Bio


Dr. Louise Sun recently joined the Stanford University School of Medicine as the Chief of Cardiothoracic Anesthesiology and Professor of Anesthesiology, Perioperative and Pain Medicine. She is an Adjunct Scientist at the Institute for Clinical Evaluative Sciences (ICES) in Toronto. Prior to this, she was an Associate Professor of Anesthesiology and Epidemiology, Director of Big Data and Health Bioinformatics Research at the University of Ottawa Heart Institute, and a Clinical Research Chair in Big Data and Cardiovascular Outcomes at the University of Ottawa.

Dr. Sun received her medical degree from McMaster University. She completed her anesthesiology residency at the University of Ottawa and her Masters of Science in Epidemiology at the Harvard School of Public Health, followed by a clinical and research fellowship in cardiac anesthesia at the University of Toronto. She then joined the Division of Cardiac Anesthesiology at the University of Ottawa Heart Institute and was cross appointed as an ICES faculty member.

Dr. Sun’s areas of clinical focus are hemodynamic monitoring and heart failure. Her methodologic areas of focus are the conduct of population-based cohort studies using large healthcare databases; predictive analytics; sex and gender epidemiology; patient engagement; innovative methods for data processing and warehousing; and software and applications development. Her research leverages big data and digital technology to bridge key gaps in the delivery of care and outcomes for patients with heart failure and/or undergoing cardiovascular interventions, zooming in on sex/gender and personalized care. She holds several patents and collaborates with health authorities and policy makers to evaluate and report on models of cardiac healthcare delivery.

Dr. Sun is active in the scientific community. She sits on a number of US, Canadian and international editorial boards and scientific and grant review committees, and collaborates nationally and internationally on a variety of population health and data science initiatives. Her patient-centered research program aims to improve access to care and outcomes, focusing on personalized risk stratification and long-term, patient-defined outcomes. She has authored over 100 peer-reviewed papers and published in leading clinical journals including JAMA, JAMA Cardiology, JAMA Internal Medicine, Circulation, JACC, Diabetes Care, and Anesthesiology. Her research program has been well funded by the Canadian Institutes of Health Research (CIHR), the Heart and Stroke Foundation of Canada, and the Ontario Ministry of Health.

Clinical Focus


  • Anesthesia

Academic Appointments


Administrative Appointments


  • Chief, Division of Cardiothoracic Anesthesiology, Stanford University School of Medicine (2022 - Present)

Professional Education


  • Board Certification: National Board of Echocardiography, Advanced Perioperative Transesophageal Echocardiography
  • Fellowship: University of Toronto (2014) Canada
  • Board Certification: Royal College of Physicians and Surgeons of Canada, Anesthesia (2013)
  • Masters of Science, Harvard University, Clinical Epidemiology (2013)
  • Residency: University of Ottawa (2013) Canada
  • Medical Education: McMaster University Michael G. DeGroote School of Medicine (2008) Canada

Patents


  • Louise Sun. "United States Patent 63/055,620 Health Care Resources Management", University of Ottawa Heart Institute, Jul 23, 2022
  • Louise Sun. "United States Patent PCT/CA2021/051033 Health Care Resources Management", University of Ottawa Heart Institute, Institute for Clinical Evaluative Sciences, Jul 23, 2022
  • Louise Sun. "United States Patent PCT/CA2022/051085 Systems, Methods and Apparatus for Predicting Hemodynamic Events", University of Ottawa Heart Institute, Jul 12, 2022
  • Louise Sun. "United States Patent 63/232,337 Systems, Methods and Apparatus for Predicting Hemodynamic Events", University of Ottawa Heart Institute, Aug 12, 2021

Research Interests


  • Data Sciences

All Publications


  • Spontaneous Coronary Artery Dissection Across the Health Care Pathway: A National, Multicenter, Patient-Informed Investigation. Journal of the American Heart Association Bouchard, K., Lalande, K., Coutinho, T., Mulvagh, S., Pacheco, C., Liu, S., Saw, J., So, D., Reed, J. L., Chiarelli, A., Stragapede, E., Robert, H., Lappa, N., Sun, L., Wells, G., Tulloch, H. 2023: e032141

    Abstract

    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.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.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.

    View details for DOI 10.1161/JAHA.123.032141

    View details for PubMedID 38084731

  • Association between Surgeon/anesthesiologist Sex Discordance and One-year Mortality Among Adults Undergoing Noncardiac Surgery: A Population-based Retrospective Cohort Study. Annals of surgery Etherington, C., Boet, S., Chen, I., Duffy, M., Mamas, M. A., Eddeen, A. B., Bateman, B. T., Sun, L. Y. 2023

    Abstract

    To investigate the association between surgeon-anesthesiologist sex discordance and patient mortality after noncardiac surgery.Evidence suggests different practice patterns exist amongst 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.We conducted a population-based, retrospective cohort study of adult Ontario residents who underwent index, inpatient noncardiac surgery between January 2007 and December 2017. Primary exposure was physician sex discordance (i.e., 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.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]).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 OR teams to optimize performance and patient outcomes.

    View details for DOI 10.1097/SLA.0000000000006111

    View details for PubMedID 37791498

  • Socioeconomic disparities in the management and outcomes of acute myocardial infarction. Heart (British Cardiac Society) Weight, N., Moledina, S., Volgman, A. S., Bagur, R., Wijeysundera, H. C., Sun, L. Y., Chadi Alraies, M., Rashid, M., Kontopantelis, E., Mamas, M. A. 2023

    Abstract

    Patients from lower socioeconomic status areas have poorer outcomes following acute myocardial infarction (AMI); however, how ethnicity modifies such socioeconomic disparities is unclear.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.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).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.

    View details for DOI 10.1136/heartjnl-2023-322601

    View details for PubMedID 37558395

  • Team principles for successful interdisciplinary research teams. American heart journal plus : cardiology research and practice Brown, S. A., Sparapani, R., Osinski, K., Zhang, J., Blessing, J., Cheng, F., Hamid, A., MohamadiPour, M. B., Lal, J. C., Kothari, A. N., Caraballo, P., Noseworthy, P., Johnson, R. H., Hansen, K., Sun, L. Y., Crotty, B., Cheng, Y. C., Echefu, G., Doshi, K., Olson, J. 2023; 32: 100306

    Abstract

    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.

    View details for DOI 10.1016/j.ahjo.2023.100306

    View details for PubMedID 38510201

    View details for PubMedCentralID PMC10946054

  • Team principles for successful interdisciplinary research teams AMERICAN HEART JOURNAL PLUS: CARDIOLOGY RESEARCH AND PRACTICE Brown, S., Sparapani, R., Osinski, K., Zhang, J., Blessing, J., Cheng, F., Hamid, A., Mohamadipour, M., Lal, J., Kothari, A. N., Caraballo, P., Noseworthy, P., Johnson, R. H., Hansen, K., Sun, L. Y., Crotty, B., Cheng, Y., Echefu, G., Doshi, K., Olson, J., Cardiooncology Artificial Intellig 2023; 32
  • STICH3C: Rationale and Study Protocol. Circulation. Cardiovascular interventions Fremes, S. E., Marquis-Gravel, G., Gaudino, M. F., Jolicoeur, E. M., Bédard, S., Masterson Creber, R., Ruel, M., Vervoort, D., Wijeysundera, H. C., Farkouh, M. E., Rouleau, J. L. 2023; 16 (8): e012527

    Abstract

    Coronary artery bypass grafting (CABG) is the recommended mode of revascularization in patients with ischemic left ventricular dysfunction (iLVSD) and multivessel disease. However, contemporary percutaneous coronary intervention (PCI) outcomes have improved with the integration of novel technologies and refinement of revascularization strategies, and PCI is often used in clinical practice in this population. There is a lack of evidence from randomized trials comparing contemporary state-of-the-art PCI versus CABG for the treatment of iLVSD and multivessel disease. This was the impetus for the STICH3C trial (Canadian CABG or PCI in Patients With Ischemic Cardiomyopathy), described here.The STICH3C trial is a prospective, unblinded, international, multicenter trial with an expected sample size of 754 participants from ≈45 centers. Patients with multivessel/left main coronary artery disease and iLVSD with left ventricular ejection fraction ≤40% considered by the local Heart Team appropriate for and amenable to revascularization by both modes of revascularization will be randomized in a 1:1 ratio to state-of-the-art PCI or CABG.The primary end point is the composite of death from any cause, stroke, spontaneous myocardial infarction, urgent repeat revascularization, or heart failure readmission, summarized as a time-to-event outcome. The key hierarchical end point is time to death and frequency of hospitalizations for heart failure. The key safety outcome is a composite of major adverse events. Disease-specific quality-of-life and health economics measures will be compared between groups. Participants will be followed for a median of 5 years, with a minimum follow-up of 4 years.STICH3C will directly inform patients, clinicians, and international practice guidelines about the efficacy and safety of CABG versus PCI in patients with iLVSD. The results will provide novel and broad evidence, including clinical events, health status, and economic assessments, to guide care for patients with iLVSD and severe coronary artery disease.URL: https://clinicaltrials.gov/; Unique identifier: NCT05427370.

    View details for DOI 10.1161/CIRCINTERVENTIONS.122.012527

    View details for PubMedID 37582169

  • Outcomes Among Patients Hospitalized With Non-COVID-19 Conditions Before and During the COVID-19 Pandemic in Alberta and Ontario, Canada. JAMA network open McAlister, F. A., Chu, A., Qiu, F., Dong, Y., van Diepen, S., Youngson, E., Yu, A. Y., de Mestral, C., Ross, H. J., Austin, P. C., Lee, D. S., Kadri, S. S., Wijeysundera, H. C. 2023; 6 (7): e2323035

    Abstract

    The association of inpatient COVID-19 caseloads with outcomes in patients hospitalized with non-COVID-19 conditions is unclear.To determine whether 30-day mortality and length of stay (LOS) for patients hospitalized with non-COVID-19 medical conditions differed (1) before and during the pandemic and (2) across COVID-19 caseloads.This retrospective cohort study compared patient hospitalizations between April 1, 2018, and September 30, 2019 (prepandemic), vs between April 1, 2020, and September 30, 2021 (during the pandemic), in 235 acute care hospitals in Alberta and Ontario, Canada. All adults hospitalized for heart failure (HF), chronic obstructive pulmonary disease (COPD) or asthma, urinary tract infection or urosepsis, acute coronary syndrome, or stroke were included.The monthly surge index for each hospital from April 2020 through September 2021 was used as a measure of COVID-19 caseload relative to baseline bed capacity.The primary study outcome was 30-day all-cause mortality after hospital admission for the 5 selected conditions or COVID-19 as measured by hierarchical multivariable regression models. Length of stay was the secondary outcome.Between April 2018 and September 2019, 132 240 patients (mean [SD] age, 71.8 [14.8] years; 61 493 female [46.5%] and 70 747 male [53.5%]) were hospitalized for the selected medical conditions as their most responsible diagnosis compared with 115 225 (mean [SD] age, 71.9 [14.7] years, 52 058 female [45.2%] and 63 167 male [54.8%]) between April 2020 and September 2021 (114 414 [99.3%] of whom had negative SARS-CoV-2 test results). Patients admitted during the pandemic with any of the selected conditions and concomitant SARS-CoV-2 infection exhibited a much longer LOS (mean [SD], 8.6 [7.1] days or a median of 6 days longer [range, 1-22 days]) and greater mortality (varying across diagnoses, but with a mean [SD] absolute increase at 30 days of 4.7% [3.1%]) than those without coinfection. Patients hospitalized with any of the selected conditions without concomitant SARS-CoV-2 infection had similar LOSs during the pandemic as before the pandemic, and only patients with HF (adjusted odds ratio [AOR], 1.16; 95% CI, 1.09-1.24) and COPD or asthma (AOR, 1.41; 95% CI, 1.30-1.53) had a higher risk-adjusted 30-day mortality during the pandemic. As hospitals experienced COVID-19 surges, LOS and risk-adjusted mortality remained stable for patients with the selected conditions but were higher in patients with COVID-19. Once capacity reached above the 99th percentile, patients' 30-day mortality AOR was 1.80 (95% CI, 1.24-2.61) vs when the surge index was below the 75th percentile.This cohort study found that during surges in COVID-19 caseloads, mortality rates were significantly higher only for hospitalized patients with COVID-19. However, most patients hospitalized with non-COVID-19 conditions and negative SARS-CoV-2 test results (except those with HF or with COPD or asthma) exhibited similar risk-adjusted outcomes during the pandemic as before the pandemic, even during COVID-19 caseload surges, suggesting resiliency in the event of regional or hospital-specific occupancy strains.

    View details for DOI 10.1001/jamanetworkopen.2023.23035

    View details for PubMedID 37436751

    View details for PubMedCentralID PMC10339156

  • Impact of the COVID-19 Pandemic on Diabetes-Related Cardiovascular Mortality in the United States. Journal of the American Heart Association Bashar, H., Kobo, O., Khunti, K., Sun, L. Y., Rutter, M. K., Chew, N. W., Curzen, N., Mamas, M. A. 2023: e028896

    Abstract

    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.

    View details for DOI 10.1161/JAHA.122.028896

    View details for PubMedID 37382097

  • Trends In ST-elevation Myocardial Infarction Hospitalisation Among Young Adults: A Binational Analysis. European heart journal. Quality of care & clinical outcomes Moledina, S. M., Matetic, A., Weight, N., Rashid, M., Sun, L., Fischman, D. L., Van Spall, H. G., Mamas, M. A. 2023

    Abstract

    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.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).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.

    View details for DOI 10.1093/ehjqcco/qcad035

    View details for PubMedID 37312274

  • 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. Angiology Weight, N., Moledina, S., Sun, L., Kragholm, K., Freeman, P., Diaz-Arocutipa, C., Dafaalla, M., Gulati, M., Mamas, M. A. 2023: 33197231182555

    Abstract

    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.

    View details for DOI 10.1177/00033197231182555

    View details for PubMedID 37306087

  • Derivation and validation of predictive indices for cardiac readmission after coronary and valvular surgery - A multicenter study. American heart journal plus : cardiology research and practice Sun, L. Y., Chu, A., Tam, D. Y., Wang, X., Fang, J., Austin, P. C., Feindel, C. M., Alexopoulos, V., Tusevljak, N., Rocha, R., Ouzounian, M., Woodward, G., Lee, D. S. 2023; 28: 100285

    Abstract

    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.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).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.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.

    View details for DOI 10.1016/j.ahjo.2023.100285

    View details for PubMedID 38511073

    View details for PubMedCentralID PMC10946031

  • Derivation and validation of predictive indices for cardiac readmission after coronary and valvular surgery - A multicenter study AMERICAN HEART JOURNAL PLUS: CARDIOLOGY RESEARCH AND PRACTICE Sun, L. Y., Chu, A., Tam, D. Y., Wang, X., Fang, J., Austin, P. C., Feindel, C. M., Alexopoulos, V., Tusevljak, N., Rocha, R., Ouzounian, M., Woodward, G., Lee, D. S. 2023; 28
  • Outcomes of ST elevation myocardial infarction in patients with cancer; a nationwide study. European heart journal. Quality of care & clinical outcomes Dafaalla, M., Abdel-Qadir, H., Gale, C. P., Sun, L., López-Fernández, T., Miller, R. J., Wojakowski, W., Nolan, J., Rashid, M., Mamas, M. A. 2023

    Abstract

    To assess processes of care and clinical outcomes in cancer patients with ST elevation myocardial infarction (STEMI) according to cancer type.This is a national population-based study of patients admitted with STEMI in England and Wales between January 2005 and March 2019. Data was obtained from the National Heart attack MINAP registry and HES 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 hematologic 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 (OR 1.39, 95% 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 highest risk of death in hospital (OR 1.75, 95% CI 1.39-2.22) and at one 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 one year.STEMI patients with cancer have 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 one year.

    View details for DOI 10.1093/ehjqcco/qcad012

    View details for PubMedID 36921979

  • Population Study of Sex-Based Outcomes After Surgical Aortic Valve Replacement. CJC open Rubens, F. D., Clarke, A. E., Lee, D. S., Wells, G. A., Sun, L. Y. 2023; 5 (3): 220-229

    Abstract

    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.

    View details for DOI 10.1016/j.cjco.2022.12.001

    View details for PubMedID 37013069

  • CKD-Associated Cardiovascular Mortality in the United States: Temporal Trends From 1999 to 2020. Kidney medicine Kobo, O., Abramov, D., Davies, S., Ahmed, S. B., Sun, L. Y., Mieres, J. H., Parwani, P., Siudak, Z., Van Spall, H. G., Mamas, M. A. 2023; 5 (3): 100597

    Abstract

    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 and2000.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 in2020.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.

    View details for DOI 10.1016/j.xkme.2022.100597

    View details for PubMedID 36814454

  • Derivation and validation of pragmatic clinical models to predict hospital length of stay after cardiac surgery in Ontario, Canada: a population-based cohort study. CMAJ open Fottinger, A., Eddeen, A. B., Lee, D. S., Woodward, G., Sun, L. Y. 2023; 11 (1): E180-E190

    Abstract

    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).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.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.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.

    View details for DOI 10.9778/cmajo.20220103

    View details for PubMedID 36854454

  • Commentary: "Multimodality advanced cardiovascular and molecular imaging for early detection and monitoring of cancer therapy-associated cardiotoxicity and the role of artificial intelligence and big data". Frontiers in cardiovascular medicine Sun, L. Y., Echefu, G., Doshi, K., Roberts, M. L., Hamid, A., Cheng, R. K., Olson, J., Brown, S. A. 2023; 10: 982028

    View details for DOI 10.3389/fcvm.2023.982028

    View details for PubMedID 36923958

    View details for PubMedCentralID PMC10009261

  • Comorbidity clusters and in-hospital outcomes in patients admitted with acute myocardial infarction in the USA: A national population-based study. PloS one Zghebi, S. S., Rutter, M. K., Sun, L. Y., Ullah, W., Rashid, M., Ashcroft, D. M., Steinke, D. T., Weng, S., Kontopantelis, E., Mamas, M. A. 2023; 18 (10): e0293314

    Abstract

    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.

    View details for DOI 10.1371/journal.pone.0293314

    View details for PubMedID 37883354

  • Palliative Care Use in Patients With Acute Myocardial Infarction and Do-Not-Resuscitate Status From a Nationwide Inpatient Cohort. Mayo Clinic proceedings Kobo, O., Moledina, S. M., Mohamed, M. O., Sinnarajah, A., Simon, J., Sun, L. Y., Slawnych, M., Fischman, D. L., Roguin, A., Mamas, M. A. 2022

    Abstract

    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.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.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]).In patients who had a DNR status and were hospitalized and received a diagnosis of AMI, only one-third received palliative care.

