Publications by authors named "Derek S Chew"

40 Publications

Economic Outcomes of Rehabilitation Therapy in Older Patients With Acute Heart Failure in the REHAB-HF Trial: A Secondary Analysis of a Randomized Clinical Trial.

JAMA Cardiol 2021 Nov 24. Epub 2021 Nov 24.

Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.

Importance: In the Rehabilitation Therapy in Older Acute Heart Failure Patients (REHAB-HF) trial, a novel 12-week rehabilitation intervention demonstrated significant improvements in validated measures of physical function, quality of life, and depression, but no significant reductions in rehospitalizations or mortality compared with a control condition during the 6-month follow up. The economic implications of these results are important given the increasing pressures for cost containment in health care.

Objective: To report the economic outcomes of the REHAB-HF trial and estimate the potential cost-effectiveness of the intervention.

Design, Setting, Participants: The multicenter REHAB-HF trial randomized 349 patients 60 years or older who were hospitalized for acute decompensated heart failure to rehabilitation intervention or a control group; patients were enrolled from September 17, 2014, through September 19, 2019. For this preplanned secondary analysis of the economic outcomes, data on medical resource use and quality of life (via the 5-level EuroQol 5-Dimension scores converted to health utilities) were collected. Medical resource use and medication costs were estimated using 2019 US Medicare payments and the Federal Supply Schedule, respectively. Cost-effectiveness was estimated using the validated Tools for Economic Analysis of Patient Management Interventions in Heart Failure Cost-Effectiveness Model, which uses an individual-patient simulation model informed by the prospectively collected trial data. Data were analyzed from March 24, 2019, to December 1, 2020.

Interventions: Rehabilitation intervention or control.

Main Outcomes And Measures: Costs, quality-adjusted life-years (QALYs), and the lifetime estimated cost per QALY gained (incremental cost-effectiveness ratio).

Results: Among the 349 patients included in the analysis (183 women [52.4%]; mean [SD] age, 72.7 [8.1] years; 176 non-White [50.4%] and 173 White [49.6%]), mean (SD) cumulative costs per patient were $26 421 ($38 955) in the intervention group (excluding intervention costs) and $27 650 ($30 712) in the control group (difference, -$1229; 95% CI, -$8159 to $6394; P = .80). The mean (SD) cost of the intervention was $4204 ($2059). Quality of life gains were significantly greater in the intervention vs control group during 6 months (mean utility difference, 0.074; P = .001) and sustained beyond the 12-week intervention. Incremental cost-effectiveness ratios were estimated at $58 409 and $35 600 per QALY gained for the full cohort and in patients with preserved ejection fraction, respectively.

Conclusions And Relevance: These analyses suggest that longer-term benefits of this novel rehabilitation intervention, particularly in the subgroup of patients with preserved ejection fraction, may yield good value to the health care system. However, long-term cost-effectiveness is currently uncertain and dependent on the assumption that benefits are sustained beyond study follow-up, which needs to be corroborated in future trials in this patient population.
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http://dx.doi.org/10.1001/jamacardio.2021.4836DOI Listing
November 2021

Pharmacological Cardioversion of Atrial Tachyarrhythmias Using Single High-Dose Oral Amiodarone: a Systematic Review and Meta-Analysis.

Circ Arrhythm Electrophysiol 2021 Nov 22:CIRCEP121010321. Epub 2021 Nov 22.

Department of Cardiac Sciences, Libin Cardiovascular Institute, University of Calgary, AB, Canada (L.Y.L., D.S.C., W.L., E.I., R.S.S., P.T.P., S.R.R.).

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http://dx.doi.org/10.1161/CIRCEP.121.010321DOI Listing
November 2021

Association between Economic and Arrhythmic Burden of Paroxysmal Atrial Fibrillation in Patients with Cardiac Implanted Electronic Devices.

Am Heart J 2021 Nov 17. Epub 2021 Nov 17.

Duke Clinical Research Institute, Duke University, Durham, NC, USA; Department of Population Health Sciences, Duke University, Durham, NC, USA; Division of Cardiology, Duke University Medical Center, Durham, NC, USA. Electronic address:

Background: As the prevalence of atrial fibrillation (AF) increases, a greater understanding of the costs associated with AF care is required. While individuals with greater arrhythmic burden may interact with the health system more frequently, the relationship between AF burden and costs remains undefined.

Methods: In a longitudinal patient cohort with paroxysmal AF and newly implanted cardiovascular implantable electronic devices (CIED) (2010-2016), we linked CIED remote-monitoring data with Medicare claims to assess the association between the 30-day averaged device-detected daily percentage of time in AF ("AF burden") and healthcare costs.

Results: Among 39,345 patients, the mean age was 77.1±8.7 years, 60.7% were male, and the mean CHADSVASc score was 4.9±1.3. The mean total 1-year costs were $18,668±29,173, driven by hospitalization costs where two-thirds of admissions were due to heart failure. Increasing AF burden was associated with increasing costs: $17,860±28,525 for 0% daily AF burden; $18,840±29,104 for 0-5% daily AF burden; and $20,968±31,228 for 5-98% daily AF burden. There was a linear relationship between AF burden expressed as a continuous variable and 1-year costs (adjusted cost rate ratio 1.031 per 10% daily duration in AF, 95% confidence interval 1.023-1.038; p<0.001).

