Association Between Surgeon/Anesthesiologist Sex Discordance and 1-year Mortality Among Adults Undergoing Noncardiac Surgery: A Population-based Retrospective Cohort Study.

OBJECTIVE: To investigate the association between surgeon-anesthesiologist sex discordance and patient mortality after noncardiac surgery. BACKGROUND: Evidence suggests different practice patterns exist among female and male physicians. However, the influence of physician sex on team-based practices in the operating room and subsequent patient outcomes remains unclear in the context of noncardiac surgery. METHODS: We conducted a population-based, retrospective cohort study of adult Ontario residents who underwent index, inpatient noncardiac surgery between January 2007 and December 2017. The primary exposure was physician sex discordance (ie, the surgeon and anesthesiologist were of the opposite sex). The primary outcome was 1-year mortality. The association between physician sex discordance and patient outcomes was modeled using multivariable Cox proportional hazard regression with adjustment for relevant physician, patient, and hospital characteristics. RESULTS: Of 541,209 patients, 158,084 (29.2%) were treated by sex-discordant physician teams. Physician sex discordance was associated with a lower rate of mortality at 1 year [5.2% vs. 5.7%; adjusted HR: 0.95 (0.91-0.99)]. Patients treated by teams composed of female surgeons and male anesthesiologists were more likely to be alive at 1 year than those treated by all-male physician teams [adjusted HR: 0.90 (0.81-0.99)]. CONCLUSIONS: Noncardiac surgery patients had a lower likelihood of 1-year mortality when treated by sex-discordant surgeon-anesthesiologist teams. The likelihood of mortality was further reduced if the surgeon was female. Further research is needed to explore the underlying mechanisms of these observations and design strategies to diversify operating room teams to optimize performance and patient outcomes.

Spontaneous Coronary Artery Dissection Across the Health Care Pathway: A National, Multicenter, Patient-Informed Investigation.

BACKGROUND: Clinical practice guidelines for the management and convalescence of patients with spontaneous coronary artery dissection (SCAD) have yet to be developed. The targeted content, delivery, and outcomes of interventions that benefit this population remain unclear. Patient-informed data are required to substantiate observational research and provide evidence to inform and standardize clinical activities. METHODS AND RESULTS: Patients diagnosed with SCAD (N=89; 86.5% women; mean age, 53.2 years) were purposively selected from 5 large tertiary care hospitals. Patients completed sociodemographic and medical questionnaires and participated in an interview using a patient-piloted semistructured interview guide. Interviews were transcribed and subjected to framework analysis using inductive and then deductive coding techniques. Approximately 1500 standard transcribed pages of interview data were collected. Emotional distress was the most commonly cited precipitating factor (56%), with an emphasis on anxiety symptoms. The awareness and detection of SCAD as a cardiac event was low among patients (35%) and perceived to be moderate among health care providers (55%). Health care providers' communication of the prognosis and self-management of SCAD were perceived to be poor (79%). Postevent psychological disorders among patients were evident (30%), and 73% feared recurrence. Short- and longer-term follow-up that was tailored to patients' needs was desired (72%). Secondary prevention programming was recommended, but there were low completion rates of conventional cardiac rehabilitation (48%), and current programming was deemed inadequate. CONCLUSIONS: This early-stage, pretrial research has important implications for the acute and long-term management of patients with SCAD. Additional work is required to validate the hypotheses generated from this patient-oriented research.

Comorbidity clusters and in-hospital outcomes in patients admitted with acute myocardial infarction in the USA: A national population-based study.