    View details for DOI 10.1016/j.mayocp.2022.08.018

    View details for PubMedID 36372598

  • Outcomes From Intraoperative Handovers of Anesthesia Care. JAMA Jones, P. M., Sun, L. Y., Brenner, M. J. 2022; 328 (18): 1869

    View details for DOI 10.1001/jama.2022.16527

    View details for PubMedID 36346419

  • Differential Patterns and Outcomes of 20.6 Million Cardiovascular Emergency Department Encounters for Men and Women in the United States. Journal of the American Heart Association Raisi-Estabragh, Z., Kobo, O., Elbadawi, A., Velagapudi, P., Sharma, G., Bullock-Palmer, R. P., Petersen, S. E., Mehta, L. S., Ullah, W., Roguin, A., Sun, L. Y., Mamas, M. A. 2022; 11 (19): e026432

    Abstract

    Background We describe sex-differential disease patterns and outcomes of >20.6 million cardiovascular emergency department encounters in the United States. Methods and Results We analyzed primary cardiovascular encounters from the Nationwide Emergency Department Sample between 2016 and 2018. We grouped cardiovascular diagnoses into 15 disease categories. The sample included 48.7% women; median age was 67 (interquartile range, 54-78) years. Men had greater overall baseline comorbidity burden; however, women had higher rates of obesity, hypertension, and cerebrovascular disease. For women, the most common emergency department encounters were essential hypertension (16.0%), hypertensive heart or kidney disease (14.1%), and atrial fibrillation/flutter (10.2%). For men, the most common encounters were hypertensive heart or kidney disease (14.7%), essential hypertension (10.8%), and acute myocardial infarction (10.7%). Women were more likely to present with essential hypertension, hypertensive crisis, atrial fibrillation/flutter, supraventricular tachycardia, pulmonary embolism, or ischemic stroke. Men were more likely to present with acute myocardial infarction or cardiac arrest. In logistic regression models adjusted for baseline covariates, compared with men, women with intracranial hemorrhage had higher risk of hospitalization and death. Women presenting with pulmonary embolism or deep vein thrombosis were less likely to be hospitalized. Women with aortic aneurysm/dissection had higher odds of hospitalization and death. Men were more likely to die following presentations with hypertensive heart or kidney disease, atrial fibrillation/flutter, acute myocardial infarction, or cardiac arrest. Conclusions In this large nationally representative sample of cardiovascular emergency department presentations, we demonstrate significant sex differences in disease distribution, hospitalization, and death.

    View details for DOI 10.1161/JAHA.122.026432

    View details for PubMedID 36073628

  • Relationship of frailty with excess mortality during the COVID-19 pandemic: a population-level study in Ontario, Canada. Aging clinical and experimental research Wijeysundera, H. C., Abdel-Qadir, H., Qiu, F., Manoragavan, R., Austin, P. C., Kapral, M. K., Kwong, J. C., Sun, L. Y., Ross, H. J., Udell, J. A., Roifman, I., Yu, A. Y., Chu, A., McAlister, F. A., Lee, D. S. 2022; 34 (10): 2557-2565

    Abstract

    There is a paucity of the literature on the relationship between frailty and excess mortality due to the COVID-19 pandemic.The entire community-dwelling adult population of Ontario, Canada, as of January 1st, 2018, was identified using the Cardiovascular Health in Ambulatory Care Research Team (CANHEART) cohort. Residents of long-term care facilities were excluded. Frailty was categorized through the Johns Hopkins Adjusted Clinical Groups (ACG® System) frailty indicator. Follow-up was until December 31st, 2020, with March 11th, 2020, indicating the beginning of the COVID-19 pandemic. Using multivariable Cox models with patient age as the timescale, we determined the relationship between frailty status and pandemic period on all-cause mortality. We evaluated the modifier effect of frailty using both stratified models as well as incorporating an interaction between frailty and the pandemic period.We identified 11,481,391 persons in our cohort, of whom 3.2% were frail based on the ACG indicator. Crude mortality increased from 0.75 to 0.87% per 100 person years from the pre- to post-pandemic period, translating to ~ 13,800 excess deaths among the community-dwelling adult population of Ontario (HR 1.11 95% CI 1.09-1.11). Frailty was associated with a statistically significant increase in all-cause mortality (HR 3.02, 95% CI 2.99-3.06). However, all-cause mortality increased similarly during the pandemic in frail (aHR 1.13, 95% CI 1.09-1.16) and non-frail (aHR 1.15, 95% CI 1.13-1.17) persons.Although frailty was associated with greater mortality, frailty did not modify the excess mortality associated with the pandemic.

    View details for DOI 10.1007/s40520-022-02173-1

    View details for PubMedID 35776284

    View details for PubMedCentralID PMC9638449

  • The association between cancer diagnosis, care, and outcomes in 1 million patients hospitalized for acute pulmonary embolism. International journal of cardiology Mai, A. S., Matetic, A., Elgendy, I. Y., Lopez-Mattei, J., Kotronias, R. A., Sun, L. Y., Yong, J. H., Bagur, R., Van Spall, H. G., Mamas, M. A. 2022

    Abstract

    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.

    View details for DOI 10.1016/j.ijcard.2022.09.049

    View details for PubMedID 36167220

  • Derivation and External Validation of a Clinical Model to Predict Heart Failure Onset in Patients With Incident Diabetes. Diabetes care Sun, L. Y., Zghebi, S. S., Eddeen, A. B., Liu, P. P., Lee, D. S., Tu, K., Tobe, S. W., Kontopantelis, E., Mamas, M. A. 2022

    Abstract

    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.

    View details for DOI 10.2337/dc22-0894

    View details for PubMedID 36107673

  • Sex-based differences in referral of heart failure patients to outpatient clinics: a scoping review. ESC heart failure Chan, E., Rooprai, J., Rodger, J., Visintini, S., Rodger, N., Philip, S., Mielniczuk, L., Sun, L. Y. 2022

    Abstract

    BACKGROUND: Guidelines recommend that hospitalized patients newly diagnosed with HF be referred to an outpatient HF clinic (HFC) within 2weeks of discharge. Our study aims were (i) to assess the current literary landscape on the impact of patient sex on HFC referral and outcomes and (ii) to provide a qualitative overview of possible considerations for the impact of sex on referral patterns and HF characteristics including aetiology, symptom severity, investigations undertaken and pharmacologic therapy.METHODS AND RESULTS: We conducted a scoping review using the Arksey and O'Malley framework and searched Medline, EMBASE, PsychINFO, Cochrane Library, Ageline databases and grey literature. Eligible articles included index HF hospitalizations or presentations to the Emergency Department (ED), a description of the HFC referral of patients not previously followed by an HF specialist and sex-specific analysis. Of the 11372 potential studies, 8 met the inclusion criteria. These studies reported on a total of 11484 participants, with sample sizes ranging between 168 and 3909 (25.6%-50.7% female). The included studies were divided into two groups: (i) those outlining the referral process to an HFC and (ii) studies which include patients newly enrolled in an HFC. Of the studies in Group 1, males (51%-82.4%) were more frequently referred to an HFC compared with females (29%-78.1%). Studies in Group 2 enrolled a higher proportion of males (62%-74% vs. 26%-38%). One study identified independent predictors of HFC referral which included male sex, younger age, and the presence of systolic dysfunction, the latter two more often found in males. Two studies, one from each group reported a higher mortality amongst males compared with females, whereas another study from Group 2 reported a higher hospitalization rate amongst females following HFC assessment.CONCLUSIONS: Males were more likely than females to be referred to HFCs after hospitalization and visits to the Emergency Department, however heterogeneity across studies precluded a robust assessment of sex-based differences in outcomes. This highlights the need for more comprehensive longitudinal data on HF patients discharged from the acute care setting to better understand the role of sex on patient outcomes.

    View details for DOI 10.1002/ehf2.14143

    View details for PubMedID 36069110

  • Impact of the admitting ward on care quality and outcomes in non-ST-segment elevation myocardial infarction: insights from a national registry. European heart journal. Quality of care & clinical outcomes Moledina, S. M., Shoaib, A., Sun, L. Y., Myint, P. K., Kotronias, R. A., Shah, B. N., Gale, C. P., Quan, H., Bagur, R., Mamas, M. A. 2022; 8 (6): 681-691

    Abstract

    Little is known about the association between the type of admission ward and quality of care and outcomes for non-ST-segment elevation myocardial infarction (NSTEMI).We analysed data from 337 155 NSTEMI admissions between 2010 and 2017 in the UK Myocardial Ischaemia National Audit Project (MINAP) database. The cohort was dichotomised according to receipt of care either on a medical (n = 142,876) or cardiac ward, inclusive of acute cardiac wards and cardiac care unit (n = 194,279) on admission to hospital. Patients admitted to a cardiac ward were younger (median age 70 y vs. 75 y, P < 0.001), and less likely to be female (33% vs. 40%, P < 0.001). Independent factors associated with admission to a cardiac ward included ischaemic ECG changes (OR: 1.20, 95% CI: 1.18-1.23) and prior percutaneous coronary intervention (PCI) (OR: 1.19, 95% CI: 1.16-1.22). Patients admitted to a cardiac ward were more likely to receive optimal pharmacotherapy with statin (85% vs. 81%, P < 0.001) and dual antiplatelet therapy (DAPT) (91% vs. 88%, P < 0.001) on discharge, undergo invasive coronary angiography (78% vs. 59%, P < 0.001), and receive revascularisation in the form of PCI (52% vs. 36%, P < 0.001). Following multivariable logistic regression, the odds of inhospital all-cause mortality (OR: 0.75, 95% CI: 0.70-0.81) and major adverse cardiovascular events (MACE) (OR: 0.84, 95% CI: 0.78-0.91) were lower in patients admitted to a cardiac ward.Patients with NSTEMI admitted to a cardiac ward on admission were more likely to receive guideline directed management and had better clinical outcomes.

    View details for DOI 10.1093/ehjqcco/qcab062

    View details for PubMedID 34482404

    View details for PubMedCentralID PMC9442842

  • Comparison of Multidimensional Frailty Instruments for Estimation of Long-term Patient-Centered Outcomes After Cardiac Surgery. JAMA network open Sun, L. Y., Jabagi, H., Fang, J., Lee, D. S. 2022; 5 (9): e2230959

    Abstract

    Little is known about the performance of available frailty instruments in estimating patient-relevant outcomes after cardiac surgery.To examine how well the Johns Hopkins Adjusted Clinical Groups (ACG) frailty indicator, the Hospital Frailty Risk Score (HFRS), and the Preoperative Frailty Index (PFI) estimate long-term patient-centered outcomes after cardiac surgery.This retrospective cohort study was conducted in Ontario, Canada, among residents 18 years and older who underwent coronary artery bypass grafting or aortic, mitral or tricuspid valve, or thoracic aorta surgery between October 2008 and March 2017. Long-term care residents, those with discordant surgical encounters, and those receiving dialysis or dependent on a ventilator within 90 days were excluded. Statistical analysis was conducted from July 2021 to January 2022.The primary outcome was patient-defined adverse cardiovascular and noncardiovascular events (PACE), defined as the composite of severe stroke, heart failure, long-term care admission, new-onset dialysis, and ventilator dependence. Secondary outcomes included mortality and individual PACE events. The association between frailty and PACE was examined using cause-specific hazard models with death as a competing risk, and the association between frailty and death was examined using Cox models. Areas under the receiver operating characteristic curve (AUROC) were determined over 10 years of follow-up for each frailty instrument.Of 88 456 patients (22 924 [25.9%] female; mean [SD] age, 66.3 [11.1] years), 14 935 (16.9%) were frail according to ACG criteria, 63 095 (71.3%) according to HFRS, and 76 754 (86.8%) according to PFI. Patients with frailty were more likely to be older, female, and rural residents; to have lower income and multimorbidity; and to undergo urgent surgery. Patients meeting ACG criteria (hazard ratio [HR], 1.66; 95% CI, 1.60-1.71) and those with higher HFRS scores (HR per 1.0-point increment, 1.10; 95% CI, 1.09-1.10) and PFI scores (HR per 0.1-point increment, 1.75; 95% CI, 1.73-1.78) had higher rates of PACE. Similar magnitudes of association were observed for each frailty instrument with death and individual PACE components. The HFRS had the highest AUROC for estimating PACE during the first 2 years and death during the first 4 years, after which the PFI had the highest AUROC.These findings could help to tailor the use of frailty instruments by outcome and follow-up duration, thus optimizing preoperative risk stratification, patient-centered decision-making, candidate selection for prehabilitation, and personalized monitoring and health resource planning in patients undergoing cardiac surgery.

    View details for DOI 10.1001/jamanetworkopen.2022.30959

    View details for PubMedID 36083582

    View details for PubMedCentralID PMC9463609

  • Trends in glucose testing among individuals without diabetes in Ontario between 2010 and 2017: a population-based cohort study. CMAJ open Chu, A., Shah, B. R., Rashid, M., Booth, G. L., Fazli, G. S., Tu, K., Sun, L. Y., Abdel-Qadir, H., Yu, C. H., Shin, S., Connelly, K. A., Tobe, S., Liu, P. P., Lee, D. S. 2022; 10 (3): E772-E780

    Abstract

    Early identification of people with diabetes or prediabetes enables greater opportunities for glycemic control and management strategies to prevent related complications. To identify gaps in screening for these conditions, we examined population trends in receipt of timely glucose testing overall and in specific clinical subgroups.Using linked administrative databases, we conducted a retrospective cohort study of people aged 40 years and older without diabetes at baseline. Our primary outcome was up-to-date glucose testing, defined as having received testing at least once in the 3 years before each index year from 2010 to 2017, using linked administrative databases of people residing in Ontario, Canada. We calculated rates of up-to-date testing by age group, sex, ethnicity (South Asian, Chinese, general population) and comorbidities (hypertension, hyperlipidemia, cardiovascular disease).Over the 8-year study period, up-to-date glucose testing rates were stable at 67% for men and 77% for women (both relative risk 1.00 per year; 95% confidence interval 1.00-1.00). Testing rates were significantly lower in men than in women (all age groups p < 0.001) and lower in younger than older age groups (except those aged ≥ 80 yr). South Asian people had the highest testing rates, although among people aged 70 years or older, testing was highest in the general population (p < 0.001). Among people with hypertension, hyperlipidemia and cardiovascular disease, annual testing rates were also stable, but only 58% overall among people with hypertension.We found lower glucose testing rates in younger men and people with hypertension. Our findings reinforce the need for initiatives to increase awareness of glycemic testing.

    View details for DOI 10.9778/cmajo.20210195

    View details for PubMedID 35998927

    View details for PubMedCentralID PMC9402266

  • Aortic stenosis post-COVID-19: a mathematical model on waiting lists and mortality. BMJ open Stickels, C. P., Nadarajah, R., Gale, C. P., Jiang, H., Sharkey, K. J., Gibbison, B., Holliman, N., Lombardo, S., Schewe, L., Sommacal, M., Sun, L., Weir-McCall, J., Cheema, K., Rudd, J. H., Mamas, M., Erhun, F. 2022; 12 (6): e059309

    Abstract

    To provide estimates for how different treatment pathways for the management of severe aortic stenosis (AS) may affect National Health Service (NHS) England waiting list duration and associated mortality.We constructed a mathematical model of the excess waiting list and found the closed-form analytic solution to that model. From published data, we calculated estimates for how the strategies listed under Interventions may affect the time to clear the backlog of patients waiting for treatment and the associated waiting list mortality.The NHS in England.Estimated patients with AS in England.(1) Increasing the capacity for the treatment of severe AS, (2) converting proportions of cases from surgery to transcatheter aortic valve implantation and (3) a combination of these two.In a capacitated system, clearing the backlog by returning to pre-COVID-19 capacity is not possible. A conversion rate of 50% would clear the backlog within 666 (533-848) days with 1419 (597-2189) deaths while waiting during this time. A 20% capacity increase would require 535 (434-666) days, with an associated mortality of 1172 (466-1859). A combination of converting 40% cases and increasing capacity by 20% would clear the backlog within a year (343 (281-410) days) with 784 (292-1324) deaths while awaiting treatment.A strategy change to the management of severe AS is required to reduce the NHS backlog and waiting list deaths during the post-COVID-19 'recovery' period. However, plausible adaptations will still incur a substantial wait to treatment and many hundreds dying while waiting.

    View details for DOI 10.1136/bmjopen-2021-059309

    View details for PubMedID 35710248

    View details for PubMedCentralID PMC9207579

  • IGFBP7 as a preoperative predictor of congestive acute kidney injury after cardiac surgery. Open heart MacMillan, Y. S., Mamas, M. A., Sun, L. Y. 2022; 9 (1)

    Abstract

    Congestive acute kidney injury (c-AKI) refers to AKI in the presence of right ventricular failure (RVF) and is a highly morbid complication of cardiac surgery. However, treatment has traditionally been reactive rather than proactive due to limited modalities to predict this complication. The objective of this study was to investigate the ability of insulin-like growth-factor binding protein 7 (IGFBP7), to predict c-AKI, AKI and RVF in patients undergoing cardiac surgery, as compared to N-terminal prohormone B-type natriuretic peptide (NT-pro-BNP) and pulmonary artery pulsatility index (PAPi).This prospective nested case-control study consisted of 350 adult patients who underwent elective cardiac surgery. The outcomes were c-AKI, AKI and RVF. Unadjusted and adjusted conditional logistic regression models and areas under the receiver operating characteristic curve (AUC) were used to assess the predictive performance of each marker.For the prediction of c-AKI, the unadjusted IGPBP7 model had an AUC of 0.81, as compared with 0.51 for NT-pro-BNP and 0.61 for PAPi. The adjusted c-AKI models had AUCs of 0.90 for IGFBP7, 0.87 for NT-pro-BNP and 0.77 for PAPi. For AKI and RVF, the predictive performance of IGFBP7 was moderate and exceeded that of NT-pro-BNP and PAPi in univariable analysis. IGFBP7 remained a robust independent predictor of all outcomes in multivariable analysis, whereas the other markers did not.IGFBP7 is a promising biomarker for prediction of AKI, RVF and c-AKI and could have value for preoperative optimisation and risk stratification of patients undergoing cardiac surgery.

    View details for DOI 10.1136/openhrt-2022-002027

    View details for PubMedID 35732353

    View details for PubMedCentralID PMC9226986

  • A standardized definition for right ventricular failure in cardiac surgery patients. ESC heart failure Jabagi, H., Nantsios, A., Ruel, M., Mielniczuk, L. M., Denault, A. Y., Sun, L. Y. 2022; 9 (3): 1542-1552

    Abstract

    Right ventricular failure (RVF) is a significant cause of mortality and morbidity after cardiac surgery. Despite its prognostic importance, RVF remains under investigated and without a universally accepted definition in the perioperative setting. We foresee that the provision of a standardized perioperative definition for RVF based on practical and objective criteria will help to improve quality of care through early detection and facilitate the generalization of RVF research to advance this field. This article provides an overview of RVF aetiology, pathophysiology, current diagnostic modalities, as well as a summary of existing RVF definitions. This is followed by our proposal for a standardized definition of perioperative RVF, one that captures RV structural and functional abnormalities through a multimodal approach based on anatomical, echocardiographic, and haemodynamic criteria that are readily available in the perioperative setting (Central Image).