Conclusion: Among older patients with paroxysmal AF and CIEDs, increasing AF burden is associated with higher healthcare costs. As the observational study design is unable to determine causal relationships, prospective study is required to explore the intriguing hypothesis that targeted AF strategies, including comorbidity management, that reduce AF burden may also reduce the high annual costs associated with AF.
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http://dx.doi.org/10.1016/j.ahj.2021.11.006DOI Listing
November 2021

Clinician needs and perceptions about cardioneuroablation for recurrent vasovagal syncope: An international clinician survey.

Heart Rhythm 2021 Aug 19. Epub 2021 Aug 19.

Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Vanderbilt Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.

Background: Cardioneuroablation (CNA) targets the intrinsic cardiac autonomic nervous system ganglionated plexi located in the peri-atrial epicardial fat. There is increasing interest in CNA as a treatment of vasovagal syncope (VVS), despite no randomized clinical trial (RCT) data.

Objective: The purpose of this study was to poll the opinion on CNA) for VVS.

Methods: A REDCap (Research Electronic Data Capture) survey was administered to international physicians treating patients with VVS on their opinion about patient selection criteria, ablation approach, RCT design, and most appropriate end points for CNA procedures.

Results: The survey was completed by 118 physicians; 86% were cardiac electrophysiologists. The majority of respondents (79%) would consider referring a patient with refractory VVS for CNA, and 27% have performed CNA for VVS themselves. Most felt patient selection should require a head-up tilt test with a cardioinhibitory response (67%) and suggest a minimum age of 18 years with a median of 3 (interquartile range 2-5) episodes in the past year. There were differences in patient selection between physicians who have performed CNA themselves and those who have not. The majority felt that the ablation strategy should include both atria (70%) with an anatomical approach in combination with autonomic stimulation (85%). Performing a sham procedure in the control arm was supported by 56% of respondents, providing equipoise in RCT design. The preferred primary outcome was freedom from syncope within 1 year of follow-up.

Conclusion: There is widespread support for well-designed RCTs to confirm the hypothesized clinical benefit of CNA, provide data to guide the risk-benefit equations during patient selection, and appropriately estimate the placebo effect.
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http://dx.doi.org/10.1016/j.hrthm.2021.08.018DOI Listing
August 2021

Effect of Implantable vs Prolonged External Electrocardiographic Monitoring on Atrial Fibrillation Detection in Patients With Ischemic Stroke: The PER DIEM Randomized Clinical Trial.

JAMA 2021 06;325(21):2160-2168

Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada.

Importance: The relative rates of detection of atrial fibrillation (AF) or atrial flutter from evaluating patients with prolonged electrocardiographic monitoring with an external loop recorder or implantable loop recorder after an ischemic stroke are unknown.

Objective: To determine, in patients with a recent ischemic stroke, whether 12 months of implantable loop recorder monitoring detects more occurrences of AF compared with conventional external loop recorder monitoring for 30 days.

Design, Setting, And Participants: Investigator-initiated, open-label, randomized clinical trial conducted at 2 university hospitals and 1 community hospital in Alberta, Canada, including 300 patients within 6 months of ischemic stroke and without known AF from May 2015 through November 2017; final follow-up was in December 2018.

Interventions: Participants were randomly assigned 1:1 to prolonged electrocardiographic monitoring with either an implantable loop recorder (n = 150) or an external loop recorder (n = 150) with follow-up visits at 30 days, 6 months, and 12 months.

Main Outcomes And Measures: The primary outcome was the development of definite AF or highly probable AF (adjudicated new AF lasting ≥2 minutes within 12 months of randomization). There were 8 prespecified secondary outcomes including time to event analysis of new AF, recurrent ischemic stroke, intracerebral hemorrhage, death, and device-related serious adverse events within 12 months.

Results: Among the 300 patients who were randomized (median age, 64.1 years [interquartile range, 56.1 to 73.7 years]; 121 were women [40.3%]; and 66.3% had a stroke of undetermined etiology with a median CHA2DS2-VASc [congestive heart failure, hypertension, age ≥75 years, diabetes, stroke or transient ischemic attack, vascular disease, age 65 to 74 years, sex category] score of 4 [interquartile range, 3 to 5]), 273 (91.0%) completed cardiac monitoring lasting 24 hours or longer and 259 (86.3%) completed both the assigned monitoring and 12-month follow-up visit. The primary outcome was observed in 15.3% (23/150) of patients in the implantable loop recorder group and 4.7% (7/150) of patients in the external loop recorder group (between-group difference, 10.7% [95% CI, 4.0% to 17.3%]; risk ratio, 3.29 [95% CI, 1.45 to 7.42]; P = .003). Of the 8 specified secondary outcomes, 6 were not significantly different. There were 5 patients (3.3%) in the implantable loop recorder group who had recurrent ischemic stroke vs 8 patients (5.3%) in the external loop recorder group (between-group difference, -2.0% [95% CI, -6.6% to 2.6%]), 1 (0.7%) vs 1 (0.7%), respectively, who had intracerebral hemorrhage (between-group difference, 0% [95% CI, -1.8% to 1.8%]), 3 (2.0%) vs 3 (2.0%) who died (between-group difference, 0% [95% CI, -3.2% to 3.2%]), and 1 (0.7%) vs 0 (0%) who had device-related serious adverse events.