BACKGROUND: The prevalence of multimorbidity in patients with acute myocardial infarction (AMI) is increasing. It is unclear whether comorbidities cluster into distinct phenogroups and whether are associated with clinical trajectories. METHODS: Survey-weighted analysis of the United States Nationwide Inpatient Sample (NIS) for patients admitted with a primary diagnosis of AMI in 2018. In-hospital outcomes included mortality, stroke, bleeding, and coronary revascularisation. Latent class analysis of 21 chronic conditions was used to identify comorbidity classes. Multivariable logistic and linear regressions were fitted for associations between comorbidity classes and outcomes. RESULTS: Among 416,655 AMI admissions included in the analysis, mean (±SD) age was 67 (±13) years, 38% were females, and 76% White ethnicity. Overall, hypertension, coronary heart disease (CHD), dyslipidaemia, and diabetes were common comorbidities, but each of the identified five classes (C) included ≥1 predominant comorbidities defining distinct phenogroups: cancer/coagulopathy/liver disease class (C1); least burdened (C2); CHD/dyslipidaemia (largest/referent group, (C3)); pulmonary/valvular/peripheral vascular disease (C4); diabetes/kidney disease/heart failure class (C5). Odds ratio (95% confidence interval [CI]) for mortality ranged between 2.11 (1.89-2.37) in C2 to 5.57 (4.99-6.21) in C1. For major bleeding, OR for C1 was 4.48 (3.78; 5.31); for acute stroke, ORs ranged between 0.75 (0.60; 0.94) in C2 to 2.76 (2.27; 3.35) in C1; for coronary revascularization, ORs ranged between 0.34 (0.32; 0.36) in C1 to 1.41 (1.30; 1.53) in C4. CONCLUSIONS: We identified distinct comorbidity phenogroups that predicted in-hospital outcomes in patients admitted with AMI. Some conditions overlapped across classes, driven by the high comorbidity burden. Our findings demonstrate the predictive value and potential clinical utility of identifying patients with AMI with specific comorbidity clustering.

Socioeconomic disparities in the management and outcomes of acute myocardial infarction.

BACKGROUND: Patients from lower socioeconomic status areas have poorer outcomes following acute myocardial infarction (AMI); however, how ethnicity modifies such socioeconomic disparities is unclear. METHODS: Using the UK Myocardial Ischaemia National Audit Project (MINAP) registry, we divided 370 064 patients with AMI into quintiles based on Index of Multiple Deprivation (IMD) score, comprising seven domains including income, health, employment and education. We compared white and 'ethnic-minority' patients, comprising Black, Asian and mixed ethnicity patients (as recorded in MINAP); further analyses compared the constituents of the ethnic-minority group. Logistic regression models examined the role of the IMD, ethnicity and their interaction on the odds of in-hospital mortality. RESULTS: More patients from the most deprived quintile (Q5) were from ethnic-minority backgrounds (Q5; 15% vs Q1; 4%). In-hospital mortality (OR 1.10, 95% CI 1.01 to 1.19, p=0.025) and major adverse cardiovascular event (MACE) (OR 1.07, 95% CI 1.00 to 1.15, p=0.048) were more likely in Q5, and MACE was more likely in ethnic-minority patients (OR 1.40, 95% CI 1.00 to 1.95, p=0.048) versus white (OR 1.05, 95% CI 0.98 to 1.13, p=0.027) in Q5. In subgroup analyses, Black patients had the highest in-hospital mortality within the most affluent quintile (Q1) (Black: 0.079, 95% CI 0.046 to 0.112, p<0.001; White: 0.062, 95% CI 0.059 to 0.066, p<0.001), but not in Q5 (Black: 0.065, 95% CI 0.054 to 0.077, p<0.001; White: 0.065, 95% CI 0.061 to 0.069, p<0.001). CONCLUSION: Patients with a higher deprivation score were more often from an ethnic-minority background, more likely to suffer in-hospital mortality or MACE when compared with the most affluent quintile, and this relationship was stronger in ethnic minorities compared with White patients.

Impact of the COVID-19 Pandemic on Diabetes-Related Cardiovascular Mortality in the United States.