    View details for DOI 10.1002/ehf2.13870

    View details for PubMedID 35266332

    View details for PubMedCentralID PMC9065859

  • Missing the Goal With the 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. The Canadian journal of cardiology Ruel, M., Williams, A., Ouzounian, M., Sun, L., Légaré, J. F., Poirier, P., Malas, T., Farkouh, M. E., Chedrawy, E., Hassan, A., Higgins, J., Connelly, K., McClure, R. S., Bewick, D., Whitlock, R., Graham, M., Arora, R. C. 2022; 38 (6): 705-708

    View details for DOI 10.1016/j.cjca.2022.03.013

    View details for PubMedID 35341903

  • Addressing disparities of care in non-ST-segment elevation myocardial infarction patients without standard modifiable risk factors: insights from a nationwide cohort study. European journal of preventive cardiology Moledina, S. M., Rashid, M., Nolan, J., Nakao, K., Sun, L. Y., Velagapudi, P., Wilton, S. B., Volgman, A. S., Gale, C. P., Mamas, M. A. 2022; 29 (7): 1084-1092

    Abstract

    The importance of standard modifiable cardiovascular risk factors (SMuRFs) in preventing non-ST-segment elevation myocardial infarction (NSTEMI) is established. However, NSTEMI may present in the absence of SMuRFs, and little is known about their outcomes.We analysed 176 083 adult (≥18 years) hospitalizations with NSTEMI using data from the United Kingdom (UK) Myocardial Infarction National Audit Project (MINAP). Clinical characteristics and all-cause in-hospital mortality were analysed according to SMuRF status, with 135 223 patients presenting with at least one of diabetes, hypertension, hypercholesterolaemia, or current smoking status and 40 860 patients without any SMuRFs. Those with a history of coronary artery disease were excluded. Patients without SMuRFs were more frequently older (median age 72 year vs. 71 years, P < 0.001), male (62% vs. 61%, P < 0.001), and Caucasian (95% vs. 92%, P < 0.001). Those without SMuRFs less frequently received statins (71% vs. 81%, P < 0.001), had their left ventricular (LV) function recorded (62% vs. 65%, P < 0.001) or for those with moderate or severe LV systolic dysfunction were prescribed angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (80% vs. 85%, P < 0.001). Following propensity score matching the odds of all-cause mortality [odds ratio (OR): 0.85, 95% confidence interval (CI): 0.77-0.93], cardiac mortality (OR: 0.85, 95% CI: 0.76-0.94), and major adverse cardiovascular events (MACE) (OR: 0.85, 95% CI: 0.77-0.93) were lower in patients without SMuRFs.More than one in five patients presenting with NSTEMI had no SMuRFs, who were less frequently received guideline-recommended management and had lower in-hospital (all-cause and cardiac) mortality and MACE than patients with SMuRFs.

    View details for DOI 10.1093/eurjpc/zwab200

    View details for PubMedID 34897399

  • Prediction of acute kidney injury risk after cardiac surgery: using a hybrid machine learning algorithm. BMC medical informatics and decision making Petrosyan, Y., Mesana, T. G., Sun, L. Y. 2022; 22 (1): 137

    Abstract

    Acute kidney injury (AKI) is a serious complication after cardiac surgery. We derived and internally validated a Machine Learning preoperative model to predict cardiac surgery-associated AKI of any severity and compared its performance with parametric statistical models.We conducted a retrospective study of adult patients who underwent major cardiac surgery requiring cardiopulmonary bypass between November 1st, 2009 and March 31st, 2015. AKI was defined according to the KDIGO criteria as stage 1 or greater, within 7 days of surgery. We randomly split the cohort into derivation and validation datasets. We developed three AKI risk models: (1) a hybrid machine learning (ML) algorithm, using Random Forests for variable selection, followed by high performance logistic regression; (2) a traditional logistic regression model and (3) an enhanced logistic regression model with 500 bootstraps, with backward variable selection. For each model, we assigned risk scores to each of the retained covariate and assessed model discrimination (C statistic) and calibration (Hosmer-Lemeshow goodness-of-fit test) in the validation datasets.Of 6522 included patients, 1760 (27.0%) developed AKI. The best performance was achieved by the hybrid ML algorithm to predict AKI of any severity. The ML and enhanced statistical models remained robust after internal validation (C statistic = 0.75; Hosmer-Lemeshow p = 0.804, and AUC = 0.74, Hosmer-Lemeshow p = 0.347, respectively).We demonstrated that a hybrid ML model provides higher accuracy without sacrificing parsimony, computational efficiency, or interpretability, when compared with parametric statistical models. This score-based model can easily be used at the bedside to identify high-risk patients who may benefit from intensive perioperative monitoring and personalized management strategies.

    View details for DOI 10.1186/s12911-022-01859-w

    View details for PubMedID 35585624

    View details for PubMedCentralID PMC9118758

  • Representation of patient diversity in anesthesia curricular materials. Canadian journal of anaesthesia = Journal canadien d'anesthesie Leir, S. A., Sun, L., Fraser, A. 2022

    View details for DOI 10.1007/s12630-022-02251-y

    View details for PubMedID 35437685

  • Patient Sex and Postoperative Outcomes after Inpatient Intraabdominal Surgery: A Population-based Retrospective Cohort Study. Anesthesiology He, J. W., Sun, L. Y., Wijeysundera, D., Vogt, K., Jones, P. M. 2022; 136 (4): 577-587

    Abstract

    Intraabdominal surgeries are frequently performed procedures that lead to a high volume of unplanned readmissions and postoperative complications. Patient sex may be a determinant of adverse outcomes in this population, possibly due to differences in biology or care delivery, but it is understudied. The authors hypothesized that there would be no association between patient sex and the risk of postoperative adverse outcomes in intraabdominal surgery.This retrospective, population-based cohort study involved adult inpatients aged 18 yr or older who underwent intraabdominal surgeries in Ontario, Canada, between April 2009 and March 2016. The authors studied the association of patient sex on the primary composite outcome of all-cause death, hospital readmission, or major postoperative complications, all within 30 postoperative days. Inverse probability of exposure weighting based on propensity scores (computed using demographic characteristics such as rural residence status and median neighborhood income quintile, common comorbidities, and surgery- and hospital-specific characteristics) was used to estimate the adjusted association of sex on outcomes.The cohort included 215,846 patients (52.3% female). The primary outcome was observed in 24,712 (21.9%) females and 25,486 (24.7%) males (unadjusted risk difference, 2.8% [95% CI, 2.5 to 3.2%]; P < 0.001). After adjustment, the association between the male sex and the primary outcome was not statistically significant (adjusted risk difference, -0.2% [95% CI, -0.5 to 0.2%]; P = 0.378).In a large population of intraabdominal surgical patients, there was no differential risk between sexes in the composite outcome of all-cause death, hospital readmission, or major postoperative complications, all within 30 postoperative days.

    View details for DOI 10.1097/ALN.0000000000004136

    View details for PubMedID 35188547

  • Age, Not Sex, Modifies the Effect of Frailty on Long-term Outcomes After Cardiac Surgery. Annals of surgery Sun, L. Y., Spence, S. D., Benton, S., Beanlands, R. S., Austin, P. C., Bader Eddeen, A., Lee, D. S. 2022; 275 (4): 800-806

    Abstract

    To examine the prevalence of frailty in surgical patients and determine whether age and sex modify the relationship between frailty and long-term mortality.Frailty is a complex and prevalent clinical syndrome. The cardiac surgery literature consists mostly of small, single-center studies, and the epidemiology of frailty remains to be fully elucidated in a real-world surgical population.This retrospective cohort study included patients who underwent coronary artery bypass grafting, and/or aortic, mitral or tricuspid valve surgery in Ontario, Canada, between 2008 and 2016. The primary outcome was all-cause mortality. Survival probabilities were calculated using the Kaplan-Meier method, and the association of covariates with the hazard of death was assessed using multivariable Cox proportional hazard models. Frailty was assessed using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator.Of 72,824 patients, 11,685 (16%) were frail. At median 5 ± 2 years of follow-up, 2921 (25.0%) frail patients and 8637 (14.1%) non-frail patients had died [adjusted hazard ratio 1.60; 95% confidence interval (CI), 1.53-1.68]. The adjusted hazard ratio was highest in patients who underwent isolated mitral (2.18; 95% CI, 1.71-2.77) and mitral + aortic valve surgery (1.85; 95% CI, 1.33-2.58) and lowest after coronary artery bypass grafting + mitral valve surgery (1.38; 95% CI, 1.11-1.70). Age, but not sex, modified the effect of frailty on mortality; such that the rate of death decreased linearly with increasing patient age.We observed a high prevalence of frailty in patients undergoing cardiac surgery, and a statistically significant association between frailty and long-term mortality after cardiac procedures. Importantly, the rate of death was inversely proportional to age, such that frailty had a stronger adverse impact on younger patients. Our findings highlight the need to incorporate frailty into the preoperative risk stratification and investigate strategies to support younger patients who are frail.

    View details for DOI 10.1097/SLA.0000000000004060

    View details for PubMedID 32541219

  • Derivation and validation of a clinical risk score to predict death among patients awaiting cardiac surgery in Ontario, Canada: a population-based study. CMAJ open Sun, L. Y., Wijeysundera, H. C., Lee, D. S., van Diepen, S., Ruel, M., Eddeen, A. B., Mesana, T. G. 2022; 10 (1): E173-E182

    Abstract

    Surgical delay may result in unintended harm to patients needing cardiac surgery, who are at risk for death if their condition is left untreated. Our objective was to derive and internally validate a clinical risk score to predict death among patients awaiting major cardiac surgery.We used the CorHealth Ontario Registry and linked ICES health administrative databases with information on all Ontario residents to identify patients aged 18 years or more who were referred for isolated coronary artery bypass grafting (CABG), valvular procedures, combined CABG-valvular procedures or thoracic aorta procedures between Oct. 1, 2008, and Sept. 30, 2019. We used a hybrid modelling approach with the random forest method for initial variable selection, followed by backward stepwise logistic regression modelling for clinical interpretability and parsimony. We internally validated the logistic regression model, termed the CardiOttawa Waitlist Mortality Score, using 200 bootstraps.Of the 112 266 patients referred for cardiac surgery, 269 (0.2%) died while awaiting surgery (118/72 366 [0.2%] isolated CABG, 81/24 461 [0.3%] valvular procedures, 63/12 046 [0.5%] combined CABG-valvular procedures and 7/3393 [0.2%] thoracic aorta procedures). Age, sex, surgery type, left main stenosis, Canadian Cardiovascular Society classification, left ventricular ejection fraction, heart failure, atrial fibrillation, dialysis, psychosis and operative priority were predictors of waitlist mortality. The model discriminated (C-statistic 0.76 [optimism-corrected 0.73]). It calibrated well in the overall cohort (Hosmer-Lemeshow p = 0.2) and across surgery types.The CardiOttawa Waitlist Mortality Score is a simple clinical risk model that predicts the likelihood of death while awaiting cardiac surgery. It has the potential to provide data-driven decision support for managing access to cardiac care and preserve system capacity during the COVID-19 pandemic, the recovery period and beyond.

    View details for DOI 10.9778/cmajo.20210031

    View details for PubMedID 35260467

    View details for PubMedCentralID PMC9259465

  • Single Versus Multiple Arterial Revascularization in Patients With Reduced Renal Function: Long-term Outcome Comparisons in 23,406 CABG Patients From Ontario, Canada. Annals of surgery Hayatsu, Y., Ruel, M., Bader Eddeen, A., Sun, L. 2022; 275 (3): 602-608

    Abstract

    To compare the long-term outcomes of MAR versus SAR in patients with renal insufficiency.Previous studies have been insufficiently powered to address whether MAR confers long-term benefit over SAR in patients with renal dysfunction who require CABG.We conducted retrospective cohort study in Ontario, Canada of patients who underwent isolated CABG (n = 23,406). The primary outcome was MACE, defined as the composite of stroke, myocardial infarction, and repeat revascularization. We compared patients by matching them on the propensity to have received SAR versus MAR, within groups with preoperative glomerular filtration rate (GFR) ≥60 mL/min/1.73 m2; GFR between 30 and 60; and GFR <30.In patients with GFR ≥60, the use of MAR versus SAR was associated with a lower rate of MACE [hazard ratio (HR) 0.87 (0.80-0.94)], and a lower rate of long-term mortality [HR 0.87 (0.79-0.97)]. In those with GFR between 30 and 60, MAR was not associated with a difference in MACE [HR 1.04 (0.87-1.26)], and a lower rate of long-term mortality [HR 0.75 (0.65-0.87)] was observed. In those with GFR <30, MAR was not associated with a difference in outcomes.MAR versus SAR does not correlate with a difference in MACE amongst patients with GFR between 30 and 60 and better survival raises the possibility of indication bias. Furthermore, MAR did not confer a benefit in those with severely reduced renal function. These data suggest that the potential long-term benefits of using MAR in CABG patients with renal insufficiency may be offset by competing health risks.

    View details for DOI 10.1097/SLA.0000000000003908

    View details for PubMedID 32590546

  • Association Between Handover of Anesthesiology Care and 1-Year Mortality Among Adults Undergoing Cardiac Surgery. JAMA network open Sun, L. Y., Jones, P. M., Wijeysundera, D. N., Mamas, M. A., Bader Eddeen, A., O'Connor, J. 2022; 5 (2): e2148161

    Abstract

    Handovers of anesthesia care from one anesthesiologist to another is an important intraoperative event. Despite its association with adverse events after noncardiac surgery, its impact in the context of cardiac surgery remains unclear.To compare the outcomes of patients who were exposed to anesthesia handover vs those who were unexposed to anesthesia handover during cardiac surgery.This retrospective cohort study in Ontario, Canada, included Ontario residents who were 18 years or older and had undergone coronary artery bypass grafting or aortic, mitral, tricuspid valve, or thoracic aorta surgical procedures between 2008 and 2019. Exclusion criteria were non-Ontario residency status and other concomitant procedures. Statistical analysis was conducted from April 2021 to June 2021, and data collection occurred between November 2020 to January 2021.Complete handover of anesthesia care, where the case is completed by the replacement anesthesiologist.The coprimary outcomes were mortality within 30 days and 1 year after surgery. Secondary outcomes were patient-defined adverse cardiac and noncardiac events (PACE), intensive care unit (ICU), and hospital lengths of stay (LOS). Inverse probability of treatment weighting based on the propensity score was used to estimate adjusted effect measures. Mortality was assessed using a Cox proportional hazard model, PACE using a cause-specific hazard model with death as a competing risk, and LOS using Poisson regression.Of the 102 156 patients in the cohort, 25 207 (24.7%) were women; the mean (SD) age was 66.4 (10.8) years; and 72 843 of surgical procedures (71.3%) were performed in teaching hospitals. Handover occurred in 1926 patients (1.9%) and was associated with higher risks of 30-day mortality (hazard ratio [HR], 1.89; 95% CI, 1.41-2.54) and 1-year mortality (HR, 1.66; 95% CI, 1.31-2.12), as well as longer ICU (risk ratio [RR], 1.43; 95% CI, 1.22-1.68) and hospital (RR, 1.17; 95% CI, 1.06-1.28) LOS. There was no statistically significant association between handover and PACE (30 days: HR 1.09; 95% CI, 0.79-1.49; 1 year: HR 0.89; 95% CI, 0.70-1.13).Handover of anesthesia care during cardiac surgical procedures was associated with higher 30-day and 1-year mortality rates and increased health care resource use. Further research is needed to evaluate and systematically improve the handover process qualitatively.

    View details for DOI 10.1001/jamanetworkopen.2021.48161

    View details for PubMedID 35147683

    View details for PubMedCentralID PMC8837916

  • Sex differences after coronary artery bypass grafting with a second arterial conduit. The Journal of thoracic and cardiovascular surgery Rubens, F. D., Wells, G. A., Coutinho, T., Eddeen, A. B., Sun, L. Y. 2022; 163 (2): 686-695.e10

    Abstract

    Double arterial conduit use during coronary artery bypass grafting is associated with improved clinical outcomes compared with single arterial conduits in the general population. However, the sex-specific outcomes of this strategy remain unknown and are needed to inform sex-specific revascularization guidelines.We conducted a population-based, retrospective cohort study of all Ontarians who underwent primary isolated coronary artery bypass grafting with single arterial conduits or double arterial conduits between October 2008 and September 2017. The primary outcome was all-cause mortality. Secondary outcomes included major adverse cardiac and cerebrovascular events, defined as a composite of myocardial infarction, heart failure hospitalization, repeat revascularization, and stroke. We used inverse probability of treatment weighting to account for group imbalances.A total of 9135 women and 36,748 men underwent coronary artery bypass grafting. At 30 days, there was no between-group difference in mortality or major adverse cardiac and cerebrovascular events in men. However, among women, a double arterial conduit was associated with an increased rate of 30-day death (hazard ratio, 1.48; 95% confidence interval, 1.23-1.79) and major adverse cardiac and cerebrovascular events (hazard ratio, 1.32; 95% confidence interval, 1.14-1.51). The risk of medium-term mortality with double arterial conduits was less in men (hazard ratio, 0.88; 95% confidence interval, 0.84-0.92) and women (hazard ratio, 0.87; 95% confidence interval, 0.81-0.94), as was the medium-term risk of major adverse cardiac and cerebrovascular events (hazard ratio, 0.91; 95% confidence interval, 0.87-0.94) [men]; hazard ratio, 0.91; 95% confidence interval, 0.86-0.97) [women]). The incremental improvement in 9-year survival was 4.0% in women with a double arterial conduit and 0.9% in men.Double arterial conduit is associated with better medium-term survival and cardiovascular outcomes in both sexes. Double arterial conduits are associated with increased perioperative risk in women, but the medium-term benefit is greater than in men.