Conclusions And Relevance: Among patients with ischemic stroke and no prior evidence of AF, implantable electrocardiographic monitoring for 12 months, compared with prolonged external monitoring for 30 days, resulted in a significantly greater proportion of patients with AF detected over 12 months. Further research is needed to compare clinical outcomes associated with these monitoring strategies and relative cost-effectiveness.

Trial Registration: ClinicalTrials.gov Identifier: NCT02428140.
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http://dx.doi.org/10.1001/jama.2021.6128DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8170545PMC
June 2021

Dapagliflozin-Does Cost Make 4-Pillar Heart Failure Therapy Too Herculean a Labor for Medicine?

JAMA Cardiol 2021 Aug;6(8):875-876

Duke Clinical Research Institute, Duke University, Durham, North Carolina.

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http://dx.doi.org/10.1001/jamacardio.2021.1448DOI Listing
August 2021

Electrophysiology studies for predicting atrioventricular block in patients with syncope: A systematic review and meta-analysis.

Heart Rhythm 2021 Aug 20;18(8):1310-1317. Epub 2021 Apr 20.

University of Alberta, Edmonton, Alberta, Canada; Smidt Heart Institute, Cedars-Sinai Hospital, Los Angeles, California.

Background: Syncope may be caused by intermittent complete heart block in patients with bundle branch block. Electrophysiology studies (EPS) testing for infra-Hisian heart block are recommended by the European Society of Cardiology syncope guidelines on the basis of decades-old estimates of their negative predictive values (NPVs) for complete heart block.

Objective: The aim of this study was to determine the NPV of EPS for complete heart block in patients with syncope and bundle branch block.

Methods: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL without language restriction from database inception to October 2019 for Medical Subject Headings terms and keywords related to "syncope," "heart block," and "programmed electrical stimulation." A random effects meta-analysis was conducted with a primary outcome of the proportion of patients with a negative EPS who later presented with complete heart block, diagnosed with surface electrocardiographic (ECG) recordings vs continuous implantable cardiac monitor (ICM).

Results: Ten reports contained 12 cohorts with 639 patients who met the inclusion criteria. The mean age was 69 ± 7 years; 35% ± 10% were women; and 85% of patients had bifascicular block. Seven cohorts recorded clinical outcomes with external ECG recordings, and 5 cohorts featured ICMs. The mean prespecified His-to-ventricle interval criterion was ≥70 ms. In studies featuring surface ECG recordings, there were 7% (95% confidence interval 7%-17%) patients who developed complete heart block compared with 29% (95% confidence interval 24%-35%) in the studies featuring ICM (P = .0001).

Conclusion: The NPV of EPS in patients with syncope and bundle branch block is 0.71, sufficiently low to question its use.
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http://dx.doi.org/10.1016/j.hrthm.2021.04.010DOI Listing
August 2021

Predictors of appropriate shock after generator replacement in patients with an implantable cardioverter defibrillator.

Pacing Clin Electrophysiol 2021 May 16;44(5):911-918. Epub 2021 Apr 16.

Department of Internal Medicine, Section of Cardiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.

Background: Implantable cardioverter defibrillators (ICDs) are indicated for the primary prevention of sudden cardiac death in patients with reduced left ventricular ejection fraction (LVEF). The ongoing risk/benefit profile of an ICD at generator replacement is unknown. This study aimed to identify predictors of appropriate ICD shocks and therapies after first ICD generator replacement, and its procedure-related complications.

Methods: We conducted a multicenter, retrospective cohort study including patients with primary prevention ICDs who underwent generator replacement between April 2005 and July 2015 at three Canadian centers. The primary and secondary outcomes were appropriate ICD shock and any appropriate ICD therapy, respectively. Procedure-related complication rates were also reported.

Results: Of the 219 patients in the cohort, 61 (28%) experienced an appropriate shock while 40 (18%) experienced appropriate antitachycardia pacing over a median follow up of 2.2 years. Independent predictors of appropriate ICD shocks included: LVEF at time of replacement (adjusted odds ratio [OR] 0.4 per 10% increase in LVEF, P < .001), a history of appropriate ICD shocks prior to replacement (OR 4.9, P < .001), and a history of inappropriate ICD shocks (OR 4.2, 95%, P < .002). Similar predictors were identified for the secondary outcome of any appropriate ICD therapy. Device-related complications were reported in 25 (11%) patients, with 1 (0.5%) resulting in death, 14 (6.3%) requiring site re-operation, and 6 (2.7%) requiring cardiac surgical management.

Conclusion: Not all primary prevention ICD patients undergoing generator replacement will require appropriate device therapies afterwards. Generator replacement is associated with several risks that should be weighed against its anticipated benefit. A comprehensive assessment of the risk-benefit profile of patients undergoing generator replacement is warranted.
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http://dx.doi.org/10.1111/pace.14236DOI Listing
May 2021

Postural orthostatic tachycardia syndrome is associated with significant employment and economic loss.