Background In the past few decades, diabetes-related cardiovascular mortality has been steadily declining. However, the impact of the COVID19 pandemic on this trend has not been previously defined. Methods and Results Diabetes-related cardiovascular mortality data were extracted for each year between 1999 and 2020 from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (WONDER) database. Regression analysis was used to calculate the trend in the 2 decades before the pandemic (1999-2019) and thereby estimate the excess cardiovascular mortality in 2020. There was a 29.2% fall in the diabetes-related cardiovascular age-adjusted mortality rate between 1999 to 2019, largely driven by a 41% decrease in ischemic heart disease deaths. In comparison to 2019, there was an overall 15.5% increase in the diabetes-related cardiovascular age-adjusted mortality rate in the first year of the pandemic, mainly due to a 14.1% rise in ischemic heart disease deaths. Younger patients (under 55 years) and the Black population experienced the greatest increase in diabetes-related cardiovascular age-adjusted mortality rate (24.0% and 25.3%, respectively). Trend analysis estimated 16 009 excess diabetes-related cardiovascular deaths in 2020, with the majority due to ischemic heart disease (8504). Black and Hispanic or Latino populations had at least one-fifth of their 2020 diabetes-related cardiovascular age-adjusted mortality rate as excess deaths (22.3% and 20.2%, respectively). Conclusions There was a sharp rise in diabetes-related cardiovascular mortality during the first pandemic year. Black, Hispanic or Latino, and young people showed the largest increases in diabetes-related cardiovascular mortality. Targeted health policies could help address the disparities observed in this analysis.

Ethnic Disparities in ST-Segment Elevation Myocardial Infarction Outcomes and Processes of Care in Patients With and Without Standard Modifiable Cardiovascular Risk Factors: A Nationwide Cohort Study.

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.

Considerations on the Management of Acute Postoperative Ischemia After Cardiac Surgery: A Scientific Statement From the American Heart Association.

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.

Trends In ST-elevation Myocardial Infarction Hospitalisation Among Young Adults: A Binational Analysis.

BACKGROUND: ST-segment myocardial infarction (STEMI) is typically associated with increased age, but there is an important group of patients that suffer STEMI under the age of fifty, that are not well characterized in studies. METHODS & RESULTS: We analysed results from Myocardial Ischemia National Audit Project (MINAP) from the United Kingdom (UK) between 2010-2017 and the National Inpatient Sample (NIS) from the United States (US) between 2010-2018. 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) (US). The proportion of white patients decreased, from 86.7% (2010) to 79.1% (2017) (UK) and 72.1% (2010) to 67.1% (2017) (US). Invasive coronary angiography (ICA) rates increased in UK (2010-2012: 89.0%, 2016-2017: 94.3%), while decreased in US (2010-2012: 88.9%, 2016-2018: 86.2% (US). 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 US 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 US, 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.

Population Study of Sex-Based Outcomes After Surgical Aortic Valve Replacement.

Background: Surgical aortic valve replacement (SAVR) is a key strategy for the treatment of aortic valve disease. However, studies have involved primarily male patients, and whether the benefits of this approach can be extrapolated to female patients is unclear. Methods: Clinical and administrative datasets for 12,207 patients undergoing isolated SAVR in Ontario from 2008 to 2019 were linked. Male and female patients were balanced using inverse probability treatment weighting. Mortality, endocarditis, and major hemorrhagic and thrombotic events, as well as 2 composite outcomes-major adverse cerebral and cardiovascular events (MACCE) and patient-derived adverse cardiovascular and noncardiovascular events (PACE)-and their component events, were compared in the weighted groups with a stratified log-rank test. Results: A total of 7485 male patients and 4722 female patients were included in the study. Median follow-up was 5.2 years in both sexes. All-cause mortality did not differ between sexes (hazard ratio [HR] 0.949 [95% confidence interval {CI} 0.851-1.059]). Male sex was associated with an increased risk of new-onset dialysis (HR 0.689 [95% CI 0.488-0.974]). Female sex was associated with a significantly increased risk of both new-onset heart failure (HR 1.211 [95% CI 1.051-1.394], P = 0.0081) and heart failure hospitalization (HR 1.200 [95% CI 1.036-1.390], P = 0.015). No statistically significant differences were seen in any of the other secondary outcomes between sexes. Conclusions: This population health study demonstrated that survival did not differ between male and female patients undergoing SAVR. Significant sex-related differences were found in the risk of heart failure and new-onset dialysis, but these findings should be considered exploratory and require further study.