    View details for DOI 10.1016/j.jtcvs.2020.04.058

    View details for PubMedID 32493659

  • Establishing an interdisciplinary research team for cardio-oncology artificial intelligence informatics precision and health equity. American heart journal plus : cardiology research and practice Brown, S. A., Sparapani, R., Osinski, K., Zhang, J., Blessing, J., Cheng, F., Hamid, A., Berman, G., Lee, K., BagheriMohamadiPour, M., Lal, J. C., Kothari, A. N., Caraballo, P., Noseworthy, P., Johnson, R. H., Hansen, K., Sun, L. Y., Crotty, B., Cheng, Y. C., Olson, J. 2022; 13

    Abstract

    A multi-institutional interdisciplinary team was created to develop a research group focused on leveraging artificial intelligence and informatics for cardio-oncology patients. Cardio-oncology is an emerging medical field dedicated to prevention, screening, and management of adverse cardiovascular effects of cancer/ cancer therapies. Cardiovascular disease is a leading cause of death in cancer survivors. Cardiovascular risk in these patients is higher than in the general population. However, prediction and prevention of adverse cardiovascular events in individuals with a history of cancer/cancer treatment is challenging. Thus, establishing an interdisciplinary team to create cardiovascular risk stratification clinical decision aids for integration into electronic health records for oncology patients was considered crucial.Core team members from the Medical College of Wisconsin (MCW), University of Wisconsin-Milwaukee (UWM), and Milwaukee School of Engineering (MSOE), and additional members from Cleveland Clinic, Mayo Clinic, and other institutions have joined forces to apply high-performance computing in cardio-oncology.The team is comprised of clinicians and researchers from relevant complementary and synergistic fields relevant to this work. The team has built an epidemiological cohort of ~5000 cancer survivors that will serve as a database for interdisciplinary multi-institutional artificial intelligence projects.Lessons learned from establishing this team, as well as initial findings from the epidemiology cohort, are presented. Barriers have been broken down to form a multi-institutional interdisciplinary team for health informatics research in cardio-oncology. A database of cancer survivors has been created collaboratively by the team and provides initial insight into cardiovascular outcomes and comorbidities in this population.

    View details for DOI 10.1016/j.ahjo.2022.100094

    View details for PubMedID 35434676

    View details for PubMedCentralID PMC9012235

  • Impact of availability of catheter laboratory facilities on management and outcomes of acute myocardial infarction presenting with out of hospital cardiac arrest. Resuscitation Dafaalla, M., Rashid, M., Sun, L., Quinn, T., Timmis, A., Wijeysundera, H., Bagur, R., Michos, E., Curzen, N., Mamas, M. A. 2022; 170: 327-334

    Abstract

    We aimed to identify whether the availability of catheter laboratory affects clinical outcomes of out-of-hospital cardiac arrest (OHCA) complicating myocardial infarction (AMI).Patients admitted with a diagnosis of AMI and OHCA from the Myocardial Ischaemia National Audit Project (MINAP) between 2010 to 2017 were stratified into three groups based on initial hospital's catheter laboratory status: hospitals without a catheter laboratory (No-catheter lab hospitals), hospitals with diagnostic catheter laboratory (Diagnostic hospitals), and hospitals with PCI facilities (PCI hospitals). We used multivariable logistic regression to evaluate factors associated with clinical outcomes.We included 12,303 patients of which 9,798 were admitted to PCI hospitals, 1,595 to no-catheter lab hospitals, and 910 to diagnostic hospitals. Patients admitted to PCI hospitals were more frequently reviewed by a cardiologist (96%, p < 0.001) than no-catheter lab hospitals (80%) and diagnostic hospitals (74%), and more likely to receive coronary angiography (PCI hospitals (87%), diagnostic hospitals (31%), no-catheter lab hospitals (54%), p < 0.001). They also were more likely to undergo PCI (PCI hospitals (42%), diagnostic hospitals (17%), no-catheter lab hospitals (17%), p < 0.001). After adjustment, there was no significant difference in the in-hospital mortality (OR 0.76, 95% CI 0.55-1.06) or re-infarction (OR 1.28, 95% CI 0.72-2.26) in patients admitted to PCI hospitals nor in patients admitted to diagnostic hospitals (mortality (OR 1.28, 95% CI 0.72-2.26), re-infarction (OR 1.38, 95% CI 0.68-2.82)).There is variation in coronary angiography use between hospitals without a catheter laboratory and PCI centres, which was not associated with better in-hospital survival.

    View details for DOI 10.1016/j.resuscitation.2021.10.031

    View details for PubMedID 34718080

  • Drivers and outcomes of variation in surgical versus transcatheter aortic valve replacement in Ontario, Canada: a population-based study. Open heart Miranda, R. N., Qiu, F., Manoragavan, R., Fremes, S., Lauck, S., Sun, L., Tarola, C., Tam, D. Y., Mamas, M., Wijeysundera, H. C. 2022; 9 (1)

    Abstract

    To understand the patient and hospital level drivers of the variation in surgical versus trascatheter aortic valve replacement (SAVR vs TAVR) for patients with aortic stenosis (AS) and to explore whether this variation translates into differences in clinical outcomes.Adoption of TAVR has grown exponentially worldwide. Notwithstanding, a wide variation in TAVR rates has been seen within and between countries and in some jurisdictions AS is still primarily being managed by SAVR.We conducted a population-based retrospective cohort study in Ontario, Canada, including individuals who received TAVR or SAVR between 2016 and 2020. We developed iterative hierarchical logistic regression models for the likelihood of receiving TAVR instead of SAVR examining sequentially patient characteristics, hospital factors and year of procedure, calculating the median ORs and variance partition coefficients for each. Using Cox proportional hazards models, we examined the relationship between TAVR/SAVR ratio on all-cause mortality and readmissions.Annual procedures rates per million population increased from 171 to 201, mainly driven by the expansion of TAVR. TAVR/SAVR ratios differed substantially between hospitals, from 0.21 to 3.27. Neither patient nor hospital factors explained the between-hospital variation in AS treatment. The TAVR/SAVR ratio was significantly associated with clinical outcomes with high ratio hospitals having lower mortality and rehospitalisations.Despite the expansion of TAVR, dramatic variation exists that is not explained by patient or hospital factors. This variation was associated with differences in clinical outcomes, suggesting that further work is needed in understanding and addressing inequity of access.

    View details for DOI 10.1136/openhrt-2021-001881

    View details for PubMedID 35101899

    View details for PubMedCentralID PMC8804707

  • Response to the Comment on "Single Versus Multiple Arterial Revascularization in Patients With Reduced Renal Function Long-Term Outcome Comparisons in 23,406 CABG Patients From Ontario, Canada". Annals of surgery Hayatsu, Y., Ruel, M., Sun, L. Y. 2021; 274 (6): e824-e825

    View details for DOI 10.1097/SLA.0000000000004476

    View details for PubMedID 33086316

  • Derivation and validation of predictive indices for 30-day mortality after coronary and valvular surgery in Ontario, Canada. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne Sun, L. Y., Chu, A., Tam, D. Y., Wang, X., Fang, J., Austin, P. C., Feindel, C. M., Oakes, G. H., Alexopoulos, V., Tusevljak, N., Ouzounian, M., Lee, D. S. 2021; 193 (46): E1757-E1765

    Abstract

    Coronary artery bypass grafting (CABG) and surgical aortic valve replacement (AVR) are the 2 most common cardiac surgery procedures in North America. We derived and externally validated clinical models to estimate the likelihood of death within 30 days of CABG, AVR or combined CABG + AVR.We obtained data from the CorHealth Ontario Cardiac Registry and several linked population health administrative databases from Ontario, Canada. We derived multiple logistic regression models from all adult patients who underwent CABG, AVR or combined CABG + AVR from April 2017 to March 2019, and validated them in 2 temporally distinct cohorts (April 2015 to March 2017 and April 2019 to March 2020).The derivation cohorts included 13 435 patients who underwent CABG (30-d mortality 1.73%), 1970 patients who underwent AVR (30-d mortality 1.68%) and 1510 patients who underwent combined CABG + AVR (30-d mortality 3.05%). The final models for predicting 30-day mortality included 15 variables for patients undergoing CABG, 5 variables for patients undergoing AVR and 5 variables for patients undergoing combined CABG + AVR. Model discrimination was excellent for the CABG (c-statistic 0.888, optimism-corrected 0.866) AVR (c-statistic 0.850, optimism-corrected 0.762) and CABG + AVR (c-statistic 0.844, optimism-corrected 0.776) models, with similar results in the validation cohorts.Our models, leveraging readily available, multidimensional data sources, computed accurate risk-adjusted 30-day mortality rates for CABG, AVR and combined CABG + AVR, with discrimination comparable to more complex American and European models. The ability to accurately predict perioperative mortality rates for these procedures will be valuable for quality improvement initiatives across institutions.

    View details for DOI 10.1503/cmaj.202901

    View details for PubMedID 34810162

    View details for PubMedCentralID PMC8608458

  • Predictors, Treatments, and Outcomes of Do-Not-Resuscitate Status in Acute Myocardial Infarction Patients (from a Nationwide Inpatient Cohort Study). The American journal of cardiology Kobo, O., Moledina, S. M., Slawnych, M., Sinnarajah, A., Simon, J., Van Spall, H. G., Sun, L. Y., Zoccai, G. B., Roguin, A., Mohamed, M. O., Mamas, M. A. 2021; 159: 8-18

    Abstract

    Little is known about how frequently do-not-resuscitate (DNR) orders are placed in patients with acute myocardial infarction (AMI), the types of patients in which they are placed, treatment strategies or clinical outcomes of such patients. Using the United States (US) National Inpatient Sample (NIS) database from 2015 to 2018, we identified 2,767,549 admissions that were admitted to US hospitals and during the hospitalization received a principle diagnosis of AMI, of which 339,270 (12.3%) patients had a DNR order (instigated both preadmission and during in-hospital stay). Patients with a DNR status were older (median age 83 vs 65, p < 0.001), more likely to be female (53.4% vs 39.3%, p < 0.001) and White (81.0% vs 73.3%, p < 0.001). Predictors of DNR status included comorbidities such as heart failure (OR: 1.47, 95% CI: 1.45 to 1.48), dementia (OR: 2.53, 95% CI: 2.50 to 2.55), and cancer. Patients with a DNR order were less likely to undergo invasive management or be discharged home (13.5% vs 52.8%), with only 1/3 receiving palliative consultation. In hospital mortality (32.7% vs 4.6%, p < 0.001) and MACCE (37.1% vs 8.8%, p < 0.001) were higher in the DNR group. Factors independently associated with in-hospital mortality among patients with a DNR order included a STEMI presentation (OR: 2.90, 95% CI: 2.84 to 2.96) and being of Black (OR: 1.29, 95% CI: 1.26 to 1.33), Hispanic (OR: 1.36, 95% CI: 1.32 to 1.41) or Asian/Pacific Islander (OR: 1.56, 95% CI:1.49-race. In conclusion, AMI patients with a DNR status were older, multimorbid, less likely to receive invasive management, with only one third of patients with DNR status referred for palliative care.

    View details for DOI 10.1016/j.amjcard.2021.07.054

    View details for PubMedID 34656317

  • Statins and SARS-CoV-2 Infection: Results of a Population-Based Prospective Cohort Study of 469 749 Adults From 2 Canadian Provinces. Journal of the American Heart Association McAlister, F. A., Wang, T., Wang, X., Chu, A., Goodman, S. G., van Diepen, S., Jackevicius, C. A., Kaul, P., Udell, J., Ko, D. T., Kwong, J. C., Austin, P. C., Lee, D. S. 2021; 10 (21): e022330

    Abstract

    Background Small observational studies have suggested that statin users have a lower risk of dying with COVID-19. We tested this hypothesis in a large, population-based cohort of adults in 2 of Canada's most populous provinces: Ontario and Alberta. Methods and Results We examined reverse transcriptase-polymerase chain reaction swab positivity rates for SARS-CoV-2 in adults using statins compared with nonusers. In patients with SARS-CoV-2 infection, we compared 30-day risk of all-cause emergency department visit, hospitalization, intensive care unit admission, or death in statin users versus nonusers, adjusting for baseline differences in demographics, clinical comorbidities, and prior health care use, as well as propensity for statin use. Between January and June 2020, 2.4% of 226 142 tested individuals aged 18 to 65 years, 2.7% of 88 387 people aged 66 to 75 years, and 4.1% of 154 950 people older than 75 years had a positive reverse transcriptase-polymerase chain reaction swab for SARS-CoV-2. Compared with 353 878 nonusers, the 115 871 statin users were more likely to test positive for SARS-CoV-2 (3.6% versus 2.8%, P<0.001), but this difference was not significant after adjustment for baseline differences and propensity for statin use in each age stratum (adjusted odds ratio 1.00 [95% CI, 0.88-1.14], 1.00 [0.91-1.09], and 1.06 [0.82-1.38], respectively). In individuals younger than 75 years with SARS-CoV-2 infection, statin users were more likely to visit an emergency department, be hospitalized, be admitted to the intensive care unit, or to die of any cause within 30 days of their positive swab result than nonusers, but none of these associations were significant after multivariable adjustment. In individuals older than 75 years with SARS-CoV-2, statin users were more likely to visit an emergency department (28.2% versus 17.9%, adjusted odds ratio 1.41 [1.23-1.61]) or be hospitalized (32.7% versus 21.9%, adjusted odds ratio 1.19 [1.05-1.36]), but were less likely to die (26.9% versus 31.3%, adjusted odds ratio 0.76 [0.67-0.86]) of any cause within 30 days of their positive swab result than nonusers. Conclusions Compared with statin nonusers, patients taking statins exhibit the same risk of testing positive for SARS-CoV-2 and those younger than 75 years exhibit similar outcomes within 30 days of a positive test. Patients older than 75 years with a positive SARS-CoV-2 test and who were taking statins had more emergency department visits and hospitalizations, but exhibited lower 30-day all-cause mortality risk.

    View details for DOI 10.1161/JAHA.121.022330

    View details for PubMedID 34689613

    View details for PubMedCentralID PMC8751814

  • Trends in cardiovascular mortality of cancer patients in the US over two decades 1999-2019. International journal of clinical practice Kobo, O., Khattak, S., Lopez-Mattei, J., Van Spall, H. G., Graham, M., Cheng, R. K., Osman, M., Sun, L., Ullah, W., Fischman, D. L., Roguin, A., Mohamed, M. O., Mamas, M. A. 2021; 75 (11): e14841

    Abstract

    Cancer is the second most common cause of death globally after cardiovascular disease, and cancer patients are at an increased risk of CV death. This recognition has led to publication of cardio-oncological guidelines and to the widespread adoption of dedicated cardio-oncology services in many institutes. However, it is unclear whether there has been a change in the incidence of CV death in cancer patients.Using Centers for Disease Control and Prevention Wide-Ranging, Online Data for Epidemiologic Research (CDC WONDER) Multiple Cause of Death dataset, we determined national trends in age-standardised mortality rates attributed to cardiovascular diseases in patients with and without cancer, from 1999 to 2019, stratified by cancer type, age, gender, race, and place of residence (state and urbanisation status). Among more than 17.8 million cardiovascular deaths in the United States, 13.6% were patients with a concomitant cancer diagnosis. During the study period, among patients with cancer, the age-adjusted mortality rate dropped by 52% (vs 38% in patients with no cancer). In cancer patients, age-adjusted mortality rate dropped more significantly among patients with gastrointestinal, breast, and prostate malignancy than among patients with haematological malignancy (59%-63% vs. 41%). Similar reduction was observed in both genders (53%-54%), but more prominent reduction was observed in older patients and in those living in metro areas.Our findings emphasise the role of multidisciplinary management of cancer patients. Widespread adoption of cardio oncology services have the potential to impact the inherent risk of increased CV mortality in both cancer patients and survivors.

    View details for DOI 10.1111/ijcp.14841

    View details for PubMedID 34514707

  • The Impact of the COVID-19 Pandemic on Cardiac Procedure Wait List Mortality in Ontario, Canada. The Canadian journal of cardiology Tam, D. Y., Qiu, F., Manoragavan, R., Fremes, S. E., Hassan, A., Ko, D. T., Lauck, S. B., Naimark, D., Ouzounian, M., Sander, B., Sun, L., Wijeysundera, H. C. 2021; 37 (10): 1547-1554

    Abstract

    The novel SARS-CoV-2 (COVID-19) pandemic has dramatically altered the delivery of healthcare services, resulting in significant referral pattern changes, delayed presentations, and procedural delays. Our objective was to determine the effect of the COVID-19 pandemic on all-cause mortality in patients awaiting commonly performed cardiac procedures.Clinical and administrative data sets were linked to identify all adults referred for: (1) percutaneous coronary intervention; (2) coronary artery bypass grafting; (3) valve surgery; and (4) transcatheter aortic valve implantation, from January 2014 to September 2020 in Ontario, Canada. Piece-wise regression models were used to determine the effect of the COVID-19 pandemic on referrals and procedural volume. Multivariable Cox proportional hazards models were used to determine the effect of the pandemic on waitlist mortality for the 4 procedures.We included 584,341 patients who were first-time referrals for 1 of the 4 procedures, of whom 37,718 (6.4%) were referred during the pandemic. The pandemic period was associated with a significant decline in the number of referrals and procedures completed compared with the prepandemic period. Referral during the pandemic period was a significant predictor for increased all-cause mortality for the percutaneous coronary intervention (hazard ratio, 1.83; 95% confidence interval, 1.47-2.27) and coronary artery bypass grafting (hazard ratio, 1.96; 95% confidence interval, 1.28-3.01), but not for surgical valve or transcatheter aortic valve implantation referrals. Procedural wait times were shorter during the pandemic period compared with the prepandemic period.There was a significant decrease in referrals and procedures completed for cardiac procedures during the pandemic period. Referral during the pandemic was associated with increased all-cause mortality while awaiting coronary revascularization.

    View details for DOI 10.1016/j.cjca.2021.05.008

    View details for PubMedID 34600793

    View details for PubMedCentralID PMC8481095

  • The association between cardiac intensive care unit mechanical ventilation volumes and in-hospital mortality. European heart journal. Acute cardiovascular care Nandiwada, S., Islam, S., Jentzer, J. C., Miller, P. E., Fordyce, C. B., Lawler, P., Alviar, C. L., Sun, L. Y., Dover, D. C., Lopes, R. D., Kaul, P., van Diepen, S. 2021; 10 (7): 797-805

    Abstract

    The incidence of respiratory failure and use of invasive or non-invasive mechanical ventilation (MV) in the cardiac intensive care units (CICUs) is increasing. While institutional MV volumes are associated with reduced mortality in medical and surgical ICUs, this volume-mortality relationship has not been characterized in the CICU.National population-based data were used to identify patients admitted to CICUs (2005-2015) requiring MV in Canada. CICUs were categorized into low (≤100), intermediate (101-300), and high (>300) volume centres based on spline knots identified in the association between annual MV volume and mortality. Outcomes of interest included all-cause in-hospital mortality, the proportion of patients requiring prolonged MV (>96 h) and CICU length of stay (LOS). Among 47 173 CICU admissions requiring MV, 89.5% (42 200) required invasive MV. The median annual CICU MV volume was 43 (inter-hospital range 1-490). Compared to low-volume centres (35.9%), in-hospital mortality was lower in intermediate [29.2%, adjusted odds ratio (aOR) 0.84, 95% confidence interval (CI) 0.72-0.97, P = 0.019] and high-volume (18.2%; aOR 0.82, 95% CI 0.66-1.02, P = 0.076) centres. Prolonged MV was higher in low-volume (29.2%) compared to high-volume (14.8%, aOR 0.70, 95% CI 0.55-0.89, P = 0.003) and intermediate-volume (23.0%, aOR 0.85, 95% CI 0.68-1.06, P = 0.14] centres. Mortality and prolonged MV were lower in percutaneous coronary intervention (PCI)-capable and academic centres, but a shorter CICU LOS was observed only in subgroup of PCI-capable intermediate- and high-volume hospitals.In a national dataset, we observed that higher CICU MV volumes were associated with lower incidence of in-hospital mortality, prolonged MV, and CICU LOS. Our data highlight the need for minimum MV volume benchmarks for CICUs caring for patients with respiratory failure.