J Intern Med 2021 07 15;290(1):203-212. Epub 2021 Feb 15.

Department of Cardiac Sciences, Cumming School of Medicine, Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada.

Background: Postural orthostatic tachycardia syndrome (POTS) is a debilitating form of chronic orthostatic intolerance that primarily affects women and causes substantial impairment in quality of life and function. Yet, there is minimal literature describing the employment and economic consequences of POTS. We explored these aspects of the POTS patient experience through a self-reported study designed using community-based participatory research principles.

Methods And Results: A comprehensive questionnaire, including employment and economic consequences, was developed in partnership with Dysautonomia International, a patient advocacy organization. The POTS community engaged in all stages of the research design and analysis. Participants were recruited through Dysautonomia International's website and social media channels. The analysis included 5,556 adult (age ≥18 years) participants with a physician-confirmed diagnosis of POTS. The majority of participants were female (95%). Forty-eight per cent of participants reported employment during the three months prior to the survey, and of these participants, 66.8% would work greater hours if not for illness limitations. Over two-thirds (70.5%) of participants have lost income due to POTS symptoms, with 36.0% of the total cohort losing more than $10,000 USD in the 12 months prior to the survey. Almost all (95%) participants reported POTS-related out-of-pocket medical expenses since diagnosis, with 51.1% of participants spending $10,000 USD or more.

Conclusions: This is the largest study reporting the employment and economic challenges experienced by individuals with POTS. Exposure of these challenges emphasizes the need for earlier diagnosis and improved therapeutic strategies to reduce the negative individual and societal consequences of this disorder.
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http://dx.doi.org/10.1111/joim.13245DOI Listing
July 2021

Assessment of dynamic cardiac repolarization and contractility in patients with hypertrophic cardiomyopathy.

PLoS One 2021 11;16(2):e0246768. Epub 2021 Feb 11.

Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America.

Aims: Arrhythmia mechanisms in hypertrophic cardiomyopathy remain uncertain. Preclinical models suggest hypertrophic cardiomyopathy-linked mutations perturb sarcomere length-dependent activation, alter cardiac repolarization in rate-dependent fashion and potentiate triggered electrical activity. This study was designed to assess rate-dependence of clinical surrogates of contractility and repolarization in humans with hypertrophic cardiomyopathy.

Methods: All participants had a cardiac implantable device capable of atrial pacing. Cases had clinical diagnosis of hypertrophic cardiomyopathy, controls were age-matched. Continuous electrocardiogram and blood pressure were recorded during and immediately after 30 second pacing trains delivered at increasing rates.

Results: Nine hypertrophic cardiomyopathy patients and 10 controls were enrolled (47% female, median 55 years), with similar baseline QRS duration, QT interval and blood pressure. Median septal thickness in hypertrophic cardiomyopathy patients was 18mm; 33% of hypertrophic cardiomyopathy patients had peak sub-aortic velocity >50mmHg. Ventricular ectopy occurred during or immediately after pacing trains in 4/9 hypertrophic cardiomyopathy patients and 0/10 controls (P = 0.03). During delivery of steady rate pacing across a range of cycle lengths, the QT-RR relationship was not statistically different between HCM and control groups; no differences were seen in subgroup analysis of patients with or without intact AV node conduction. Similarly, there was no difference between groups in the QT interval of the first post-pause recovery beat after pacing trains. No statistically significant differences were seen in surrogate measures for cardiac contractility.

Conclusion: Rapid pacing trains triggered ventricular ectopy in hypertrophic cardiomyopathy patients, but not controls. This finding aligns with pre-clinical descriptions of excessive cardiomyocyte calcium loading during rapid pacing, increased post-pause sarcoplasmic reticulum calcium release, and subsequent calcium-triggered activity. Normal contractility at all diastolic intervals argues against clinical significance of altered length-dependent myofilament activation.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0246768PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7877626PMC
August 2021

Economic evaluation of an absorbable antibiotic envelope for prevention of cardiac implantable electronic device infection.

Europace 2021 05;23(5):767-774

Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada.

Aims: Recent evidence suggests that an antibiotic impregnated envelope inserted at time of cardiac implantable electronic device (CIED) implantation may reduce risk of subsequent CIED infection compared with standard of care (SoC). The objective of the current work was to perform a cost-effectiveness analysis comparing an antibiotic impregnated envelope with SoC at time of CIED insertion.

Methods And Results: Decision analytic models were used to project healthcare costs and benefits of two strategies, an antibiotic impregnated envelope plus SoC (Env+SoC) vs. SoC alone, in a cohort of patients undergoing CIED implantation over a 1-year time horizon. Evidence from published literature informed the model inputs. Probabilistic and deterministic sensitivity analyses were performed. The primary outcome was the incremental cost per infection prevented, assessed from the Canadian healthcare system perspective. Envelope plus SoC was associated with fewer CIED infection (7 CIED infections/1000 patients) at higher total costs ($29 033 000/1000 patients) compared with SoC (11 CIED infections and $27 926 000/1000 patients). The incremental cost per infection prevented over 1 year was $274 416. Use of Env+SoC was cost saving only when baseline CIED infection risk was increased to 6% (vs. base case of 1.2%).