Contexte: La chirurgie de remplacement valvulaire aortique est une stratégie importante dans le traitement de la valvulopathie aortique. Cependant, les études ont été menées principalement auprès de patients masculins, et il est difficile d'affirmer si les avantages de cette approche peuvent être extrapolés aux patientes. Méthodologie: Les ensembles de données cliniques et administratives de 12 207 patients ayant subi uniquement une chirurgie de remplacement valvulaire aortique en Ontario entre 2008 et 2019 ont été regroupés. Les groupes de patients hommes et femmes ont été équilibrés à l'aide d'une pondération par probabilité inverse du traitement. La mortalité, l'endocardite et les événements hémorragiques et thrombotiques majeurs en plus de deux critères composés ­ les événements cérébrovasculaires et cardiovasculaires indésirables majeurs et les événements cardiovasculaires et non cardiovasculaires indésirables rapportés par les patients ­ et leurs événements constituants ont été comparés dans les groupes pondérés à l'aide d'un test logarithmique par rangs stratifié. Résultats: Au total, 7485 hommes et 4722 femmes ont été inclus dans l'étude. La durée médiane du suivi était de 5,2 ans chez les femmes comme chez les hommes. La mortalité toutes causes confondues ne différait pas entre les sexes (rapport de risques instantanés [RRI] : 0,949, intervalle de confiance [IC] à 95 % : 0,851 à 1,059). Le sexe masculin était associé à un risque accru d'instauration d'une dialyse (RRI : 0,689; IC à 95 % : 0,488 à 0,974). Le sexe féminin était associé à une augmentation significative du risque d'insuffisance cardiaque inaugurale (RRI : 1,211; IC à 95 % : 1,051 à 1,394; p = 0,0081) et d'hospitalisation pour une insuffisance cardiaque (RRI : 1,200; IC à 95 % : 1,036 à 1,390; p = 0,015). Aucune différence statistiquement significative n'a été notée entre les sexes pour les autres critères secondaires. Conclusions: Cette étude en santé des populations a montré que la survie chez les personnes subissant une chirurgie de remplacement valvulaire aortique ne diffère pas entre les hommes et les femmes. Des différences significatives fondées sur le sexe ont été notées dans le risque d'insuffisance cardiaque et de l'instauration d'une dialyse, mais ces constats doivent être considérés comme exploratoires et faire l'objet d'autres études.

Outcomes of ST elevation myocardial infarction in patients with cancer: a nationwide study.

AIMS: To assess processes of care and clinical outcomes in cancer patients with ST elevation myocardial infarction (STEMI) according to cancer type. METHODS AND RESULTS: This 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. CONCLUSION: STEMI 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.

Derivation and validation of pragmatic clinical models to predict hospital length of stay after cardiac surgery in Ontario, Canada: a population-based cohort study.

BACKGROUND: Cardiac surgery is resource intensive and often requires multidisciplinary involvement to facilitate discharge. To facilitate evidence-based resource planning, we derived and validated clinical models to predict postoperative hospital length of stay (LOS). METHODS: We used linked, population-level databases with information on all Ontario residents and included patients aged 18 years or older who underwent coronary artery bypass grafting, valvular or thoracic aorta surgeries between October 2008 and September 2019. The primary outcome was hospital LOS. The models were derived by using patients who had surgery before Sept. 30, 2016, and validated after that date. To address the rightward skew in LOS data and to identify top-tier resource users, we used logistic regression to derive a model to predict the likelihood of LOS being more than the 98th percentile (> 30 d), and γ regression in the remainder to predict continuous LOS in days. We used backward stepwise variable selection for both models. RESULTS: Among 105 193 patients, 2422 (2.3%) had an LOS of more than 30 days. Factors predicting prolonged LOS included age, female sex, procedure type and urgency, comorbidities including frailty, high-risk acute coronary syndrome, heart failure, reduced left ventricular ejection fraction and psychiatric and pulmonary circulatory disease. The C statistic was 0.92 for the prolonged LOS model and the mean absolute error was 2.4 days for the continuous LOS model. INTERPRETATION: We derived and validated clinical models to identify top-tier resource users and predict continuous LOS with excellent accuracy. Our models could be used to benchmark clinical performance based on expected LOS, rationally allocate resources and support patient-centred operative decision-making.

CKD-Associated Cardiovascular Mortality in the United States: Temporal Trends From 1999 to 2020.