    View details for DOI 10.1093/ehjacc/zuab055

    View details for PubMedID 34318875

    View details for PubMedCentralID PMC9067446

  • Derivation and validation of a clinical model to predict death or cardiac hospitalizations while on the cardiac surgery waitlist. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne Sun, L. Y., Eddeen, A. B., Wijeysundera, H. C., Mamas, M. A., Tam, D. Y., Mesana, T. G. 2021; 193 (34): E1333-E1340

    Abstract

    Waitlist management is a global challenge. For patients with severe cardiovascular diseases awaiting cardiac surgery, prolonged wait times are associated with unplanned hospitalizations. To facilitate evidence-based resource allocation, we derived and validated a clinical risk model to predict the composite outcome of death and cardiac hospitalization of patients on the waitlist for cardiac surgery.We used the CorHealth Ontario Registry and linked ICES health care administrative databases, which have information on all Ontario residents. We included patients 18 years or older who waited at home for coronary artery bypass grafting, valvular or thoracic aorta surgeries between 2008 and 2019. The primary outcome was death or an unplanned cardiac hospitalizaton, defined as nonelective admission for heart failure, myocardial infarction, unstable angina or endocarditis. We randomly divided two-thirds of these patients into derivation and one-third into validation data sets. We derived the model using a multivariable Cox proportional hazard model with backward stepwise variable selection.Among 62 375 patients, 41 729 patients were part of the derivation data set and 20 583 were part of the validation data set. Of the total, 3033 (4.9%) died or had an unplanned cardiac hospitalization while waiting for surgery. The area under the curve of our model at 15, 30, 60 and 89 days was 0.85, 0.82, 0.81 and 0.80, respectively, in the derivation cohort and 0.83, 0.80, 0.78 and 0.78, respctively, in the validation cohort. The model calibrated well at all time points.We derived and validated a clinical risk model that provides accurate prediction of the risk of death and unplanned cardiac hospitalization for patients on the cardiac surgery waitlist. Our model could be used for quality benchmarking and data-driven decision support for managing access to cardiac surgery.

    View details for DOI 10.1503/cmaj.210170

    View details for PubMedID 34462293

    View details for PubMedCentralID PMC8432314

  • Impact of surgeon and anaesthesiologist sex on patient outcomes after cardiac surgery: a population-based study. BMJ open Sun, L. Y., Boet, S., Chan, V., Lee, D. S., Mesana, T. G., Bader Eddeen, A., Etherington, C. 2021; 11 (8): e051192

    Abstract

    Effective teamwork between anaesthesiologists and surgeons is essential for optimising patient safety in the cardiac operating room. While many factors may influence the relationship between these two physicians, the role of sex and gender have yet to be investigated.We sought to determine the association between cardiac physician team sex discordance and patient outcomes.We performed a population-based, retrospective cohort study.Adult patients who underwent coronary artery bypass grafting (CABG) and/or aortic, mitral or tricuspid valve surgery between 2008 and 2018 in Ontario, Canada.The primary outcome was all-cause 30-day mortality. Secondary outcomes included major adverse cardiovascular events at 30 days and hospital and intensive care unit lengths of stay (LOS). Mixed effects logistic regression was used for categorical outcomes and Poisson regression for continuous outcomes.79 862 patients underwent cardiac surgery by 98 surgeons (11.2% female) and 279 anaesthesiologists (23.3% female); 19 893 (24.9%) were treated by sex-discordant physician teams. Physician sex discordance was not associated with overall patient mortality or LOS; however, patients who underwent isolated CABG experienced longer hospital LOS when treated by an all-male physician team as compared with an all-female team (adjusted OR=1.07; p=0.049). When examining the impact of individual physician sex, the length of hospital stay was longer when isolated CABG procedures were attended by a male surgeon (OR=1.10; p=0.004) or anaesthesiologist (OR=1.02; p=0.01).Patient mortality and length of stay after cardiac surgery may vary by sex concordance of the attending surgeon-anaesthesiologist team. Further research is needed to examine the underlying mechanisms of these observed relationships.

    View details for DOI 10.1136/bmjopen-2021-051192

    View details for PubMedID 34433609

    View details for PubMedCentralID PMC8388286

  • Implications of the ISCHEMIA trial on the practice of surgical myocardial revascularization. The Journal of thoracic and cardiovascular surgery Ruel, M., Sun, L. Y., Farkouh, M. E., Gaudino, M. F. 2021; 162 (1): 90-99

    View details for DOI 10.1016/j.jtcvs.2020.07.123

    View details for PubMedID 33069424

  • Predictors of cumulative cost for patients with severe aortic stenosis referred for surgical or transcatheter aortic valve replacement: a population-based study in Ontario, Canada. European heart journal. Quality of care & clinical outcomes Sunner, M., Qiu, F., Manoragavan, R., Roifman, I., Tam, D. Y., Fremes, S. C., Sun, L., Rahal, M., Woodward, G., Austin, P. C., Wijeysundera, H. C. 2021; 7 (3): 265-272

    Abstract

    Transcatheter aortic valve replacement (TAVR) as an alternative to surgical aortic valve replacement (SAVR) has transformed severe aortic stenosis (AS) management. Our aim was understand AS cost drivers from referral to 1-year post-procedure.We identified patients referred for either TAVR/SAVR between 1 April 2015 and 31 March 2018, with follow-up until 31 March 2019 in Ontario, Canada. We stratified costs into (i) a referral phase, (ii) a procedural phase from the procedure date to 60 days post-procedure, and (iii) post-procedure phase from 61 days to 1 year. Multivariable regression modelling using generalized linear models with a log link gamma distribution was used to identify cost drivers in each phase. The study cohort included 12 086 AS patients; 4832 were referred for TAVR and 7254 were referred for SAVR. The median cost for TAVR was higher than SAVR in the referral ($3593 vs. $2944) and post-procedural ($5938 vs. $3257) phases. In contrast, for the procedural phase, SAVR had a median cost of $29 756 vs. $27 907 for TAVR. Predictors of high cost in the referral phase were longer wait-time, and an urgent in-hospital procedure. In the procedural phase, procedural complications were the major drivers of higher cost. In the post-procedural phase, patient co-morbidities were the major drivers, specifically dialysis, liver disease, cancer, peripheral vascular disease, and diabetes mellitus.We identified distinct patterns of cost accumulation and modifiable drivers for SAVR compared with TAVR; these drivers may guide clinical and health policy decisions to make AS care more efficient.

    View details for DOI 10.1093/ehjqcco/qcaa094

    View details for PubMedID 33351143

  • Disability-free survival after major cardiac surgery: a population-based retrospective cohort study. CMAJ open Sun, L. Y., Eddeen, A. B., Mesana, T. G. 2021; 9 (2): E384-E393

    Abstract

    Cardiovascular research has traditionally been dedicated to "tombstone" outcomes, with little attention dedicated to the patient's perspective. We evaluated disability-free survival as a patient-defined outcome after cardiac surgery.We conducted a retrospective cohort study of patients aged 40 years and older who underwent coronary artery bypass grafting (CABG) or single or multiple valve (aortic, mitral, tricuspid) surgery in Ontario between Oct. 1, 2008, and Dec. 31, 2016. The primary outcome was disability (a composite of stroke, 3 or more nonelective hospital admissions and admission to a long-term care facility) within 1 year after surgery. We assessed the procedure-specific risk of disability using cumulative incidence functions, and the relative effect of covariates on the subdistribution hazard using Fine and Gray models.The study included 72 824 patients. The 1-year incidence of disability and death was 2431 (4.6%) and 1839 (3.5%) for CABG, 677 (6.5%) and 539 (5.2%) for single valve, 118 (9.0%) and 140 (10.7%) for multiple valve, 718 (9.0%) and 730 (9.2%) for CABG and single valve, and 87 (13.1%) and 94 (14.1%) for CABG and multiple valve surgery, respectively. With CABG as the reference group, the adjusted hazard ratios for disability were 1.34 (95% confidence interval [CI] 1.21-1.48) after single valve, 1.43 (95% CI 1.18-1.75) after multiple valve, 1.38 (95% CI 1.26-1.51) after CABG and single valve, and 1.78 (95% CI 1.43-2.23) after CABG and multiple valve surgery. Combined CABG and multiple valve surgery, heart failure, creatinine 180 μmol/L or greater, alcohol use disorder, dementia and depression were independent risk factors for disability.The cumulative incidence of disability was lowest after CABG and highest after combined CABG and multiple valve surgery. Our findings point to a need for models that predict personalized disability risk to enable better patient-centred care.

    View details for DOI 10.9778/cmajo.20200096

    View details for PubMedID 33863796

    View details for PubMedCentralID PMC8084566

  • Patients With Severely Reduced Ejection Fraction Undergoing Revascularization-Is Something Missing?-Reply. JAMA cardiology Sun, L. Y., Gaudino, M., Ruel, M. 2021; 6 (2): 242

    View details for DOI 10.1001/jamacardio.2020.4887

    View details for PubMedID 33052370

  • Derivation of Patient-Defined Adverse Cardiovascular and Noncardiovascular Events Through a Modified Delphi Process. JAMA network open Sun, L. Y., Rodger, J., Duffett, L., Tulloch, H., Crean, A. M., Chong, A. Y., Rubens, F. D., MacPhee, E., Mesana, T. G., Lee, D. S., van Diepen, S., Beanlands, R. S., Ruel, M., Julien, A. M., Bilodeau, J. 2021; 4 (1): e2032095

    Abstract

    There is little evidence to support patient-centered outcomes in patients with cardiovascular disease.To derive patient-defined adverse cardiovascular and noncardiovascular events (PACE) through a consensus-based process.This pan-Canadian, consensus-based, qualitative study used an iterative Delphi method to achieve consensus within a 35-member panel consisting of patients with cardiovascular diseases and their caregivers and clinicians. The process included 4 rounds of online questionnaires, followed by an in-person final consensus meeting. Data analysis was performed in September 2019.Defining PACE as a 5-item composite outcome.Thirty-five potential panelists consented to participate, including 11 clinicians (8 men [73%]) and 24 patients and caregivers (13 men [54%]). Twenty-nine (83%), 28 (80%), 26 (74%), and 23 (66%) of the panelists participated in each of respective the online rounds. A shortlist of 11 patient-defined items was further refined at the in-person meeting, which 20 of the panelists attended. The PACE definition that was decided through the consensus process was a composite of severe stroke necessitating hospitalization for 14 days or longer or inpatient rehabilitation, ventilator dependence, new onset or worsening heart failure, nursing home admission, or new onset dialysis.This study defined PACE as a versatile, patient-centered outcome through a consensus process with input from patients, caregivers, and clinicians. Given the paucity of patient-centered outcomes in cardiovascular research, PACE may be considered as a potential outcome after methodological evaluation of its reliability.

    View details for DOI 10.1001/jamanetworkopen.2020.32095

    View details for PubMedID 33394003

    View details for PubMedCentralID PMC7783543

  • Trends in sex-based differences in outcomes following coronary artery bypass grafting in the United States between 2004 and 2015. International journal of cardiology Mohamed, W., Mohamed, M. O., Hirji, S., Ouzounian, M., Sun, L. Y., Coutinho, T., Percy, E., Mamas, M. A. 2020; 320: 42-48

    Abstract

    The present study sought to examine the trends of sex-based differences in clinical outcomes after coronary artery bypass grafting (CABG), an area in which the current evidence remains limited.All US adults hospitalized for first-time isolated CABG in the National Inpatient Sample database between 2004 and 2015 were included, stratified by sex. Multivariable regression analysis examined the adjusted odds ratios (OR) of postoperative in-hospital complications in females versus males. Trend analyses of sex-based differences in in-hospital post-operative complications over the study period were performed.Overall, 2,537,767 CABG procedures were analyzed, including 27.9% (n = 708,459) females. Female sex was associated with an increase in adjusted odds of all-cause mortality (OR 1.43 95% CI 1.40, 1.45), stroke (OR 1.34 95% CI 1.32, 1.37) and thoracic complications (OR 1.28 95% CI 1.27, 1.29) and lower odds of all-cause bleeding (OR 0.87 95% CI 0.86, 0.89) compared to males. Trend analysis revealed these sex differences to be persistent for mortality, stroke and thoracic complications (ptrend = non-significant) but eliminated for bleeding over the study period (ptrend < 0.001).Despite technical advances over the 12-year period, worse post-operative outcomes including death, stroke, and thoracic complications have persisted in female patients after CABG. These findings are concerning and underscore the need for risk reduction strategies to address this disparity gap.

    View details for DOI 10.1016/j.ijcard.2020.07.039

    View details for PubMedID 32735897

  • Sex-specific temporal trends in ambulatory heart failure incidence, mortality and hospitalisation in Ontario, Canada from 1994 to 2013: a population-based cohort study. BMJ open Sun, L. Y., Mielniczuk, L. M., Liu, P. P., Beanlands, R. S., Chih, S., Davies, R., Coutinho, T., Lee, D. S., Austin, P. C., Bader Eddeen, A., Tu, J. V. 2020; 10 (11): e044126

    Abstract

    To examine the temporal trends in mortality and heart failure (HF) hospitalisation in ambulatory patients following a new diagnosis of HF.Retrospective cohort study SETTING: Outpatient PARTICIPANTS: Ontario residents who were diagnosed with HF in an outpatient setting between 1994 and 2013.The primary outcome was all-cause mortality within 1 year of diagnosis and the secondary outcome was HF hospitalisation within 1 year. Risks of mortality and hospitalisation were calculated using the Kaplan-Meier method and the relative hazard of death was assessed using multivariable Cox proportional hazard models.A total of 352 329 patients were studied (50% female). During the study period, there was a greater decline in age standardised 1-year mortality rates (AMR) in men (33%) than in women (19%). Specifically, female AMR at 1 year was 10.4% (95% CI 9.1% to 12.0%) in 1994 and 8.5% (95% CI 7.5% to 9.5%) in 2013, and male AMR at 1 year was 12.3% (95% CI 11.1% to 13.7%) in 1994 and 8.3% (95% CI 7.5% to 9.1%) in 2013. Conversely, age standardised HF hospitalisation rates declined in men (11.4% (95% CI 10.1% to 12.9%) in 1994 and 9.1% (95% CI 8.2% to 10.1%) in 2013) but remained unchanged in women (9.7% (95% CI 8.3% to 11.3%) in 1994 and 9.8% (95% CI 8.6% to 11.0%) in 2013).Among patients with HF over a 20-year period, there was a greater improvement in the prognosis of men compared with women. Further research should focus on the determinants of this disparity and ways to reduce this gap in outcomes.

    View details for DOI 10.1136/bmjopen-2020-044126

    View details for PubMedID 33243819

    View details for PubMedCentralID PMC7692840

  • Derivation and Validation of a Clinical Model to Predict Intensive Care Unit Length of Stay After Cardiac Surgery. Journal of the American Heart Association Sun, L. Y., Bader Eddeen, A., Ruel, M., MacPhee, E., Mesana, T. G. 2020; 9 (21): e017847

    Abstract

    Background Across the globe, elective surgeries have been postponed to limit infectious exposure and preserve hospital capacity for coronavirus disease 2019 (COVID-19). However, the ramp down in cardiac surgery volumes may result in unintended harm to patients who are at high risk of mortality if their conditions are left untreated. To help optimize triage decisions, we derived and ambispectively validated a clinical score to predict intensive care unit length of stay after cardiac surgery. Methods and Results Following ethics approval, we derived and performed multicenter valida tion of clinical models to predict the likelihood of short (≤2 days) and prolonged intensive care unit length of stay (≥7 days) in patients aged ≥18 years, who underwent coronary artery bypass grafting and/or aortic, mitral, and tricuspid value surgery in Ontario, Canada. Multivariable logistic regression with backward variable selection was used, along with clinical judgment, in the modeling process. For the model that predicted short intensive care unit stay, the c-statistic was 0.78 in the derivation cohort and 0.71 in the validation cohort. For the model that predicted prolonged stay, c-statistic was 0.85 in the derivation and 0.78 in the validation cohort. The models, together termed the CardiOttawa LOS Score, demonstrated a high degree of accuracy during prospective testing. Conclusions Clinical judgment alone has been shown to be inaccurate in predicting postoperative intensive care unit length of stay. The CardiOttawa LOS Score performed well in prospective validation and will complement the clinician's gestalt in making more efficient resource allocation during the COVID-19 period and beyond.

    View details for DOI 10.1161/JAHA.120.017847

    View details for PubMedID 32990156

    View details for PubMedCentralID PMC7763427

  • Impact of physician's sex/gender on processes of care, and clinical outcomes in cardiac operative care: a systematic review. BMJ open Etherington, N., Deng, M., Boet, S., Johnston, A., Mansour, F., Said, H., Zheng, K., Sun, L. Y. 2020; 10 (9): e037139

    Abstract

    This systematic review aimed to assess the role of physician's sex and gender in relation to processes of care and/or clinical outcomes within the context of cardiac operative care.A systematic review.Searches were conducted in PsycINFO, Embase and Medline from inception to 6 September 2018. The reference lists of relevant systematic reviews and included studies were also searched.Quantitative studies of any design were included if they were published in English or French, involved patients of any age undergoing a cardiac surgical procedure and specifically assessed differences in processes of care or clinical patient outcomes by physician's sex or gender. Studies were screened in duplicate by two pairs of independent reviewers.Processes of care, patient morbidity and patient mortality.The search yielded 2095 publications after duplicate removal, of which two were ultimately included. These studies involved various types of surgery, including cardiac. One study found that patients treated by female surgeons compared with male surgeons had a lower 30-day mortality. The other study, however, found no differences in patient outcomes by surgeon's sex. There were no studies that investigated anaesthesiologist's sex/gender. There were also no studies investing physician's sex or gender exclusively in the cardiac operating room.The limited data surrounding the impact of physician's sex/gender on the outcomes of cardiac surgery inhibits drawing a robust conclusion at this time. Results highlight the need for primary research to determine how these factors may influence cardiac operative practice, in order to optimise provider's performance and improve outcomes in this high-risk patient group.