Conclusions: A strategy of Env+SoC was not economically favourable compared with SoC alone, and the opportunity cost of widescale implementation should be considered. Future work is required to develop validated risk stratification tools to identify patients at greatest risk of CIED infection. The value proposition of Env+SoC improves when applying this intervention to patients at greatest infection risk.
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http://dx.doi.org/10.1093/europace/euaa291DOI Listing
May 2021

Atrial fibrillation burden and heart failure: Data from 39,710 individuals with cardiac implanted electronic devices.

Heart Rhythm 2021 05 26;18(5):709-716. Epub 2021 Jan 26.

Department of Population Health, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Duke University, Durham, North Carolina; Division of Cardiology, Duke University Medical Center, Durham, North Carolina.

Background: Atrial fibrillation (AF) and heart failure (HF) often accompany one another, and each is independently associated with poor outcomes. However, the association between AF burden and outcomes is poorly understood.

Objective: The purpose of this study was to describe the association between device-based AF burden and HF clinical outcomes.

Methods: We used a nationwide, remote monitoring database of cardiac implantable electronic devices (CIEDs) linked to Medicare claims. We included patients with nonpermanent AF, undergoing new CIED implant, stratified by baseline HF. The outcomes were new-onset HF, HF hospitalization, and all-cause mortality at 1 and 3 years.

Results: We identified 39,710 patients who met inclusion criteria (25,054 with HF; 14,656 without HF). Patients with HF were younger (mean age 76.3 vs 78.5 years; P <.001), more often male (65% vs 54%; P <.001), and had higher mean CHADS-VASc scores (5.4 vs 4.1; P <.001). Among those without HF, increasing device-based AF burden was significantly associated with increased risk of new-onset HF (adjusted hazard ratio [HR] 1.09 per 10% AF burden; 95% confidence interval [CI] 1.06-1.12; P <.001) and all-cause mortality (adjusted HR 1.05 per 10% AF burden; 95% CI 1.01-1.10; P = .012). Among patients with HF, increasing AF burden was significantly associated with increased risk of HF hospitalization (adjusted HR 1.05 per 10% AF burden; 95% CI 1.04-1.06; P <.001) and all-cause mortality (adjusted HR 1.06 per 10% AF burden; 95% CI 1.05-1.08; P <.001).

Conclusion: Among older patients with AF receiving a CIED, increasing AF burden is significantly associated with increasing risk of adverse HF outcomes and all-cause mortality.
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http://dx.doi.org/10.1016/j.hrthm.2021.01.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8096675PMC
May 2021

Trends in health care resource use and expenditures in patients with newly diagnosed paroxysmal supraventricular tachycardia in the United States.

Am Heart J 2021 03 15;233:132-140. Epub 2021 Jan 15.

Duke University Medical Center, Durham, NC. Electronic address:

Background: Few data are available on the temporal patterns of health resource utilization (HRU) and expenditures around paroxysmal supraventricular tachycardia (PSVT) diagnosis. This study assessed the longitudinal trends in HRU and expenditures in the 3 years preceding and subsequent to PSVT diagnosis.

Methods: Adult patients (age 18-65 years) with newly diagnosed PSVT were identified using administrative claims from the IBM MarketScan Research Database between January 1, 2008 and December 31, 2016 and propensity-score matched (1:1) with non-PSVT controls.

Results: Among the 12,305 PSVT patients compared with matched controls, PSVT was associated with statistically significant higher annual rates of emergency department visits, physician office visits, inpatient hospitalizations, and diagnostic testing. HRU increased in the years preceding PSVT diagnosis, reaching its peak in the year following PSVT diagnosis. Over the 6-year follow-up period, PSVT was associated with higher mean annual per patient expenditures ($12,665) compared to matched controls ($6,004; P < .001). Upon diagnosis of PSVT, the mean expenditures per PSVT patient doubled from $11,714 in the year immediately preceding index diagnosis to $23,335 in the first postdiagnosis year. Inpatient services, diagnostic testing, and ablation procedures were the principle drivers of higher mean expenditures in the first year post-PSVT diagnosis versus the year prior to PSVT diagnosis.

Conclusions: PSVT presents a substantial economic burden to health care systems. The annual expenditure per PSVT patient is within the range previously reported for atrial fibrillation. The increased HRU and expenditures in the year following diagnosis, which do not return to baseline, suggest a potential gap in non-interventional, long-term PSVT management.
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http://dx.doi.org/10.1016/j.ahj.2020.12.012DOI Listing
March 2021

Cost-Effectiveness of Earlier Transition to Angiotensin Receptor Neprilysin Inhibitor in Patients With Heart Failure and Reduced Ejection Fraction.

CJC Open 2020 Nov 4;2(6):447-453. Epub 2020 Jun 4.

Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.

