Long-term Clinical Outcomes in Contemporary Patients Undergoing Left Atrial Appendage Occlusion Procedures in Ontario, Canada.

Background: Percutaneous left atrial appendage occlusion (LAAO) is an alternative for stroke prevention in patients with atrial fibrillation with contraindications to oral anticoagulation. Population-level real-world data describing the use and outcomes of LAAO procedures are evolving, with a paucity of longer-term follow-up data. We report on the patient characteristics, procedure complications, and longer-term clinical outcomes in all patients undergoing LAAO procedures in Ontario, Canada. Methods: All patients undergoing LAAO procedure between April 1, 2013 and March 31, 2022 were identified. Linked administrative databases were utilized to determine patient clinical and procedural characteristics. Outcomes of interest included procedural complications at 7 and 30 days, and longer-term rates of stroke, bleeding, all-cause rehospitalization, and mortality. Results: A total of 549 individuals were included in the study cohort. The average age was 75 ± 8 years, with 66% being of male sex, with a mean CHA2DS2VASc score of 4.4 ± 1.6, and with 68% not receiving oral anticoagulation. Follow-up for 2.6 ± 2.0 patient-years was available. Stroke occurred in 2.8% during the follow-up period (1.1 per 100 patient-years), bleeding in 10% (4.0 per 100 patient-years), and any hospital readmission in 63% (43 per 100 patient-years). A total of 29% of the cohort died during the follow-up period (11 per 100 patient-years), with 1.8% of the cohort dying during the procedural hospitalization. The mortality rate was unchanged during the study period (P for trend = 0.72). Conclusions: Long-term stroke and bleeding rates are low in patients undergoing LAAO procedures in Ontario, Canada. All-cause mortality in this population is high and remained unchanged during the study period.

Contexte: La fermeture percutanée de l'appendice auriculaire gauche (FPAAG) est une intervention possible pour prévenir les accidents vasculaires cérébraux (AVC) chez les patients atteints de fibrillation auriculaire chez qui les anticoagulants oraux sont contre-indiqués. Les données populationnelles en contexte réel décrivant l'utilisation de la FPAAG et les résultats cliniques qui y sont associés sont de plus en plus nombreuses, mais il y a toujours peu de données sur le suivi à long terme. Nous présentons ici les caractéristiques des patients, les complications liées à l'intervention et les résultats cliniques à long terme pour l'ensemble des patients ayant subi une FPAAG en Ontario (Canada). Méthodologie: Tous les patients ayant subi une FPAAG entre le 1er avril 2013 et le 31 mars 2022 ont été recensés. Des bases de données administratives liées ont été utilisées pour relever les caractéristiques des patients et des interventions. Les résultats cliniques d'intérêt incluaient les complications liées à l'intervention à 7 et à 30 jours ainsi que les taux de divers événements à long terme : AVC, hémorragie, réadmission à l'hôpital toutes causes confondues et mortalité. Résultats: Au total, 549 personnes faisaient partie de la cohorte à l'étude. L'âge moyen des patients était de 75 ± 8 ans, et 66 % étaient des hommes. La moyenne du score CHA2DS2VASc s'élevait à 4,4 ± 1,6, et 68 % des patients ne prenaient pas d'anticoagulants par voie orale. En moyenne, les données de suivi portaient sur 2,6 ± 2,0 patients-années. Un AVC est survenu chez 2,8 % des patients au cours du suivi (1,1 pour 100 patients-années), une hémorragie est survenue chez 10 % des patients (4,0 pour 100 patients-années) et le taux de réadmission hospitalière toutes causes confondues s'élevait à 63 % (43 pour 100 patients-années). Au total, 29 % des patients de la cohorte sont morts au cours de la période de suivi (11 pour 100 patients-années), et 1,8 % des patients de la cohorte sont morts au cours de l'hospitalisation liée à l'intervention. Le taux de mortalité est demeuré le même au cours de la période à l'étude (valeur p de 0,72 pour la tendance). Conclusions: Les taux de survenue d'AVC et d'hémorragie à long terme sont faibles chez les patients ayant subi une FPAAG en Ontario (Canada), mais leur taux de mortalité toutes causes confondues est élevé et est demeuré le même au cours de la période à l'étude.

Variations in Use of Optimal Medical Therapy in Patients With Nonobstructive Coronary Artery Disease: A Population-Based Study.