    View details for DOI 10.1136/bmjopen-2020-037139

    View details for PubMedID 32994237

    View details for PubMedCentralID PMC7526284

  • Long-Term Survival After Surgical or Percutaneous Revascularization in Patients With Diabetes and Multivessel Coronary Disease. Journal of the American College of Cardiology Tam, D. Y., Dharma, C., Rocha, R., Farkouh, M. E., Abdel-Qadir, H., Sun, L. Y., Wijeysundera, H. C., Austin, P. C., Udell, J. A., Gaudino, M., Fremes, S. E., Lee, D. S. 2020; 76 (10): 1153-1164

    Abstract

    There remains a paucity of real-world observational evidence comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) in patients with diabetes and multivessel coronary artery disease (CAD).This study compared early and long-term outcomes of PCI versus CABG in patients with diabetes.Clinical and administrative databases in Ontario, Canada were linked to obtain records of all patients with diabetes with angiographic evidence of 2- or 3-vessel CAD who were treated with either PCI or isolated CABG from 2008 to 2017. A 1:1 propensity score match was performed to account for baseline differences. All-cause mortality and the composite of myocardial infarction, repeat revascularization, stroke, or death (termed major cardiovascular and cerebrovascular events [MACCEs]) were compared between the matched groups using a stratified log-rank test and Cox proportional hazards model.A total of 4,519 and 9,716 patients underwent PCI and CABG, respectively. Before matching, patients who underwent CABG were significantly younger (age 65.7 years vs. 68.3 years), were more likely to be men (78% vs. 73%) and had more severe CAD. Propensity score matching based on 23 baseline covariates yielded 4,301 well-balanced pairs. There was no difference in early mortality between PCI and CABG (2.4% vs. 2.3%; p = 0.721) after matching. The median and maximum follow-ups were 5.5 and 11.5 years, respectively. All-cause mortality (hazard ratio [HR]: 1.39; 95% CI: 1.28 to 1.51) and overall MACCEs (HR: 1.99; 95% CI: 1.86 to 2.12) were significantly higher with PCI compared with CABG.In patients with multivessel CAD and diabetes, CABG was associated with improved long-term mortality and freedom from MACCEs compared with PCI.

    View details for DOI 10.1016/j.jacc.2020.06.052

    View details for PubMedID 32883408

    View details for PubMedCentralID PMC7861124

  • Coronary Artery Disease in Patients With Cancer: It's Always the Small Pieces That Make the Bigger Picture. Mayo Clinic proceedings Mamas, M. A., Brown, S. A., Sun, L. Y. 2020; 95 (9): 1819-1821

    View details for DOI 10.1016/j.mayocp.2020.07.006

    View details for PubMedID 32861320

  • Can Biomarkers Provide Right Ventricular-Specific Prognostication in the Perioperative Setting? Journal of cardiac failure Jabagi, H., Ruel, M., Sun, L. Y. 2020; 26 (9): 776-780

    Abstract

    Since the introduction of biomarkers in the late 1980s, considerable research has been dedicated to their validation and application. As a result, many biomarkers are now commonly used in clinical practice. However, the role of biomarkers in the prediction of right ventricular failure (RVF) and in the prognostication for patients with RVF remains underexplored. Barriers include a lack of awareness of the importance of right ventricular function, especially in the perioperative setting, as well as a lack of reproducible means to assess right ventricular function in this setting. We provide an overview of biomarkers with right ventricular prognostic capabilities that could be further explored in patients expecting cardiac surgery, who are notoriously susceptible to developing RVF. We discuss biomarkers' mechanistic pathways and highlight their potential strengths and weaknesses in use in research and clinical care.

    View details for DOI 10.1016/j.cardfail.2019.09.007

    View details for PubMedID 31539620

  • Direct Implant of a Transcatheter Aortic Valve Prosthesis for Prosthetic Mitral Valve Endocarditis. CJC open Hayatsu, Y., Dryden, A., Messika-Zeitoun, D., Sun, L. Y., Mesana, T., Ruel, M. 2020; 2 (4): 303-305

    Abstract

    We describe the case of a 64-year-old woman presenting with severe prosthetic mitral valve endocarditis 1 year after coronary artery bypass grafting and double valve replacement. Echocardiogram revealed high-pressure gradients through the bioprosthetic MV with a bulky vegetation. As the patient had presented operative difficulties due to severe mitral annular calcification, was in renal failure, and in the absence of any perivalvular involvement, an open-heart surgical catheter-based valve implantation was successfully performed after removal of the infected leaflets, leaving the stent frame and sewing cuff behind. Albeit controversial, this case represents an alternative approach for select high-risk reoperative mitral cases with mitral annular calcification.

    View details for DOI 10.1016/j.cjco.2020.03.003

    View details for PubMedID 32695980

    View details for PubMedCentralID PMC7365828

  • Incorporation of renal function in mortality risk assessment for pulmonary arterial hypertension. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation Zelt, J. G., Hossain, A., Sun, L. Y., Mehta, S., Chandy, G., Davies, R. A., Contreras-Dominguez, V., Dunne, R., Doyle-Cox, C., Wells, G., Stewart, D. J., Mielniczuk, L. M. 2020; 39 (7): 675-685

    Abstract

    Risk assessment is important for prognostication and individualized treatment decisions for patients with pulmonary arterial hypertension (PAH). The purpose was (1) to compare contemporary risk assessment tools and (2) to determine the prognostic significance of risk parameters of kidney function and whether they can further improve risk prediction for patients with PAH.We identified a cohort of treatment-naive patients (n = 211) who received an incident diagnosis of PAH at the University of Ottawa Heart Institute. Using demographics, disease characteristics, and hemodynamic data at diagnosis, we categorized patients as low, intermediate, or high risk according to current European guidelines (European Society of Cardiology [ESC]) and registry to evaluate early and long-term pulmonary arterial hypertension disease management (REVEAL) risk scores. The primary end-point was transplant-free survival (TFS).Patients were predominantly women (64.6%) with World Health Organization function Class III symptoms (66.5%). The median TFS was 7.09 years. There was little agreement between ESC- and REVEAL-based risk estimates (weighted kappa = 0.21-0.34). Although both the ESC (log-rank, p = 0.0002) and REVEAL algorithms stratified TFS risk (p < 0.0001), the REVEAL score provided superior discrimination (C-statistic = 0.70 vs 0.59, p = 0.004). Renal function at diagnosis (p < 0.0001) and Δ renal function at 6 months (p < 0.0001) were identified as novel risk parameters and served to reclassify some patients in the intermediate-risk category to a lower or higher risk stratum (p < 0.0001).REVEAL-based strategies provide superior TFS risk discrimination to ESC/European Respiratory Society-based approaches. However, the classification of intermediate-risk patients varied significantly across tools. We demonstrate the importance of renal function, which further improved the stratification of risk in patients with PAH, particularly in patients who are considered intermediate risk.

    View details for DOI 10.1016/j.healun.2020.03.026

    View details for PubMedID 32336606

  • The Impact of Preoperative Risk on the Association between Hypotension and Mortality after Cardiac Surgery: An Observational Study. Journal of clinical medicine Ristovic, V., de Roock, S., Mesana, T. G., van Diepen, S., Sun, L. Y. 2020; 9 (7)

    Abstract

    Despite steady improvements in cardiac surgery-related outcomes, our understanding of the physiologic mechanisms leading to perioperative mortality remains incomplete. Intraoperative hypotension is an important risk factor for mortality after noncardiac surgery but remains relatively unexplored in the context of cardiac surgery. We examined whether the association between intraoperative hypotension and in-hospital mortality varied by patient and procedure characteristics, as defined by the validated Cardiac Anesthesia Risk Evaluation (CARE) mortality risk score.We conducted a retrospective cohort study of consecutive adult patients who underwent cardiac surgery requiring cardiopulmonary bypass (CPB) from November 2009-March 2015. Those who underwent off-pump, thoracic aorta, transplant and ventricular assist device procedures were excluded. The primary outcome was in-hospital mortality. Hypotension was categorized by mean arterial pressure (MAP) of <55 and between 55-64 mmHg before, during and after CPB. The relationship between hypotension and death was modeled using multivariable logistic regression in the intermediate and high-risk groups.Among 6627 included patients, 131 (2%) died in-hospital. In-hospital mortality in patients with CARE scores of 1, 2, 3, 4 and 5 was 0 (0%), 7 (0.3%), 35 (1.3%), 41 (4.6%) and 48 (13.6%), respectively. In the intermediate-risk group (CARE = 3-4), MAP < 65 mmHg post-CPB was associated with increased odds of death in a dose-dependent fashion (adjusted OR 1.30, 95% CI 1.13-1.49, per 10 min exposure to MAP < 55 mmHg, p = 0.002; adjusted OR 1.18 [1.07-1.30] per 10 min exposure to MAP 55-64 mmHg, p = 0.001). We did not observe an association between hypotension and mortality in the high-risk group (CARE = 5).Post-CPB hypotension is a potentially modifiable risk factor for mortality in intermediate-risk patients. Our findings provide impetus for clinical trials to determine if hemodynamic goal-directed therapies could improve survival in these patients.

    View details for DOI 10.3390/jcm9072057

    View details for PubMedID 32629948

    View details for PubMedCentralID PMC7408639

  • Long-term Outcomes in Patients With Severely Reduced Left Ventricular Ejection Fraction Undergoing Percutaneous Coronary Intervention vs Coronary Artery Bypass Grafting. JAMA cardiology Sun, L. Y., Gaudino, M., Chen, R. J., Bader Eddeen, A., Ruel, M. 2020; 5 (6): 631-641

    Abstract

    Data are lacking on the outcomes of patients with severely reduced left ventricular ejection fraction (LVEF) who undergo revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).To compare the long-term outcomes in patients undergoing revascularization by PCI or CABG.This retrospective cohort study performed in Ontario, Canada, from October 1, 2008, and December 31, 2016, included data from Ontario residents between 40 and 84 years of age with LVEFs less than 35% and left anterior descending (LAD), left main, or multivessel coronary artery disease (with or without LAD involvement) who underwent PCI or CABG. Exclusion criteria were concomitant procedures, previous CABG, metastatic cancer, dialysis, CABG and PCI on the same day, and emergency revascularization within 24 hours of a myocardial infarction (MI). Data analysis was performed from June 2, 2018, to December 28, 2018.Revascularization by PCI or CABG.The primary outcome was all-cause mortality. Secondary outcomes were death from cardiovascular disease, major adverse cardiovascular events (MACE; defined as stroke, subsequent revascularization, and hospitalization for MI or heart failure), and each of the individual MACE.A total of 12 113 patients (mean [SD] age, 64.8 (11.0) years for the PCI group and 65.6 [9.7] years for the CABG group; 5084 (72.5%) male for the PCI group and 4229 (82.9%) male for the PCI group) were propensity score matched on 30 baseline characteristics: 2397 patients undergoing PCI and 2397 patients undergoing CABG. The median follow-up was 5.2 years (interquartile range, 5.0-5.3). Patients who received PCI had significantly higher rates of mortality (hazard ratio [HR], 1.6; 95% CI, 1.3-1.7), death from cardiovascular disease (HR 1.4, 95% CI, 1.1-1.6), MACE (HR, 2.0; 95% CI, 1.9-2.2), subsequent revascularization (HR, 3.7; 95% CI, 3.2-4.3), and hospitalization for MI (HR, 3.2; 95% CI, 2.6-3.8) and heart failure (HR, 1.5; 95% CI, 1.3-1.6) compared with matched patients who underwent CABG.In this study, higher rates of mortality and MACE were seen in patients who received PCI compared with those who underwent CABG. The findings may provide insight to physicians who are involved in decision-making for these patients.

    View details for DOI 10.1001/jamacardio.2020.0239

    View details for PubMedID 32267465

    View details for PubMedCentralID PMC7142806

  • Management of Challenging Cardiopulmonary Bypass Separation. Journal of cardiothoracic and vascular anesthesia Monaco, F., Di Prima, A. L., Kim, J. H., Plamondon, M. J., Yavorovskiy, A., Likhvantsev, V., Lomivorotov, V., Hajjar, L. A., Landoni, G., Riha, H., Farag, A. M., Gazivoda, G., Silva, F. S., Lei, C., Bradic, N., El-Tahan, M. R., Bukamal, N. A., Sun, L., Wang, C. Y. 2020; 34 (6): 1622-1635

    Abstract

    SEPARATION from cardiopulmonary bypass (CPB) after cardiac surgery is a progressive transition from full mechanical circulatory and respiratory support to spontaneous mechanical activity of the lungs and heart. During the separation phase, measurements of cardiac performance with transesophageal echocardiography (TEE) provide the rationale behind the diagnostic and therapeutic decision-making process. In many cases, it is possible to predict a complex separation from CPB, such as when there is known preoperative left or right ventricular dysfunction, bleeding, hypovolemia, vasoplegia, pulmonary hypertension, or owing to technical complications related to the surgery. Prompt diagnosis and therapeutic decisions regarding mechanical or pharmacologic support have to be made within a few minutes. In fact, a complex separation from CPB if not adequately treated leads to a poor outcome in the vast majority of cases. Unfortunately, no specific criteria defining complex separation from CPB and no management guidelines for these patients currently exist. Taking into account the above considerations, the aim of the present review is to describe the most common scenarios associated with a complex CPB separation and to suggest strategies, pharmacologic agents, and para-corporeal mechanical devices that can be adopted to manage patients with complex separation from CPB. The routine management strategies of complex CPB separation of 17 large cardiac centers from 14 countries in 5 continents will also be described.

    View details for DOI 10.1053/j.jvca.2020.02.038

    View details for PubMedID 32276758

  • Defining an Intraoperative Hypotension Threshold in Association with De Novo Renal Replacement Therapy after Cardiac Surgery. Anesthesiology Ngu, J. M., Jabagi, H., Chung, A. M., Boodhwani, M., Ruel, M., Bourke, M., Sun, L. Y. 2020; 132 (6): 1447-1457

    Abstract

    Acute kidney injury (AKI) is a frequent and deadly complication after cardiac surgery. In the absence of effective therapies, a focus on risk factor identification and modification has been the mainstay of management. The authors sought to determine the impact of intraoperative hypotension on de novo postoperative renal replacement therapy in patients undergoing cardiac surgery, hypothesizing that prolonged periods of hypotension during and after cardiopulmonary bypass (CPB) were associated with an increased risk of renal replacement therapy.Included in this single-center retrospective cohort study were adult patients who underwent cardiac surgery requiring CPB between November 2009 and April 2015. Excluded were patients who were dialysis dependent, underwent thoracic aorta or off-pump procedures, or died before receiving renal replacement therapy. Degrees of hypotension were defined by mean arterial pressure (MAP) as less than 55, 55 to 64, and 65 to 74 mmHg before, during, and after CPB. The primary outcome was de novo renal replacement therapy.Of 6,523 patient records, 336 (5.2%) required new postoperative renal replacement therapy. Each 10-min epoch of MAP less than 55 mmHg post-CPB was associated with an adjusted odds ratio of 1.13 (95% CI, 1.05 to 1.23; P = 0.002), and each 10-min epoch of MAP between 55 and 64 mmHg post-CPB was associated with an adjusted odds ratio of 1.12 (95% CI, 1.06 to 1.18; P = 0.0001) for renal replacement therapy. The authors did not observe an association between hypotension before and during CPB with renal replacement therapy.MAP less than 65 mmHg for 10 min or more post-CPB is associated with an increased risk of de novo postoperative renal replacement therapy. The association between intraoperative hypotension and AKI was weaker in comparison to factors such as renal insufficiency, heart failure, obesity, anemia, complex or emergent surgery, and new-onset postoperative atrial fibrillation. Nonetheless, post-CPB hypotension is a potentially easier modifiable risk factor that warrants further investigation.

    View details for DOI 10.1097/ALN.0000000000003254

    View details for PubMedID 32205546

  • Readmission rates following heart failure: a scoping review of sex and gender based considerations. BMC cardiovascular disorders Hoang-Kim, A., Parpia, C., Freitas, C., Austin, P. C., Ross, H. J., Wijeysundera, H. C., Tu, K., Mak, S., Farkouh, M. E., Sun, L. Y., Schull, M. J., Mason, R., Lee, D. S., Rochon, P. A. 2020; 20 (1): 223

    Abstract

    Although hospital readmission for heart failure (HF) is an issue for both men and women, little is known about differences in readmission rates by sex. Consequently, strategies to optimize readmission reduction programs and care strategies for women and men remain unclear. Our study aims were: (1) to identify studies examining readmission rates according to sex, and (2) to provide a qualitative overview of possible considerations for the impact of sex or gender.We conducted a scoping review using the Arksey and O'Malley framework to include full text articles published between 2002 and 2017 drawn from multiple databases (MEDLINE, EMBASE), grey literature (i.e. National Technical information, Duck Duck Go), and expert consultation. Eligible articles included an index heart failure episode, readmission rates, and sex/gender-based analysis.The search generated 5887 articles, of which 746 underwent full abstract text consideration for eligibility. Of 164 eligible articles, 34 studies addressed the primary outcome, 103 studies considered sex differences as a secondary outcome and 25 studies stratified data for sex. Good inter-rater agreement was reached: 83% title/abstract; 88% full text; kappa: 0.69 (95%CI: 0.53-0.85). Twelve of 34 studies reported higher heart failure readmission rates for men and six studies reported higher heart failure readmission rates for women. Using non composite endpoints, five studies reported higher HF readmission rates for men compared to three studies reporting higher HF readmission rates for women. Overall, there was heterogeneity between studies when examined by sex, but one observation emerged that was related to the timing of readmissions. Readmission rates for men were higher when follow-up duration was longer than 1 year. Women were more likely to experience higher readmission rates than men when time to event was less than 1 year.Future studies should consider different time horizons in their designs and avoid the use of composite measures, such as readmission rates combined with mortality, which are highly skewed by sex. Co-interventions and targeted post-discharge approaches with attention to sex would be of benefit to the HF patient population.