Rationale & Objective: Chronic kidney disease (CKD) is associated with an increased risk of cardiovascular (CV) mortality, but there are limited data on temporal trends disaggregated by sex, race, and urban/rural status in this population. Study Design: Retrospective observational study. Setting & Participants: The Centers for Disease Control and Prevention Wide-Ranging, Online Data for Epidemiologic Research database. Exposure & Predictors: Patients with CKD and end-stage kidney disease (ESKD) stratified according to key demographic groups. Outcomes: Etiologies of CKD- and ESKD-associated mortality between 1999 and 2000. Analytical Approach: Presentation of age-adjusted mortality rates (per 100,000 people) characterized by CV categories, ethnicity, sex (male or female), age categories, state, and urban/rural status. Results: Between 1999 and 2020, we identified 1,938,505 death certificates with CKD (and ESKD) as an associated cause of mortality. Of all CKD-associated mortality, the most common etiology was CV, with 31.2% of cases. Between 1999 and 2020, CKD-related age-adjusted mortality increased by 50.2%, which was attributed to an 86.6% increase in non-CV mortality but a 7.1% decrease in CV mortality. Black patients had a higher rate of CV mortality throughout the study period, although Black patients experienced a 38.6% reduction in mortality whereas White patients saw a 2.7% increase. Hispanic patients experienced a greater reduction in CV mortality over the study period (40% reduction) compared to non-Hispanic patients (3.6% reduction). CV mortality was higher in urban areas in 1999 but in rural areas in 2020. Limitations: Reliance on accurate characterization of causes of mortality in a large dataset. Conclusions: Among patients with CKD-related mortality in the United States between 1999 and 2020, there was an increase in all-cause mortality though a small decrease in CV-related mortality. Overall, temporal decreases in CV mortality were more prominent in Hispanic versus non-Hispanic patients and Black patients versus White patients.

Palliative Care Use in Patients With Acute Myocardial Infarction and Do-Not-Resuscitate Status From a Nationwide Inpatient Cohort.

OBJECTIVE: To examine the predictors, treatments, and outcomes of the use of palliative care in patients hospitalized with acute myocardial infarction (AMI) who had a do-not-resuscitate (DNR) order. PATIENTS AND METHODS: Using the National (Nationwide) Inpatient Sampling database for 2015-2018, we examined the predictors, in-hospital procedures, and outcomes of palliative care recipients among patients with AMI who had a DNR order. RESULTS: We identified 339,270 admissions with AMI that had a DNR order, including patients who received palliative care (n=113,215 [33.4%]). Compared with patients who did not receive palliative care, these patients were more frequently younger (median age, 81 vs 83 years; P<.001), were less likely to be female (50.9% [57,626 of 113,215] vs 54.7% [123,652 of 226,055]; P<.001), and were more likely to present with cardiac arrest (11.6% [13,133 of 113,215] vs 6.9% [15,598 of 226,055]; P<.001). Patients were more likely to receive palliative care at a large (odds ratio [OR], 1.47; 95% CI, 1.44 to 1.50) or teaching (OR, 2.10; 95% CI, 2.04 to 2.16) hospitals compared with small or rural ones. Patients receiving palliative care were less likely to be treated invasively, with reduced rates of invasive coronary angiography (OR, 0.46; 95% CI, 0.45 to 0.47) and percutaneous coronary intervention (OR, 0.47; 95% CI, 0.45 to 0.48), and were more likely to die in the hospital (52.4% [59,325 of 113,215] vs 22.9% [51,766 of 226,055]). CONCLUSION: In patients who had a DNR status and were hospitalized and received a diagnosis of AMI, only one-third received palliative care.

The association between cancer diagnosis, care, and outcomes in 1 million patients hospitalized for acute pulmonary embolism.