Background: Angiotensin receptor neprilysin inhibitor (ARNi) therapy improves clinical outcomes in patients with heart failure and reduced left ventricular ejection fraction. However, ARNi therapy uptake remains modest, potentially in part due to perceived cost considerations of early transition from angiotensin converting enzyme inhibitor or angiotensin receptor blocker therapy.

Methods: We constructed a decision-analytic Markov model to assess cost-effectiveness of 3 different ARNi initiation strategies according to timing of initiation: (1) , or immediate initiation at baseline, (2) Early or after 3 months, or (3) Late, or after 9 months. Initiation strategies were compared with (4) current care, with utilization of ARNi derived from a large observational database. Total costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER) were estimated over a 5-year time horizon in the base case analysis.

Results: Current care was associated with the lowest total cost (CAD$26,664) and accrued benefit (3.28 QALYs). The strategy yielded an ICER of $34,727 per QALY gained, whereas Early and Late initiation strategies yielded a less favourable ICER per QALY gained of $35,871 and $40,234, respectively. The model was most sensitive to the cost of ARNi therapy.

Conclusion: A strategy of ARNi initiation is economically attractive and becomes less favourable as the delay of initiation increases. Our results suggest that ARNi therapy should be initiated as soon as possible for patients with heart failure and reduced left ventricular ejection fraction.
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http://dx.doi.org/10.1016/j.cjco.2020.05.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7710928PMC
November 2020

Economic Evaluation of Catheter Ablation of Atrial Fibrillation in Patients with Heart Failure With Reduced Ejection Fraction.

Circ Cardiovasc Qual Outcomes 2020 12 7;13(12):e007094. Epub 2020 Dec 7.

Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., Z.L., M.F., A.L., J.A.R., A.D.D., D.B.M., J.P.P.).

Background: Randomized clinical trials have demonstrated that catheter ablation for atrial fibrillation in patients with heart failure with reduced ejection fraction may improve survival and other cardiovascular outcomes.

Methods: We constructed a decision-analytic Markov model to estimate the costs and benefits of catheter ablation and medical management in patients with symptomatic heart failure with reduced ejection fraction (left ventricular ejection fraction ≤35%) and atrial fibrillation over a lifetime horizon. Evidence from the published literature informed the model inputs, including clinical effectiveness data from meta-analyses. Probabilistic and deterministic sensitivity analyses were performed. A 3% discount rate was applied to both future costs and benefits. The primary outcome was the incremental cost-effectiveness ratio assessed from the US health care sector perspective.

Results: Catheter ablation was associated with 6.47 (95% CI, 5.89-6.93) quality-adjusted life years (QALYs) and a total cost of $105 657 (95% CI, $55 311-$191 934; 2018 US dollars), compared with 5.30 (95% CI, 5.20-5.39) QALYs and $63 040 (95% CI, $37 624-$102 260) for medical management. The incremental cost-effectiveness ratio for catheter ablation compared with medical management was $38 496 (95% CI, $5583-$117 510) per QALY gained. Model inputs with the greatest variation on incremental cost-effectiveness ratio estimates were the cost of ablation and the effect of catheter ablation on mortality reduction. When assuming a more conservative estimate of the treatment effect of catheter ablation on mortality (hazard ratio of 0.86), the estimated incremental cost-effectiveness ratio was $74 403 per QALY gained. At a willingness-to-pay threshold of $100 000 per QALY gained, atrial fibrillation ablation was found to be economically favorable compared with medical management in 95% of simulations.

Conclusions: Catheter ablation in patients with heart failure with reduced ejection fraction patients and atrial fibrillation may be considered economically attractive at current benchmarks for societal willingness-to-pay in the United States.
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http://dx.doi.org/10.1161/CIRCOUTCOMES.120.007094DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7738404PMC
December 2020

Economic evaluation of extended electrocardiogram monitoring for atrial fibrillation in patients with cryptogenic stroke.

Int J Stroke 2021 10 24;16(7):809-817. Epub 2020 Nov 24.

Department of Cardiac Sciences, University of Calgary, Alberta, Canada.

Background: Timely identification of occult atrial fibrillation following cryptogenic stroke facilitates consideration of oral anticoagulation therapy. Extended electrocardiography monitoring beyond 24 to 48 h Holter monitoring improves atrial fibrillation detection rates, yet uncertainty remains due to upfront costs and the projected long-term benefit. We sought to determine the cost-effectiveness of three electrocardiography monitoring strategies in detecting atrial fibrillation after cryptogenic stroke.

Methods: A decision-analytic Markov model was used to project the costs and outcomes of three different electrocardiography monitoring strategies (i.e. 30-day electrocardiography monitoring, three-year implantable loop recorder monitoring, and conventional Holter monitoring) in acute stroke survivors without previously documented atrial fibrillation.

Results: The lifetime discounted costs and quality-adjusted life years were $206,385 and 7.77 quality-adjusted life years for conventional monitoring, $207,080 and 7.79 quality-adjusted life years for 30-day extended electrocardiography monitoring, and $210,728 and 7.88 quality-adjusted life years for the implantable loop recorder strategy. Additional quality-adjusted life years could be attained at a more favorable incremental cost per quality-adjusted life year with the implantable loop recorder strategy, compared with the 30-day electrocardiography monitoring strategy, thereby eliminating the 30-day strategy by extended dominance. The implantable loop recorder strategy was associated with an incremental cost per quality-adjusted life year gained of $40,796 compared with conventional monitoring. One-way sensitivity analyses indicated that the model was most sensitive to the rate of recurrent ischemic stroke.