    View details for DOI 10.1186/s12872-020-01422-3

    View details for PubMedID 32408892

    View details for PubMedCentralID PMC7222562

  • Preoperative Risk, Blood Pressure, and Acute Kidney Injury. Anesthesiology Sun, L. Y. 2020; 132 (3): 416-417

    View details for DOI 10.1097/ALN.0000000000003101

    View details for PubMedID 31929330

  • The SYNTAX score according to diabetic status: What does it mean for the patient requiring myocardial revascularization? The Journal of thoracic and cardiovascular surgery Ruel, M., Sun, L. Y., Gaudino, M. F. 2020; 159 (3): 857-860

    View details for DOI 10.1016/j.jtcvs.2019.04.088

    View details for PubMedID 31204128

  • Prospective validation and refinement of the APPROACH cardiovascular surgical intensive care unit readmission score. Journal of critical care Verma, S., Southern, D. A., Raslan, I. R., Norris, C. M., Graham, M. M., Bagshaw, S. M., Nagendran, J., Maclure, T., Sun, L. Y., Chin, W. D., van Diepen, S. 2019; 54: 117-121

    Abstract

    The APPROACH cardiovascular surgical intensive care unit (CVICU) readmission score has excellent discrimination and calibration for CVICU readmission after discharge to a surgical ward; however, it has not been prospectively validated.In a prospective consecutive cohort of 805 patients ≥18 years admitted to the CVICU after coronary artery bypass and/or valvular surgery, the APPROACH CVICU readmission score was calculated at the time of discharge to a surgical ward. The study compared observed versus predicted CVICU readmission and the model discrimination was evaluated using AUC c-index. The incremental prognostic utility of 6 pre-specified prospectively collected respiratory (re-intubation, tracheostomy, oxygen at discharge) and hemodynamic variables (heart rate, systolic blood pressure, inotropes at discharge) were tested using net reclassification index (NRI) and integrated discrimination improvement (IDI).A total of 37 (4.6%) patients were readmitted to the CVICU. The median CVICU length of stay (9.0 vs 2.0 days, p < .001) and all-cause in-hospital mortality (8.1% vs 0.4%, p < .001) was higher among readmitted patients. The model had good discrimination (c-index = 0.748). Systolic blood pressure at discharge yielded the largest improvement in model discrimination (c-index = 0.782; Hosmer-Lemshow p = .749).In a prospective validation cohort, the APPROACH CVICU readmission risk score had good discrimination and could be operationalized in future research and clinical practice.

    View details for DOI 10.1016/j.jcrc.2019.08.018

    View details for PubMedID 31421527

  • Renal insufficiency and severe coronary artery disease: should coronary artery bypass grafting, off-pump coronary artery bypass grafting or percutaneous coronary intervention be performed? Current opinion in cardiology Hayatsu, Y., Ruel, M., Sun, L. Y. 2019; 34 (6): 645-649

    Abstract

    Chronic kidney disease (CKD) is an important determinant of long-term survival. However, the optimal revascularization strategy for patients with CKD is still controversial. Herein we review the impact of different treatment modalities on the outcomes of patients with CKD.CABG could confer better long-term outcomes than PCI in patients with CKD, irrespective of CKD severity. CABG as compared with PCI may be associated with improved long-term survival albeit higher short-term risk. Off-pump as compared with on-pump CABG may be associated with better short-term outcomes but no demonstrable long-term benefit. In CKD patients who are treated with PCI, the use of drug-eluting stents may be associated with better intermediate-term outcomes than bare metal stents.There is insufficient evidence to inform the optimal revascularization strategy for patients with CKD and severe coronary artery disease. CABG as compared with PCI confers greater long-term benefit but higher upfront risk. A multidisciplinary, team-based evaluation based on individual patient comorbidity, frailty and anatomical disease burden, is recommended when making treatment decisions.

    View details for DOI 10.1097/HCO.0000000000000687

    View details for PubMedID 31567443

  • The Effect of Preoperative Anemia on Patients Undergoing Cardiac Surgery: A Propensity-Matched Analysis. Seminars in thoracic and cardiovascular surgery Jabagi, H., Boodhwani, M., Tran, D. T., Sun, L., Wells, G., Rubens, F. D. 2019; 31 (2): 157-163

    Abstract

    It is unknown if anemia in the absence of transfusions is an independent risk factor for adverse outcomes in cardiac surgery, and if correction to higher hemoglobin targets impacts these outcomes. This is a retrospective review of 3848 cardiac surgery patients. Propensity matching was completed using 41 covariates. Intraoperative Anemia Analysis matched patients with or without anemia who did not receive intraoperative transfusions (n = 392/group), while Intraoperative Transfusion Analysis matched anemic patients treated conventionally with intraoperative transfusions to end cardiopulmonary bypass hemoglobin greater or less than 95 g/L (n = 261/group). Outcomes of death, renal failure, and 2 composite outcomes were assessed using paired analysis techniques. Study composite 1 consisted of prolonged ventilation, renal failure, myocardial infarction, stroke, or deep sternal wound infection, while composite 2 was the TRICS-III composite. In the Intraoperative Anemia Analysis, anemia was associated with mortality (P = 0.034), stroke (P = 0.021), renal failure (P = 0.015), and a significant increase in the composite measure (control 8.7% vs anemia 16.1%, P = 0.002). These findings were unchanged in patients who did not receive any postoperative transfusions. The Intraoperative Transfusion Analysis showed no difference in mortality or the composite outcome between groups. There was a significant increase in low cardiac output in the lower threshold group (P = 0.001). There were no differences in outcomes between those who did and did not receive postoperative transfusions (P > 0.05). Preoperative anemia in the absence of transfusions is a risk factor for morbidity and mortality after cardiac surgery, and there is no evidence that transfusion to higher end cardiopulmonary bypass hemoglobin levels impacted this risk.

    View details for DOI 10.1053/j.semtcvs.2018.09.015

    View details for PubMedID 30273647

  • Ethnic differences in acute heart failure outcomes in Ontario. International journal of cardiology Sun, L. Y., Kimmoun, A., Takagi, K., Liu, P. P., Bader Eddeen, A., Mebazaa, A. 2019; 291: 177-182

    Abstract

    Previous studies have identified ethnic differences in outcomes after episodes of acute heart failure in natives of Asia as compared to those of Europe. Whether these ethnic differences in outcomes would still exist, years after migration to a different geographical and cultural setting remain unclear. We investigated the one-year mortality after an episode of acute heart failure admission in Ontario residents of South Asian and Chinese descent as compared to the General Population.We conducted a population-based, retrospective cohort study of adult Ontarions who were hospitalized for AHF between April 1, 2010 and March 31, 2016. Ethnicity was categorized using validated surname-based algorithms. The primary outcome was all-cause one-year mortality. Mortality rates were calculated using the Kaplan-Meier method. The relative hazard of death was assessed using a multivariable Cox proportional hazard model.Of 82,125 patients, 1287 (1.6%) were Chinese, 1662 (2.0%) were South Asians, and the remaining 79,176 (96.4%) were of the General Population. The risk of mortality was markedly lower amongst South Asians (adjusted HR 0.81, 95% CI [0.73-0.89]) relative to the General Population. There was no statistically significant difference in the risk of mortality between Chinese and the General Population (adjusted HR 1.00 [0.91-1.10]). In addition, guideline-directed medical therapies were associated with similar survival benefit in patients of all three ethnic origins.We found a lower risk of one-year mortality after acute heart failure hospitalization amongst South Asians compared to Chinese and the General Population, and similar benefit of medical therapy in all three groups. Further studies are needed to explore the etiologies of these ethnic disparities to truly improve outcomes at the population level.

    View details for DOI 10.1016/j.ijcard.2019.05.043

    View details for PubMedID 31153653

  • Sex Differences in Long-Term Survival After Major Cardiac Surgery: A Population-Based Cohort Study. Journal of the American Heart Association Johnston, A., Mesana, T. G., Lee, D. S., Eddeen, A. B., Sun, L. Y. 2019; 8 (17): e013260

    Abstract

    Background Little attention has been paid to the importance of sex in the long-term prognosis of patients undergoing cardiac surgery. Methods and Results We conducted a retrospective cohort study of Ontario residents, aged ≥40 years, who underwent coronary artery bypass grafting (CABG) and/or aortic, mitral, or tricuspid valve surgery between October 1, 2008, and December 31, 2016. The primary outcome was all-cause mortality. The mortality rate in each surgical group was calculated using the Kaplan-Meier method. The risk of death was assessed using multivariable Cox proportional hazard models. Sex-specific mortality risk factors were identified using multiplicative interaction terms. A total of 72 824 patients were included in the study (25% women). The median follow-up period was 5 (interquartile range, 3-7) years. The long-term age-standardized mortality rate was lowest in patients who underwent isolated CABG and highest among those who underwent combined CABG/multiple valve surgery. Women had significantly higher age-standardized mortality rate than men after CABG and combined CABG/mitral valve surgery. Men had lower rates of long-term mortality than women after isolated mitral valve repair, whereas women had lower rates of long-term mortality than men after isolated mitral valve replacement. We observed a statistically significant association between female sex and long-term mortality after adjustment for key risk factors. Conclusions Female sex was associated with long-term mortality after cardiac surgery. Perioperative optimization and long-term follow-up should be tailored to younger women with a history of myocardial infarction and percutaneous coronary intervention and older men with a history of chronic obstructive pulmonary disease and depression.

    View details for DOI 10.1161/JAHA.119.013260

    View details for PubMedID 31438770

    View details for PubMedCentralID PMC6755832

  • The Current Role of Viability Imaging to Guide Revascularization and Therapy Decisions in Patients With Heart Failure and Reduced Left Ventricular Function. The Canadian journal of cardiology Kandolin, R. M., Wiefels, C. C., Mesquita, C. T., Chong, A. Y., Boland, P., Glineur, D., Sun, L., Beanlands, R. S., Mielniczuk, L. M. 2019; 35 (8): 1015-1029

    Abstract

    This review describes the current evidence and controversies for viability imaging to direct revascularization decisions and the impact on patient outcomes. Balancing procedural risks and possible benefit from revascularization is a key question in patients with heart failure of ischemic origin (IHF). Different stages of ischemia induce adaptive changes in myocardial metabolism and function. Viable but dysfunctional myocardium has the potential to recover after restoring blood flow. Modern imaging techniques demonstrate different aspects of viable myocardium; perfusion (single-photon emission computed tomography [SPECT], positron emission tomography [PET], cardiovascular magnetic resonance [CMR]), cell metabolism (PET), cell membrane integrity and mitochondrial function (201Tl and 99mTc-based SPECT), contractile reserve (stress echocardiography, CMR) and scar (CMR). Observational studies suggest that patients with IHF and significant viable myocardium may benefit from revascularization compared with medical treatment alone but that in patients without significant viability, revascularization appears to offer no survival benefit or could even worsen the outcome. This was not supported by 2 randomized trials (Surgical Treatment for Ischemic Heart Failure [STICH] and PET and Recovery Following Revascularization [PARR] -2) although post-hoc analyses suggest that benefit can be achieved if decisions had been strictly based on viability imaging recommendations. Based on current evidence, viability testing should not be the routine for all patients with IHF considered for revascularization but rather integrated with clinical data to guide decisions on revascularization of high-risk patients with comorbidities.

    View details for DOI 10.1016/j.cjca.2019.04.029

    View details for PubMedID 31376903

  • Hypotension and Stroke in Cardiac Surgery: Reply. Anesthesiology Sun, L. Y., Ruel, M. 2019; 131 (1): 217-218

    View details for DOI 10.1097/ALN.0000000000002787

    View details for PubMedID 31219865

  • Post-Operative Calcium-Channel Blocker Use After Radial Artery Grafting: Do We Now Have a Definitive Answer? Journal of the American College of Cardiology Ruel, M., Sun, L. Y. 2019; 73 (18): 2307-2309

    View details for DOI 10.1016/j.jacc.2019.02.053

    View details for PubMedID 31072575

  • Biomarkers in the Diagnosis, Management, and Prognostication of Perioperative Right Ventricular Failure in Cardiac Surgery-Are We There Yet? Journal of clinical medicine Jabagi, H., Mielniczuk, L. M., Liu, P. P., Ruel, M., Sun, L. Y. 2019; 8 (4)

    Abstract

    Right ventricular failure (RVF) is a major risk factor for end organ morbidity and mortality following cardiac surgery. Perioperative RVF is difficult to predict and detect, and to date, no convenient, accurate, or reproducible measure of right ventricular (RV) function is available. Few studies have examined the use of biomarkers in RVF, and even fewer have examined their utility in the perioperative setting of patients undergoing cardiac surgery. Of the available classes of biomarkers, this review focuses on biomarkers of (1) inflammation and (2) myocyte injury/stress, due to their superior potential in perioperative RV assessment, including Galectin 3, ST2/sST2, CRP, cTN/hs-cTn, and BNP/NT-proBNP. This review was performed to help highlight the importance of perioperative RV function in patients undergoing cardiac surgery, to review the current modalities of RV assessment, and to provide a review of RV specific biomarkers and their potential utilization in the clinical and perioperative setting in cardiac surgery. Based on current evidence, we suggest the potential utility of ST2, sST2, Gal-3, CRP, hs-cTn, and NT-proBNP in predicting and detecting RVF in cardiac surgery patients, as they encompass the multifaceted nature of perioperative RVF and warrant further investigation to establish their clinical utility.

    View details for DOI 10.3390/jcm8040559

    View details for PubMedID 31027170

    View details for PubMedCentralID PMC6517903

  • Utility of Novel Cardiorenal Biomarkers in the Prediction and Early Detection of Congestive Kidney Injury Following Cardiac Surgery. Journal of clinical medicine Zelt, J. G., Mielniczuk, L. M., Liu, P. P., Dupuis, J. Y., Chih, S., Akbari, A., Sun, L. Y. 2018; 7 (12)

    Abstract

    Acute Kidney Injury (AKI) in the context of right ventricular failure (RVF) is thought to be largely congestive in nature. This study assessed the utility of biomarkers high sensitivity cardiac troponin T (hs-cTnT), N-Terminal Pro-B-Type Natriuretic Peptide (NT-proBNP), and neutrophil gelatinase-associated lipocalin (NGAL) for prediction and early detection of congestive AKI (c-AKI) following cardiac surgery. This prospective nested case-control study recruited 350 consecutive patients undergoing elective cardiac surgery requiring cardiopulmonary bypass. Cases were patients who developed (1) AKI (2) new or worsening RVF, or (3) c-AKI. Controls were patients free of these complications. Biomarker levels were measured at baseline after anesthesia induction and immediately postoperatively. Patients with c-AKI had increased mean duration of mechanical ventilation and length of stay in hospital and in the intensive care unit (p < 0.01). For prediction of c-AKI, baseline NT-proBNP yielded an area under the curve (AUC) of 0.74 (95% CI, 0.60⁻0.89). For early detection of c-AKI, postoperative NT-proBNP yielded an AUC of 0.78 (0.66⁻0.91), postoperative hs-cTnT yielded an AUC of 0.75 (0.58⁻0.92), and ∆hs-cTnT yielded an AUC of 0.80 (0.64⁻0.96). The addition of baseline creatinine to ∆hs-cTnT improved the AUC to 0.87 (0.76⁻0.99), and addition of diabetes improved the AUC to 0.93 (0.88⁻0.99). Δhs-cTnT alone, or in combination with baseline creatinine or diabetes, detects c-AKI with high accuracy following cardiac surgery.

    View details for DOI 10.3390/jcm7120540

    View details for PubMedID 30545066

    View details for PubMedCentralID PMC6306702

  • Genetics, coronary artery disease, and myocardial revascularization: will novel genetic risk scores bring new answers? Indian journal of thoracic and cardiovascular surgery Hui, S. K., Sun, L., Ruel, M. 2018; 34 (Suppl 3): 213-221

    Abstract

    Both percutaneous coronary intervention (PCI) and coronary artery bypass graft surgery (CABG) are options for revascularization in multi-vessel coronary artery disease (CAD). However, the best form of revascularization remains controversial. Results from clinical trials (FREEDOM, SYNTAX, NOBLE, EXCEL) have identified factors related to CAD severity such as diabetes and SYNTAX score as indicators that patients may have better outcomes with CABG compared to PCI. Nevertheless, the discovery of other predictors of optimal revascularization therapy is necessary to improve decision-making and personalize the treatment of multi-vessel CAD. Genome-wide association studies have identified numerous previously unknown DNA variants that increase predisposition for CAD. Recently, a composite polygenic risk score has been developed to better assess the relative contribution of multiple SNPs and quantify overall genetic risk for CAD. High polygenic risk score is associated with increased coronary events and greater benefit from statin therapy in large observational studies. This effect is independent from traditional cardiovascular risk factors. At the same time, randomized clinical trials have shown that CAD severity is a determinant of optimal revascularization treatment. It remains unknown whether polygenic risk score is robustly associated with increased CAD severity at presentation, and whether this score can be used to identify patients who will show greater benefit from revascularization with CABG or with PCI.

    View details for DOI 10.1007/s12055-017-0635-6

    View details for PubMedID 33060941

    View details for PubMedCentralID PMC7525392

  • Disability-free survival after coronary artery bypass grafting in women and men with heart failure. Open heart Sun, L. Y., Tu, J. V., Lee, D. S., Beanlands, R. S., Ruel, M., Austin, P. C., Eddeen, A. B., Liu, P. P. 2018; 5 (2): e000911

    Abstract

    Heart failure (HF) impairs survival post coronary artery bypass grafting (CABG), but little is known about the postoperative quality of life (QoL) in patients with HF. We derived a patient-centred QoL surrogate and assessed the impact of different HF subtypes on this surrogate in the year post-CABG.We surveyed 3112 cardiovascular patients to derive a patient-centred disability outcome and studied this outcome in a population-based cohort. We defined preserved ejection fraction as ≥50% and reduced ejection fraction as <50%. The primary outcome was disability, defined according to compiled patient-derived values. The secondary outcomes consisted of each individual component of disability, and death. The incidence of disability was calculated using cumulative incidence functions, with death as a competing risk. We identified predictors of disability using cause-specific hazard models.Patient-derived disability outcome consisted of stroke, nursing home admission and recurrent hospitalisations. When applied to 40 083 CABG patients (20.6% women), the incidence of disability was 5.4% while the incidence of death was 3.7% in the year post-CABG. Female sex was associated with an adjusted HR of 1.25 (95% CI 1.13 to 1.37) for disability. Women with HF with preserved ejection fraction had an adjusted HR of 1.73 (95% CI 1.52 to 1.98) for disability.Disability was a more frequent complication than death in the year post-CABG. Women experienced higher burden of disability than men, and female sex and the presence of HF were important disability risk factors. Efforts should be dedicated to disability risk prediction to enable patient-centred operative decision-making and to developing sex-specific treatment strategies to improve outcomes.