BACKGROUND: There is a paucity of data on the need for optimal medical therapy (OMT) in nonobstructive coronary artery disease . We sought to understand if there was variation in the use of OMT between hospitals for patients with nonobstructive coronary artery disease, the factors associated with such variation, and its clinical consequences. METHODS AND RESULTS: Using a population-level clinical registry in Ontario, Canada, we identified all patients >66 years undergoing coronary angiography for the indication of stable angina, who had nonobstructive coronary artery disease between November 1, 2010, and October 31, 2013. Hierarchical multivariable logistic models were developed to identify the factors associated with OMT use, with median odds ratio used to quantify the degree of variation between hospitals not explained by the modeled risk factors. Clinical outcomes of interest were all-cause mortality and rehospitalization, with follow-up until March 31, 2015. Our cohort consisted of 5413 patients, of whom 2554 (47.2%) were receiving OMT within 1 year. There was a 2-fold variation in OMT across hospitals (30.4%-61.8%). The variation between hospitals was fully explained by preangiography medication use (median odds ratio of 1.21 in the null model and 1.03 in the full model). There was no difference in risk-adjusted mortality (hazard ratio, 0.94; 95% confidence interval, 0.76-1.16); however, patients receiving OMT had a lower risk of all-cause hospital readmission (hazard ratio, 0.89; 95% confidence interval, 0.84-0.95). CONCLUSIONS: There is wide variation in the use of OMT in patients with nonobstructive coronary artery disease, the major driver of which is differences in baseline medication use.

Short Length of Stay After Elective Transfemoral Transcatheter Aortic Valve Replacement is Not Associated With Increased Early or Late Readmission Risk.

BACKGROUND: Elderly patients undergoing transcatheter aortic valve replacement (TAVR) are at risk of hospital readmission postprocedure. It is not known whether the index hospital length of stay and, specifically, early discharge post-TAVR is associated with an increased risk of readmission. We hypothesized a nonlinear relationship whereby both short and long lengths of stay were associated with increased readmission risk. METHODS AND RESULTS: We performed a retrospective multicenter cohort analysis of patients undergoing elective transfemoral TAVR and surviving to discharge between January 2007 and March 2014. The exposure variable was hospital length of stay measured from the procedure date to the date of discharge and modeled as a continuous variable in a multivariable cause-specific Cox regression. Main outcome measures were 30-day and 1-year all-cause readmissions. The study population consisted of 709 patients with a median length of stay of 6 days (interquartile range, 4-8). At 30-days and 1-year, 13.5% and 44.0% of patients were readmitted, respectively. Although post-TAVR length of stay was not associated with 30-day all-cause readmissions (P=0.925), there existed a significant association with 1-year readmission (P=0.010) after adjustment for baseline clinical variables. The association between post-TAVR length of stay and 1-year readmission was linear (P=0.549 for nonlinearity) with no evidence supporting an increased readmission risk for shorter length of stays. CONCLUSIONS: Among elderly survivors of elective transfemoral TAVR, a short postprocedural length of stay was not associated with an increased risk readmission within 30 days or 1 year. However, the risk of 1-year readmission increased with longer post-TAVR lengths of stay.

Comparing the ambulatory care and outcomes for rural and urban patients with chronic ischemic heart disease: a population-based cohort study.

BACKGROUND: Little is known about variations in the quality of ambulatory care between urban and rural communities for patients with stable ischemic heart disease. The objectives of this study were to understand the effect of rurality on variations of ambulatory processes of care and outcomes for patients with stable ischemic heart disease. METHODS AND RESULTS: A population-based cohort study was conducted, which included all Ontario patients with stable ischemic heart disease confirmed on cardiac catheterization between October 1, 2008, and September 30, 2011. Patients were categorized as rural or urban based on the Rurality Index for Ontario score. Ambulatory processes of care of interest were diagnostic testing, medication usage, and access to general/speciality physicians over a 1-year time-horizon. Primary outcome was 1-year mortality. Secondary outcomes included 1-year myocardial infarction, repeat cardiac/all-cause hospitalization, and emergency department visits. The cohort consisted of 38 804 patients, of whom 34 949 (90%) were urban and 3855 (10%) were rural patients. After risk-adjustment, rural patients had lower rates of cholesterol assessment (odds ratios 0.41; 95% confidence interval [CI], 0.38-0.44; P<0.001), hemoglobin A1C assessment (odds ratios 0.41; 95% CI, 0.38-0.44; P<0.001), and statin use (odds ratios 0.67; 95% CI, 0.57-0.79; P<0.001) compared with urban patients. Rural patients had fewer total ambulatory physician visits (rate ratio 0.76; 95% CI, 0.75-0.78; P<0.001)), primary care (0.76; 95% CI, 0.74-0.78; P<0.001), and cardiology visits (0.71; 95% CI, 0.68-0.74; P<0.001) over 1 year. Emergency department utilization was higher among rural patients (odds ratios 1.82; 95% CI, 1.70-1.96; P<0.001), but myocardial infarction, hospitalization, and mortality rates were similar. CONCLUSIONS: Despite variation in ambulatory processes of care between urban and rural patients with stable ischemic heart disease, there were no outcome differences.