Association Between Revascularization and Quality of Life in Patients With Coronary Chronic Total Occlusions: A Systematic Review.

BACKGROUND: Percutaneous revascularization of coronary chronic total occlusions (CTO) has increased due to advances in technology and operator expertise. Quality of life (QoL) remains an important but understudied outcome following CTO revascularization. Our aim is to conduct a systematic review of the impact of CTO revascularization on QoL. METHODS: We searched three databases (Ovid MEDLINE, EMBASE, EBM reviews) from January 1st, 1990 to May 17th, 2020. Studies reporting on the following QoL metrics post CTO revascularization were included: QoL subscale of the Seattle Angina Questionnaire (SAQ-QoL). The ROBINS-I tool and Cochrane risk of bias tool were used to critically assess for risk of bias. RESULTS: We identified 1476 articles, of which 21 articles met inclusion criteria. Three categories of studies were identified with distinct patient populations. In the first category (1 study), CTO patients treated with either PCI or CABG compared to medical therapy had a significant improvement in SAQ-QoL compared to baseline (PCI 54.2 to 74.3; CABG 56.1 to 78.0; p < 0.05). In the second category (1 study), CTO patients compared to non-CTO patients had similar improvements in SAQ-QoL post PCI (CTO baseline 53.2 to 80.3; non-CTO baseline 56.5 to 80.6; p < 0.05). Finally, a third category with only CTO patients treated with PCI to the CTO vessel included 19 studies, all of which on average showed a significant improvement in SAQ-QoL post successful PCI, compared to non-successful PCI. CONCLUSION: Despite the limited literature, revascularization of CTO vessel was generally associated with improvement in QoL. BRIEF SUMMARY: Quality of life (QoL) is an important but understudied outcome following CTO revascularization. We conducted a systematic review of the impact of CTO revascularization on QoL. Despite the limitations of a lack of enough randomized control trials and the small number of studies, our systematic review highlights a trend of improvement in QoL indices after revascularization of CTO.

Providing dental insurance can positively impact oral health outcomes in Ontario.

BACKGROUND: Universal coverage for dental care is a topical policy debate across Canada, but the impact of dental insurance on improving oral health-related outcomes remains empirically unexplored in this population. METHODS: We used data on individuals 12 years of age and older from the Canadian Community Health Survey 2013-2014 to estimate the marginal effects (ME) of having dental insurance in Ontario, Canada's most populated province (n = 42,553 representing 11,682,112 Ontarians). ME were derived from multi-variable logistic regression models for dental visiting behaviour and oral health status outcomes. We also investigated the ME of insurance across income, education and age subgroups. RESULTS: Having dental insurance increased the proportion of participants who visited the dentist in the past year (56.6 to 79.4%, ME: 22.8, 95% confidence interval (CI): 20.9-24.7) and who reported very good or excellent oral health (48.3 to 57.9%, ME: 9.6, 95%CI: 7.6-11.5). Compared to the highest income group, having dental insurance had a greater ME for the lowest income groups for dental visiting behaviour: dental visit in the past 12 months (ME highest: 17.9; 95% CI: 15.9-19.8 vs. ME lowest: 27.2; 95% CI: 25.0-29.3) and visiting a dentist only for emergencies (ME highest: -11.5; 95% CI: - 13.2 to - 9.9 vs. ME lowest: -27.2; 95% CI: - 29.5 to - 24.8). CONCLUSIONS: Findings suggest that dental insurance is associated with improved dental visiting behaviours and oral health status outcomes. Policymakers could consider universal dental coverage as a means to support financially vulnerable populations and to reduce oral health disparities between the rich and the poor.

Bedside risk score for prediction of acute kidney injury after transcatheter aortic valve replacement.

Background: Acute kidney injury (AKI) is a common post-transcatheter aortic valve replacement (TAVR) complication associated with a poor prognosis. We sought to create a risk calculator using information that would be available during the work-up period. Methods: Data were obtained from a multicentre TAVR registry (n=1993) with cases from 1 January 2012 to 31 December 2015. We used logistic regression to create a risk calculator to predict AKI as defined by the Valve Academic Research Consortium Guidelines. We internally validated our risk calculator using bootstrapping, and evaluated model discrimination and calibration. Results: A simple risk score was derived with six variables, including New York Heart Association functional classification class 4, non-femoral access site, valve-in-valve procedure, haemoglobin, creatinine clearance and weight in kilograms. The score was able to predict the absolute risk of AKI from 1% to 72%. The model showed good discrimination with c-statistic 0.713, with good agreement between predicted and observed AKI rates across quintiles of risk. Conclusions: This is the first risk calculator to assess post-TAVR risk of AKI. We found that information known pre-procedurally can be used to predict AKI. This may allow for more informed decision-making as well as identifying high-risk patients.

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.