Conclusions: An implantable loop recorder strategy for detection of occult atrial fibrillation in patients with cryptogenic stroke is more economically attractive than 30-day electrocardiography monitoring compared to conventional monitoring and is associated with a cost per quality-adjusted life year gained in the range of other publicly funded therapies. The value proposition is improved when considering patients at the highest risk of recurrent ischemic stroke. However, the implantable loop recorder strategy is associated with increased health care costs, and the opportunity cost of wide scale implementation must be considered.
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http://dx.doi.org/10.1177/1747493020974561DOI Listing
October 2021

Non-Pharmacological and Pharmacological Management of Cardiac Dysautonomia Syndromes.

J Atr Fibrillation 2020 Jun-Jul;13(1):2395. Epub 2020 Jun 30.

Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada.

Vasovagal syncope, postural orthostatic tachycardia syndrome, and inappropriate sinus tachycardia comprise a heterogenous group of common autonomic disorders that are associated with significant symptoms that impair quality of life. Clinical management of these disorders should prioritize conservative non-pharmacological therapies and consider incorporating pharmacological agents for recurrences. The selection and titration of medications may be complicated by the occurrence of potentially overlapping pathophysiological variants, differences in specific clinical presentations, and commonly associated comorbidities. However, with appropriate long-term management and specialist input, most patients note both symptomatic improvement and functional restoration over time.
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http://dx.doi.org/10.4022/jafib.2395DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7533143PMC
June 2020

Differential diagnosis of orthostatic hypotension.

Auton Neurosci 2020 11 1;228:102713. Epub 2020 Aug 1.

Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada; Autonomic Dysfunction Center, Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA. Electronic address:

Orthostatic hypotension (OH) is a common clinical manifestation characterized by a significant fall in blood pressure with postural change and is frequently accompanied by debilitating symptoms of orthostatic intolerance. The reported prevalence of OH ranges between 5 and 10% in middle-aged adults with a burden that increases concomitantly with age; in those over 60 years of age, the prevalence is estimated to be over 20%. Unfortunately, the clinical course of OH is not necessarily benign. OH patients are at an increased risk of adverse clinical outcomes including death, falls, cardiovascular and cerebrovascular events, syncope, and impaired quality of life. The differential diagnosis of OH is broad and includes acute precipitants as well as chronic underlying medical conditions, especially of neurological origin. Appropriate diagnosis relies on a systematic history and physical examination with particular attention to orthostatic vital signs, keeping in mind that ambient conditions during diagnostic testing may affect OH detection due to factors such as diurnal variation.
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http://dx.doi.org/10.1016/j.autneu.2020.102713DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7502506PMC
November 2020

Postprocedural Antithrombotic Therapy Following Left Atrial Appendage Occlusion: No Longer Adrift in Uncertainty?

Circ Cardiovasc Interv 2020 07 17;13(7):e009534. Epub 2020 Jul 17.

Duke Clinical Research Institute, Duke University, Durham, NC. Division of Cardiology, Duke University Medical Center, Durham, NC.

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http://dx.doi.org/10.1161/CIRCINTERVENTIONS.120.009534DOI Listing
July 2020

Cost-Effectiveness of Extended Electrocardiogram Monitoring for Atrial Fibrillation After Stroke: A Systematic Review.

Stroke 2020 07 5;51(7):2244-2248. Epub 2020 Jun 5.

Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta (D.S.C., D.V.E.), University of Calgary, Canada.

Background And Purpose: Management of cryptogenic stroke involves the identification of modifiable risk factors, such as atrial fibrillation (AF). Extended rhythm monitoring increases AF detection rates but at an increased device cost compared with conventional Holter monitoring. The objective of the study was to identify and synthesize the existing literature on the cost-effectiveness of prolonged rhythm monitoring devices for AF detection in cryptogenic stroke.

Methods: We conducted a systematic review of available economic evaluations of prolonged ECG monitoring for AF detection following cryptogenic stroke compared with standard care.

Results: Of the 530 unique citations, 8 studies assessed the cost-utility of prolonged ECG monitoring compared with standard care following cryptogenic stroke. The prolonged ECG monitoring strategies included 7-day ambulatory monitoring, 30-day external loop recorders or intermittent ECG monitoring, and implantable loop recorders. The majority of cost-utility analyses reported incremental cost-effectiveness ratios below $50 000 per QALY gained; and two studies reported a cost-savings.

Conclusions: There is limited economic literature on the cost-effectiveness of extended ECG monitoring devices for detection of atrial fibrillation in cryptogenic stroke. In patients with cryptogenic stroke, extended ECG monitoring for AF detection may be economically attractive when traditional willingness-to-pay thresholds are adopted. However, there was substantial variation in the reported ICERs. The direct comparison of cost-effectiveness across technologies is limited by heterogeneity in modeling assumptions.
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http://dx.doi.org/10.1161/STROKEAHA.120.029340DOI Listing
July 2020

Diagnosis-to-Ablation Time and Recurrence of Atrial Fibrillation Following Catheter Ablation: A Systematic Review and Meta-Analysis of Observational Studies.