    View details for DOI 10.1136/openhrt-2018-000911

    View details for PubMedID 30487983

    View details for PubMedCentralID PMC6242014

  • Genetics of coronary artery disease: should they impact the choice of revascularization? Current opinion in cardiology Hui, S. K., Lindale, E., Sun, L., Ruel, M. 2018; 33 (6): 605-612

    Abstract

    Patients with multivessel coronary artery disease (CAD) may undergo revascularization by either percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG). This review will discuss the use of polygenic risk scores for risk-stratification of patients with multivessel CAD in order to guide the choice of revascularization.A 57-single nucleotide polymorphism (SNP)-polygenic risk score can accurately risk-stratify patients with CAD and identify those who will receive greater benefit from statin therapy. The most recent genomic studies reveal 243 different SNPs are now significantly associated with CAD. Randomized clinical trials comparing PCI vs. CABG (FREEDOM, SYNTAX, NOBLE, EXCEL) have uncovered factors related to CAD severity (diabetes, SYNTAX score) are critical determinants of outcomes after revascularization.There is a need to discover predictors of outcomes after PCI vs. CABG to improve clinical decision-making in multivessel CAD. High polygenic risk score is associated with increased CAD severity and better outcomes with statin therapy. Randomized clinical trials indicate CAD severity is associated with better outcomes after CABG compared with PCI. Accordingly, polygenic risk score could also be associated with better outcomes after CABG vs. PCI and used to optimize revascularization for patients with multivessel CAD.

    View details for DOI 10.1097/HCO.0000000000000560

    View details for PubMedID 30188420

  • Sex-Specific Trends in Incidence and Mortality for Urban and Rural Ambulatory Patients with Heart Failure in Eastern Ontario from 1994 to 2013. Journal of cardiac failure Sun, L. Y., Tu, J. V., Sherrard, H., Rodger, N., Coutinho, T., Turek, M., Chan, E., Tulloch, H., McDonnell, L., Mielniczuk, L. M. 2018; 24 (9): 568-574

    Abstract

    Differences in outcomes have previously been reported between urban and rural settings across a multitude of chronic diseases. Whether these discrepancies have changed over time, and how sex may influence these findings is unknown for patients with ambulatory heart failure (HF). We examined the temporal incidence and mortality trends by geography in these patients.We conducted a retrospective cohort study of 36,175 eastern Ontario residents who were diagnosed with HF in an outpatient setting from 1994 to 2013. The primary outcome was 1-year mortality. We examined temporal changes in mortality risk factors with the use of multivariable Cox proportional hazard models. The incidence of HF decreased in women and men across both rural and urban settings. Age-standardized mortality rates also decreased over time in both sexes but remained greater in rural men compared with rural women.The incidence of HF in the ambulatory setting was greater for men than women and greater in rural than urban areas, but mortality rates remained higher in rural men compared with rural women. Further research should focus on ways to reduce this gap in the outcomes of men and women with HF.

    View details for DOI 10.1016/j.cardfail.2018.07.465

    View details for PubMedID 30099191

  • Defining an Intraoperative Hypotension Threshold in Association with Stroke in Cardiac Surgery. Anesthesiology Sun, L. Y., Chung, A. M., Farkouh, M. E., van Diepen, S., Weinberger, J., Bourke, M., Ruel, M. 2018; 129 (3): 440-447

    Abstract

    WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Stroke is a leading cause of morbidity, mortality, and disability in patients undergoing cardiac surgery. Identifying modifiable perioperative stroke risk factors may lead to improved patient outcomes. The association between the severity and duration of intraoperative hypotension and postoperative stroke in patients undergoing cardiac surgery was evaluated.A retrospective cohort study was conducted of adult patients who underwent cardiac surgery requiring cardiopulmonary bypass at a tertiary center between November 1, 2009, and March 31, 2015. The primary outcome was postoperative ischemic stroke. Intraoperative hypotension was defined as the number of minutes spent within mean arterial pressure bands of less than 55, 55 to 64, and 65 to 74 mmHg before, during, and after cardiopulmonary bypass. The association between stroke and hypotension was examined by using logistic regression with propensity score adjustment.Among the 7,457 patients included in this analysis, 111 (1.5%) had a confirmed postoperative diagnosis of stroke. Stroke was strongly associated with sustained mean arterial pressure of less than 64 mmHg during cardiopulmonary bypass (adjusted odds ratio 1.13; 95% CI, 1.05 to 1.21 for every 10 min of mean arterial pressure between 55 and 64 mmHg; adjusted odds ratio 1.16; 95% CI, 1.08 to 1.23 for every 10 min of mean arterial pressure less than 55 mmHg). Other factors that were independently associated with stroke were older age, hypertension, combined coronary artery bypass graft/valve surgery, emergent operative status, prolonged cardiopulmonary bypass duration, and postoperative new-onset atrial fibrillation.Hypotension is a potentially modifiable risk factor for perioperative stroke. The study's findings suggest that mean arterial pressure may be an important intraoperative therapeutic hemodynamic target to reduce the incidence of stroke in patients undergoing cardiopulmonary bypass.

    View details for DOI 10.1097/ALN.0000000000002298

    View details for PubMedID 29889106

  • Association of Frailty and Long-Term Survival in Patients Undergoing Coronary Artery Bypass Grafting. Journal of the American Heart Association Tran, D. T., Tu, J. V., Dupuis, J. Y., Bader Eddeen, A., Sun, L. Y. 2018; 7 (15)

    Abstract

    Frailty is increasing in prevalence and poses a formidable challenge for clinicians. The cardiac surgery literature consists primarily of small single-center studies with limited follow-up, and the epidemiological features of frailty remain to be elucidated in long-term follow-up.We conducted a population-based, retrospective, cohort study in Ontario, Canada, between 2008 and 2015. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty indicator (a multidimensional instrument validated for research using administrative data). The primary outcome was mortality. Mortality rates were calculated using the Kaplan-Meier method. The hazard of death was assessed using a multivariable Cox proportional hazard model. Of 40 083 patients, 8803 (22%) were frail. At 4±2 years of follow-up, age- and sex-standardized mortality rate per 1000 person-years was higher in frail (33; 95% confidence interval, 29-36) compared with nonfrail (22; 95% confidence interval, 19-24) patients. Frailty was associated with an increased risk of long-term mortality (adjusted hazard ratio, 1.20; 95% confidence interval, 1.12-1.28) and greater differences in the survival of patients between 40 and 74 years of age than in those who were ≥85 years old.Frailty was present in a large proportion of patients undergoing coronary artery bypass grafting and was independently associated with long-term mortality. The adjusted risk of frailty-related death was inversely proportional to age. Our findings highlight the need for more comprehensive preoperative risk stratification models to assist with optimal selection of operative candidates. In addition, we identified the <75 years age group as a potential target for comprehensive preoperative optimization programs, such as cardiac prehabilitation, nutritional augmentation, and psychosocial support.

    View details for DOI 10.1161/JAHA.118.009882

    View details for PubMedID 30030214

    View details for PubMedCentralID PMC6201467

  • Sex differences in outcomes of heart failure in an ambulatory, population-based cohort from 2009 to 2013. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne Sun, L. Y., Tu, J. V., Coutinho, T., Turek, M., Rubens, F. D., McDonnell, L., Tulloch, H., Eddeen, A. B., Mielniczuk, L. M. 2018; 190 (28): E848-E854

    Abstract

    Heart failure remains a substantial cause of morbidity and mortality in women. We examined the sex differences in heart failure incidence, mortality and hospital admission in a population-based cohort.All Ontario residents who were diagnosed with heart failure in an ambulatory setting between Apr. 1, 2009, and Mar. 31, 2014, were included in this study. Incident cases of heart failure were captured through physician billing using a validated algorithm. Outcomes were mortality and hospital admission for heart failure within 1 year of the diagnosis. Probability of death and hospital admission were calculated using the Kaplan-Meier method. The hazard of death was assessed using a multivariable Cox proportional hazard model.A total of 90 707 diagnoses of heart failure were made in an ambulatory setting during the study period (47% women). Women were more likely to be older and more frail, and had different comorbidities than men. The incidence of heart failure decreased during the study period in both sexes. The mortality rate decreased in both sexes, but remained higher in women than men. The female age-standardized mortality rate was 89 (95% confidence interval [CI] 80-100) per 1000 in 2009 and 85 (95% CI 75-95) in 2013, versus male age-standardized mortality rates of 88 (95% CI 80-97) in 2009 and 83 (95% CI 75-91) in 2013. Conversely, the rates of incident heart failure hospital admissions after heart failure diagnosis decreased in men and increased in women.Despite decreases in overall heart failure incidence and mortality in ambulatory patients, mortality rates remain higher in women than in men, and rates of hospital admission for heart failure increased in women and declined in men. Further studies should focus on sex differences in health-seeking behaviour, medical therapy and response to therapy to provide guidance for personalized care.

    View details for DOI 10.1503/cmaj.180177

    View details for PubMedID 30012800

    View details for PubMedCentralID PMC6050123

  • Pivotal contemporary trials of percutaneous coronary intervention vs. coronary artery bypass grafting: a surgical perspective. Annals of cardiothoracic surgery Ngu, J. M., Sun, L. Y., Ruel, M. 2018; 7 (4): 527-532

    Abstract

    Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are the two revascularization strategies for patients with coronary artery disease (CAD). While CABG continues to be the gold standard for revascularization, advancements in PCI technology have triggered numerous, often industry-funded investigations to challenge this role. This perspective will provide a summary of previous RCTs comparing CABG vs. PCI. The recently published NOBLE and EXCEL trials will be discussed in depth. Future directions of research pertaining to CABG vs. PCI will be briefly discussed in this document.

    View details for DOI 10.21037/acs.2018.05.12

    View details for PubMedID 30094218

    View details for PubMedCentralID PMC6082775

  • Prevalence and Long-Term Survival After Coronary Artery Bypass Grafting in Women and Men With Heart Failure and Preserved Versus Reduced Ejection Fraction. Journal of the American Heart Association Sun, L. Y., Tu, J. V., Bader Eddeen, A., Liu, P. P. 2018; 7 (12)

    Abstract

    Heart failure (HF) with reduced ejection fraction (rEF) is a widely regarded prognosticator after coronary artery bypass grafting. HF with preserved ejection fraction (pEF) accounts for up to half of all HF cases and is associated with considerable morbidity and mortality in hospitalized cohorts. However, HFpEF outcomes have not been elucidated in cardiac surgical patients. We investigated the prevalence and outcomes of HFpEF and HFrEF in women and men following coronary artery bypass grafting.We conducted a retrospective cohort study in Ontario, Canada, between October 1, 2008, and March 31, 2015, using Cardiac Care Network and Canadian Institute of Health Information data. HF is captured through a validated population-based database of all Ontarians with physician-diagnosed HF. We defined pEF as ejection fraction ≥50% and rEF as ejection fraction <50%. The primary outcome was all-cause mortality. Analyses were stratified by sex. Mortality rates were calculated using Kaplan-Meier method. The relative hazard of death was assessed using multivariable Cox proportional hazard models. Of 40 083 patients (20.6% women), 55.5% had pEF without HF, 25.7% had rEF without HF, 6.9% had HFpEF, and 12.0% had HFrEF. Age-standardized HFpEF mortality rates at 4±2 years of follow-up were similar in women and men. HFrEF standardized HFpEF mortality rates were higher in women than men.We found a higher prevalence and poorer prognosis of HFpEF in women. A history of HF was a more important prognosticator than ejection fraction. Preoperative screening and extended postoperative follow-up should be focused on women and men with HF rather than on rEF alone.

    View details for DOI 10.1161/JAHA.118.008902

    View details for PubMedID 29909401

    View details for PubMedCentralID PMC6220539

  • The State of Affairs for Cardiovascular Health Research in Indigenous Women in Canada: A Scoping Review. The Canadian journal of cardiology Prince, S. A., McDonnell, L. A., Turek, M. A., Visintini, S., Nahwegahbow, A., Kandasamy, S., Sun, L. Y., Coutinho, T. 2018; 34 (4): 437-449

    Abstract

    Cardiovascular disease (CVD) is the leading cause of death among Indigenous peoples in Canada. As rates of CVD rise, the impacts among the growing population of Indigenous women will emerge as an important health issue. The objective of this scoping review was to advance the state of knowledge about cardiovascular health research in Indigenous women in Canada. Five databases and grey literature (non-peer reviewed works) were searched to identify all studies that reported on the prevalence, pathophysiology, diagnosis, treatment, or interventions for CVD among adult Indigenous women in Canada, including First Nations, Métis, and Inuit. Searching identified 3194 potential articles; 61 of which were included. The most commonly researched topics were the prevalence of CVD, hypertension, and dyslipidemia. Rates of CVD and associated mortality among Indigenous women appear to have surpassed those of their nonindigenous counterparts. Very little research has examined the pathophysiology, diagnosis, and treatment of CVD. Gaps in the research identified the need for sex-based analyses, comparison with nonindigenous women, comprehensive longitudinal data, assessment of diagnosis criteria, development and evaluation of cardiovascular health interventions, and a better understanding of the role of culture and traditions in the prevention and treatment of CVD among Indigenous women. Although comprehensive CVD data are lacking, rates of CVD among Indigenous women in Canada are rising and are nearing or surpassing those of nonindigenous women. This review serves as a call to action to seek further research on the pathophysiology, diagnosis, and treatment of CVD among Indigenous women from across Canada.

    View details for DOI 10.1016/j.cjca.2017.11.019

    View details for PubMedID 29439893

  • Association of intraoperative hypotension with acute kidney injury after elective noncardiac surgery. Anesthesiology Sun, L. Y., Wijeysundera, D. N., Tait, G. A., Beattie, W. S. 2015; 123 (3): 515-23

    Abstract

    Intraoperative hypotension (IOH) may be associated with postoperative acute kidney injury (AKI), but the duration of hypotension for triggering harm is unclear. The authors investigated the association between varying periods of IOH with mean arterial pressure (MAP) less than 55, less than 60, and less than 65 mmHg with AKI.The authors conducted a retrospective cohort study of 5,127 patients undergoing noncardiac surgery (2009 to 2012) with invasive MAP monitoring and length of stay of 1 or more days. Exclusion criteria were preoperative MAP less than 65 mmHg, dialysis dependence, urologic surgery, and surgical duration less than 30 min. The primary exposure was IOH. The primary outcome was AKI (50% or 0.3 mg/dl increase in creatinine) during the first 2 postoperative days. Multivariable logistic regression was used to model the exposure-outcome relationship.AKI occurred in 324 (6.3%) patients and was associated with MAP less than 60 mmHg for 11 to 20 min and MAP less than 55 mmHg for more than 10 min in a graded fashion. The adjusted odds ratio of AKI for MAP less than 55 mmHg was 2.34 (1.35 to 4.05) for 11- to 20-min exposure and 3.53 (1.51 to 8.25) for more than 20 min. For MAP less than 60 mmHg, the adjusted odds ratio for AKI was 1.84 (1.11 to 3.06) for 11- to 20-min exposure.In this analysis, postoperative AKI is associated with sustained intraoperative periods of MAP less than 55 and less than 60 mmHg. This study provides an impetus for clinical trials to determine whether interventions that promptly treat IOH and are tailored to individual patient physiology could help reduce the risk of AKI.

    View details for DOI 10.1097/ALN.0000000000000765

    View details for PubMedID 26181335

  • Trends in Pulmonary Function Testing Before Noncardiothoracic Surgery. JAMA internal medicine Sun, L. Y., Gershon, A. S., Ko, D. T., Thilen, S. R., Yun, L., Beattie, W. S., Wijeysundera, D. N. 2015; 175 (8): 1410-2

    View details for DOI 10.1001/jamainternmed.2015.2087

    View details for PubMedID 26053615

  • The association between tracheostomy and sternal wound infection in postoperative cardiac surgery patients. Canadian journal of anaesthesia = Journal canadien d'anesthesie Sun, L., Boodhwani, M., Baer, H., McDonald, B. 2013; 60 (7): 684-91

    Abstract

    To investigate whether tracheostomy increases the risk of sternal wound infection (SWI) post cardiac surgery.All patients undergoing cardiac surgery via median sternotomy from September 1997 to October 2010 were included in this retrospective observational study. Primary exposure was tracheostomy performed during admission to the cardiac surgical intensive care unit. The primary outcome was SWI during hospital admission. Multivariable logistic regression was used to determine if tracheostomy was an independent predictor of SWI. Restriction and propensity score analyses were then used to assess if tracheostomy is a causal risk factor for SWI.Four hundred and eleven of 18,845 patients (2.2%) were treated with tracheostomy. Incidences of SWI in tracheostomy and non-tracheostomy groups were 19.5% (80/411) and 0.8% (154/18,434), respectively. Using multivariable logistic regression analysis, tracheostomy was found to be an independent predictor of SWI (odds ratio [OR] 2.8; 95% confidence interval [CI] 1.9 to 4.2). In an analysis restricted to respiratory failure patients, tracheostomy was associated with sternal wound infection (OR 3.4; 95% CI 2.4 to 4.9). When the analysis was stratified by the risk of receiving tracheostomy as represented by propensity score (PS), 46 patients (12%) in the intermediate risk category (PS 0.2-0.4) had SWIs (adjusted OR 2.97; 95% CI 1.6 to 5.6), and 52 patients (14%) in the highest risk category (PS > 0.4) had SWIs (OR 1.52; 95% CI 0.85 to 2.87).Our single-centre observational study of cardiac surgery patients found tracheostomy to be an independent risk factor for SWI. Our analysis showed a robust association when restricted to patients with respiratory failure and after the population was stratified by the propensity to have a tracheostomy.

    View details for DOI 10.1007/s12630-013-9950-6

    View details for PubMedID 23640661

  • Mean transit time as an index of cerebral perfusion pressure in experimental systemic hypotension. Physiological measurement Murphy, M. J., Tichauer, K. M., Sun, L., Chen, X., Lee, T. Y. 2011; 32 (4): 395-405

    Abstract

    Early diagnosis of cerebrovascular disease requires the accurate identification of brain regions with compromised cerebral perfusion pressure (CPP). Current clinical measures of CPP are invasive and lack regional information. Dynamic contrast-enhanced imaging provides a means of looking at regional cerebral hemodynamics. The purpose of this study was to determine if any of the parameters associated with dynamic contrast-enhanced imaging could be used as an index for CPP under graded systemic hypotension in a rabbit model. Cerebral blood flow (CBF), cerebral blood volume, mean transit time (MTT), and cerebrovascular reserve (CVR) were measured using Computed Tomography Perfusion in three groups: normotensive (n = 14), mild hypotensive (n = 9), and moderate hypotensive (n = 6). MTT demonstrated the strongest correlation with CPP (ρ = -0.642, P < 0.05). CBF was the only other parameter to demonstrate a statistically significant correlation (ρ = 0.575, P < 0.05). CVR is gaining momentum for diagnosing cerebrovascular disease; however, the technique requires patients to be given a hemodynamic challenge, which could aggravate symptoms and even trigger stroke. The results of this study suggest that the use of MTT, not requiring hemodynamic manipulation, is more sensitive to subtle changes in CPP, as would occur in the early stages of cerebrovascular disease.

    View details for DOI 10.1088/0967-3334/32/4/002

    View details for PubMedID 21343653