OBJECTIVES: To evaluate the clinical care provided to cancer patients hospitalized for acute pulmonary embolism (PE), as well as the association between type of cancer, in-hospital care, and clinical outcomes. METHODS: This study examined the in-hospital care (systemic thrombolysis, catheter-directed thrombolysis, and surgical thrombectomy/embolectomy) and clinical outcomes (mortality, major bleeding, and hemorrhagic stroke) among adults hospitalized due to acute PE between October 2015 to December 2018 using the National Inpatient Sample (NIS). Multivariable logistic regression analysis was used to determine adjusted odds ratios (aOR) with 95% confidence interval (95% CI). RESULTS: Of 1,090,130 hospital records included in the analysis, 216,825 (19.9%) had current cancer diagnoses, including lung (4.7%), hematological (2.5%), colorectal (1.6%), breast (1.3%), prostate (0.8%), and 'other' cancer (9.0%). Cancer patients had lower adjusted odds of receiving systemic thrombolysis, catheter-directed therapy, and surgical thrombectomy/embolectomy compared with their non-cancer counterparts (P < 0.001), except for systemic thrombolysis (aOR 0.96, 95% CI 0.85-1.09, P = 0.553) and catheter-directed therapy (aOR 0.82, 95% CI 0.67-1.00, P = 0.053) for prostate cancer. Cancer patients had greater odds of mortality (P < 0.05). Lung cancer patients had the highest odds of mortality (aOR 2.68, 95% CI 2.61-2.76, P < 0.001) and hemorrhagic stroke (aOR 1.75, 95% CI 1.61-1.90, P < 0.001), while colorectal cancer patients had the greatest odds of bleeding (aOR 2.04, 95% CI 1.94-2.15, P < 0.001). CONCLUSION: Among those hospitalized for PE, cancer diagnoses were associated with lower odds of invasive management and poorer in-hospital outcomes, with metastatic status being an especially important determinant. Appropriateness of care could not be assessed in this study.

Team principles for successful interdisciplinary research teams.

Interdisciplinary research teams can be extremely beneficial when addressing difficult clinical problems. The incorporation of conceptual and methodological strategies from a variety of research disciplines and health professions yields transformative results. In this setting, the long-term goal of team science is to improve patient care, with emphasis on population health outcomes. However, team principles necessary for effective research teams are rarely taught in health professional schools. To form successful interdisciplinary research teams in cardio-oncology and beyond, guiding principles and organizational recommendations are necessary. Cardiovascular disease results in annual direct costs of $220 billion (about $680 per person in the US) and is the leading cause of death for cancer survivors, including adult survivors of childhood cancers. Optimizing cardio-oncology research in interdisciplinary research teams has the potential to aid in the investigation of strategies for saving hundreds of thousands of lives each year in the United States and mitigating the annual cost of cardiovascular disease. Despite published reports on experiences developing research teams across organizations, specialties and settings, there is no single journal article that compiles principles for cardiology or cardio-oncology research teams. In this review, recurring threads linked to working as a team, as well as optimal methods, advantages, and problems that arise when managing teams are described in the context of career development and research. The worth and hurdles of a team approach, based on practical lessons learned from establishing our multidisciplinary research team and information gleaned from relevant specialties in the development of a successful team are presented.

Derivation and validation of predictive indices for cardiac readmission after coronary and valvular surgery - A multicenter study.

Objective: To derive and validate models to predict the risk of a cardiac readmission within one year after specific cardiac surgeries using information that is commonly available from hospital electronic medical records. Methods: In this retrospective cohort study, we derived and externally validated clinical models to predict the likelihood of cardiac readmissions within one-year of isolated CABG, AVR, and combined CABG+AVR in Ontario, Canada, using multiple clinical registries and routinely collected administrative databases. For all adult patients who underwent these procedures, multiple Fine and Gray subdistribution hazard models were derived within a competing-risk framework using the cohort from April 2015 to March 2018 and validated in an independent cohort (April 2018 to March 2020). Results: For the model that predicted post-CABG cardiac readmission, the c-statistic was 0.73 in the derivation cohort and 0.70 in the validation cohort at one-year. For the model that predicted post-AVR cardiac readmission, the c-statistic was 0.74 in the derivation and 0.73 in the validation cohort at one-year. For the model that predicted cardiac readmission following CABG+AVR, the c-statistic was 0.70 in the derivation and 0.66 in the validation cohort at one-year. Conclusions: Prediction of one-year cardiac readmission for isolated CABG, AVR, and combined CABG+AVR can be achieved parsimoniously using multidimensional data sources. Model discrimination was better than existing models derived from single and multicenter registries.

Derivation and External Validation of a Clinical Model to Predict Heart Failure Onset in Patients With Incident Diabetes.

OBJECTIVE: 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 sex-specific 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, HbA1c, 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.