 and 2010. Subjects were classified as normal weight (BMI 18.5-24.9), overweight (25-29.9), obese class I (30-34.9), obese class II (35-39.9), or obese class III (≥40 kg/m2). Outcome of interest was time to repeat revascularization: the 1st percutaneous coronary intervention or CABG after index CABG. Cox proportional hazard models were used to determine the association between adiposity and freedom from repeat revascularization. Results: There were 13416 subjects included in this study, 23% normal weight. The more obese subjects were younger and had a higher prevalence of diabetes (p&lt;0.0001 across categories). Median follow-up time was 6.3 years; there were 1029 subjects who underwent repeat revascularization. In unadjusted models BMI was associated with increased revascularization (overweight Hazard Ratio (HR), 1.22, 95%CI 1.03, 1.45; Obese Class I 1.22, 95%CI 1.01, 1.48; Obese Class II/III 1.60, 95%CI 1.28, 2.00). This association persisted following adjustment for sex, age and clinical characteristics in overweight (HR 1.20, 95%CI 1.01, 1.42) and obese class II/III subjects (HR 1.41, 95% CI 1.12, 1.77). Discussion: Despite improved survival in obese subjects with CAD, we found obesity is associated with an increased risk of revascularization. This may represent elevated residual risk in obese patients. This finding is novel, and highlights the need to pay particular attention to residual risk in obese subjects with CAD.

Abstract 19178: Cardiac Rehabilitation in the Elderly: An Under Referred Population That Does Not Attend

Introduction: Elderly subjects have been shown in recent years to derive benefit from attending cardiac rehabilitation (CR). However, they are less likely to attend. Further, the dependency of CR referral on patient age has not been explored. Methods: The Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) database was used to obtain information on all patients. Subjects with at least one vessel CAD were considered as the pool of subjects to be referred. Patients were categorized according to age, &lt;50 years, 50-60 years, 60-70 years, 70-80 years, and over 80 years of age. Rates of referral to and subsequent attendance at CR were compared across age categories. Logistic regression models were constructed to assess whether age predicted referral or attendance. Results: A total of 25,958 (24.6% female) subjects were included; of those, 3,266 (12.6%) were under 50 years of age, 6,330 (24.4%) were 50-60, 7,618 (29.4%) were 60-70, 6,798 (26.2%) were 70-80, and 1946 (7.5%) were over 80 years of age. Subjects in the higher age ranges had a greater prevalence of congestive heart failure and chronic obstructive pulmonary disease but lower prevalence of diabetes than their younger counterparts (all p&lt;0.0001). Advanced age was associated with both decreased attendance and referral, though the association was stronger with referral (both p&lt;0.0001, Figure 1). Relative to the youngest group, each age category had reduced referral in unadjusted and adjusted models (adjusted OR (95%CI): age 50-60: 0.86 (0.79, 0.95); age 60-70: 0.57 (0.52, 0.63); age 70-80: 0.34 (0.31, 0.38); age&gt;80: 0.15 (0.13, 0.17)). Only the two oldest groups were less likely to attend. Conclusions: Advanced age represents a barrier to CR in two ways: one, elderly subjects are less likely to be referred, and subsequently less likely to attend. As elderly subjects have been shown to derive similar benefits from CR as their younger counterparts, age as a barrier to CR needs to be addressed.

Abstract 19545: The Association Between Adiposity and Mortality in Patients with Coronary Artery Disease is Modified by Time

Introduction: Obese Coronary Artery Disease (CAD) patients have improved short and intermediate term outcomes compared to those of normal weight. However excess mass may be associated with poor long-term outcomes. The objective of this study was to assess the association between weight and mortality in a population with CAD in different time frames. Methods: We used the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) database. Subjects were classified by BMI as normal weight (18.5 - 24.9kg/m2), overweight (25 - 29.9kg/m2), obese class I (30 - 34.9kg/m2), obese class II (35 - 39.9kg/m2), or obese class III (≥40 kg/m2). Mortality was considered over the entire follow-up, within 2 years of catheterization (short-term) or more than 2 years post-catheterization (long-term). Cox models were used to determine the association between weight and mortality. Models were adjusted for all clinical risk factors and initial treatment strategy. Results: There were 45494 subjects with ≥ one vessel CAD (overweight: 41.9%, obese class I: 23.8%, obese class II: 7.8%, obese class III: 3.5%; 23.9% female; mean age 64.0 years). There were 7904 deaths over a median of 5.6 years of follow-up (61% after 2 years). In the complete follow-up period, compared to normal weight, the hazard ratio (HR) for mortality among overweight subjects was 0.84 (p&lt;0.0001), obesity class I was 0.91 (p=0.004), obesity class II 0.98 (p=0.61), obesity class III 1.15 (p=0.038). There was a significant interaction between time and each weight class (p&lt;0.0001). In short-term follow-up, the HR for overweight was 0.80 (p&lt;0.001), for obese class I was 0.77 (p&lt;0.001), for obese class II 0.80 (p=0.006) and for obese class III was 0.92 (p=0.434). With deaths in the first two years excluded, only overweight status was associated with reduced mortality, while obese class III was associated with increased mortality (HR 1.31 (95% CI 1.12, 1.54). Conclusion: The association of adiposity with mortality in CAD patients varies by time, with the protective effect of excess weight diminishing over time. Conditions that decrease mass may result in early deaths.