Timing of Conduction Abnormalities Leading to Permanent Pacemaker Insertion After Transcatheter Aortic Valve Implantation-A Single-Centre Review.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is the preferred alternative to traditional surgical aortic valve replacement; however, it remains expensive. One potential driver of cost is the need for postprocedural monitoring for conduction abnormalities after TAVI. Given the paucity of literature on the optimal length of monitoring, we aimed to determine when clinically significant conduction abnormalities leading to permanent pacemaker (PPM) insertion after TAVI were first identified. METHODS: We identified all patients in the Sunnybrook Health Sciences Centre TAVI registry (Toronto, Canada) who underwent TAVI between 2009 and 2016, excluding those with pre-existing PPMs or those who underwent emergency open heart surgery. Through dedicated chart review, the timing and type of conduction abnormalities leading to PPM were recorded. Patients were divided according to the timing of conduction abnormality: during the procedure vs after the procedure. RESULTS: The overall PPM insertion rate was 15.6% (80 of 512 cases), with all but 1 patient receiving a PPM for class I indications. PPMs were inserted for complete heart block/high-grade atrioventricular block (91.3%), severe sinus node dysfunction (3.8%), and alternating bundle branch block (3.8%). Of these conduction abnormalities, 55.0% occurred during the procedure (intraprocedure; n = 44 patients). The mean time to the development of a conduction abnormality necessitating PPM was 1.2 days (interquartile range, 0-2 days), with 88.8% occurring within 72 hours of the procedure (n = 71 patients). In the entire TAVI cohort, < 3% had conduction abnormalities beyond 48 hours after the procedure leading to PPM. CONCLUSIONS: The majority of conduction abnormalities leading to PPM insertion after TAVI occur in the very early periprocedural period, suggesting that early mobilization and discharge will be safe from a conduction standpoint.

Use of Two-Dimensional Ultrasonographically Guided Access to Reduce Access-Related Complications for Transcatheter Aortic Valve Replacement.

BACKGROUND: Major vascular complications have been associated with increased mortality and morbidity in patients undergoing transcatheter aortic valve replacement (TAVR). Our objective was to compare vascular and bleeding outcomes with the routine use of 2-dimensional ultrasonography (2D-US) guided femoral artery access in percutaneous transfemoral TAVR compared with traditional anatomic landmark palpation with angiographically-guided access. METHODS: This single-centre retrospective cohort study was conducted in Ontario, Canada. We enrolled patients from January 1, 2012-June 30, 2016. Routine 2D-US was used in all transfemoral TAVR after January 1, 2014; before this, all cases were performed with angiographic guidance alone. RESULTS: The primary outcome of interest was the composite of any access-related red blood cell transfusion or vascular/bleeding complications. Definitions were based on the Valve Academic Research Consortium (VARC-2) criteria. Fully adjusted multivariable regression models were developed to determine the impact of 2D-US. The study cohort included 387 patients, 109 (28%) of whom underwent femoral artery puncture guided by anatomic and angiographic landmarks, whereas 278 (72%) patients had 2D-US guidance. After adjusting for baseline differences in our multivariable models, we found that 2D-US-guided access was associated with an odds ratio of 0.42 (95% confidence interval, 0.25-0.70; P < 0.01) for the composite end point of access-related vascular or bleeding complications and red blood cell transfusion. CONCLUSIONS: The routine use of 2D-US in transfemoral TAVR was associated with substantial reductions in access-related vascular and bleeding complications.

Factors associated with length of stay following trans-catheter aortic valve replacement - a multicenter study.

BACKGROUND: Most patients undergoing Transcatheter aortic valve implantation (TAVR) are elderly with significant co-morbidities and there is limited information available regarding factors that influence length of stay (LOS) post-procedure. The aim of this study was to identify the patient, and procedural factors that affect post-TAVR LOS using a contemporary multinational registry. METHODS: We conducted a retrospective cohort study, with patients recruited from three high volume tertiary institutions. The primary outcome was the LOS post-TAVR procedure. We examined patient and procedural factors in a cause-specific Cox multivariable regression model to elucidate their effect on LOS, accounting for the competing risk of post-procedural death. Hazard ratios (HR) greater than 1 indicate a shorter LOS, while HRs less than 1 indicate a longer LOS. RESULTS: The cohort consisted of 809 patients. Patient factors associated with longer LOS were older age, prior atrial fibrillation, and greater patient urgency. Patient factors associated with shorter LOS were lower NYHA class, higher ejection fraction and higher mean aortic valve gradients. Procedural characteristics associated with shorter LOS were conscious sedation (HR = 1.19, 95% CI 1.06-1.35, p = 0.004). Transapical access was associated with prolonged LOS (HR = 0.49, 95% CI 0.41-0.58, p < 0.001). CONCLUSION: This multicenter study identified potentially modifiable patient and procedural factors associated with a prolonged LOS. Future research is needed to determine if interventions focused on these factors will translate to a shorter LOS.

The burden of obesity among adults with bipolar disorder in the United States.

OBJECTIVES: Previous studies of clinical samples of adults with bipolar disorder (BD) suggest that there is increased prevalence of obesity and that obesity is associated with greater BD severity. We therefore examined this topic in a representative epidemiologic sample. METHODS: The 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions was used to determine whether the prevalence of obesity is elevated among subjects with lifetime BD, and whether obesity is associated with greater severity of BD. RESULTS: The age-, race-, and sex-adjusted prevalence of obesity was significantly greater among subjects with BD versus controls [odds ratio (OR) = 1.65, 95% confidence interval (CI): 1.45-1.89, p < 0.001]. Obesity among subjects with BD was significantly positively associated with greater age, female sex, comorbid anxiety and medical conditions, and depression-related treatment utilization, and significantly negatively associated with past-year substance use disorder (SUD). In multivariable analyses, obesity among adults with BD was positively associated with age, comorbid anxiety disorders, duration of depressive episodes, and history of hospitalization for depression, and negatively associated with past-year SUD. CONCLUSIONS: The increased prevalence of obesity in BD and its association with illness severity, particularly in relation to depression, cannot be attributed to biases inherent in treatment-seeking samples. Future studies are needed to examine the direction of the observed associations and to develop preventive and treatment strategies seeking to mitigate the burden of obesity in BD.