Circ Arrhythm Electrophysiol 2020 04 19;13(4):e008128. Epub 2020 Mar 19.

Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., E.B.-M., Z.L., D.B.M., J.P.P.).

Background: The optimal timing of catheter ablation for atrial fibrillation (AF) in reference to the time of diagnosis is unknown. We sought to assess the impact of the duration between first diagnosis of AF and ablation, or diagnosis-to-ablation time (DAT), on AF recurrence following catheter ablation.

Methods: We conducted a systematic electronic search for observational studies reporting the outcomes associated with catheter ablation for atrial fibrillation stratified by diagnosis-to-ablation time. The primary meta-analysis using a random effects model assessed AF recurrence stratified by DAT ≤1 year versus >1 year. A secondary analysis assessed outcomes stratified by DAT ≤3 years versus >3 years.

Results: Of the 632 screened studies, 6 studies met inclusion criteria for a total of 4950 participants undergoing AF ablation for symptomatic AF. A shorter DAT ≤1 year was associated with a lower relative risk of AF recurrence compared with DAT >1 year (relative risk, 0.73 [95% CI, 0.65-0.82]; <0.001). Heterogeneity was moderate (I=51%). When excluding the one study consisting of only patients with persistent AF, the heterogeneity improved substantially (I=0%, Cochran's Q =0.55) with a similar estimate of effect (relative risk, 0.78 [95% CI, 0.71-0.85]; <0.001).

Conclusions: Shorter duration between time of first AF diagnosis and AF ablation is associated with an increased likelihood of ablation procedural success. Additional study is required to confirm these results and to explore implementation of earlier catheter AF ablation and patient outcomes within the current AF care pathway. Visual Overview A visual overview is available for this article.
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http://dx.doi.org/10.1161/CIRCEP.119.008128DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7359927PMC
April 2020

Follow-Up of Patients With Atrial Fibrillation Discharged From the Emergency Department: Why, Who, When, and How?

Circ Arrhythm Electrophysiol 2019 12 16;12(12):e008087. Epub 2019 Dec 16.

Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, AB, Canada.

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http://dx.doi.org/10.1161/CIRCEP.119.008087DOI Listing
December 2019

Narrow Complex Tachycardia With an Unusual Block.

Circulation 2019 12 9;140(24):2040-2043. Epub 2019 Dec 9.

Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Canada (D.S.C., F.R.Q., S.B.W.).

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http://dx.doi.org/10.1161/CIRCULATIONAHA.119.043297DOI Listing
December 2019

Neglected cause of recurrent syncope: a case report of neurogenic orthostatic hypotension.

Eur Heart J Case Rep 2019 Jun;3(2)

Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, GAC70, HRIC Building, 3280 Hospital Drive NW, Calgary, AB T3H 0M8, Canada.

Background: Syncope commonly results in emergency room and physician visits, leading to hospitalization and invasive investigations. Up to 24% of these presentations may be caused by neurogenic orthostatic hypotension (nOH), which continues to be an under-recognized clinical entity. We review an approach to diagnosing nOH.

Case Summary: An 85-year-old man with a history of Parkinson's disease was referred for a history of recurrent syncope, which had resulted in extensive cardiac investigation. Collateral history revealed that the events were orthostatic in nature, but with variable time to onset of symptoms. The patient was found to have significant postural drop in blood pressure without compensatory tachycardia. Cardiovascular autonomic function testing was performed, which confirmed significant autonomic nervous system failure, including a marked hypotensive response on tilt-table testing and a lack of vasoconstriction during Valsalva manoeuvre. The patient was diagnosed with nOH and initiated on midodrine with subjective improvement in the frequency of syncope.

Discussion: Autonomic nervous system failure, with nOH, is a common cause of recurrent syncope, particularly in older patients. Attention to detail during the medical history, including precipitating factors and the presence of prodromal symptoms prior to syncope, is critical for making the correct diagnosis. Measuring orthostatic vital signs correctly in patients with syncope provides valuable information, is cost-effective, and critical to diagnose nOH.
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http://dx.doi.org/10.1093/ehjcr/ytz031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6601146PMC
June 2019

Monomorphic Ventricular Tachycardia as a Presentation of Giant Cell Myocarditis.

Case Rep Cardiol 2019 19;2019:7276516. Epub 2019 Jun 19.

Libin Cardiovascular Institute of Alberta, Cummings School of Medicine, University of Calgary, Alberta, Canada.

Background: Idiopathic giant cell myocarditis (GCM) has a fulminant course and typically presents in middle-aged adults with acute heart failure or ventricular arrhythmia. It is a rare disorder which involves T lymphocyte-mediated myocardial inflammation. Diagnosis is challenging and requires a high index of suspicion since therapy may improve an otherwise uniformly fatal prognosis.

Case Summary: A previously healthy 54-year-old female presented with hemodynamically significant ventricular arrhythmia (VA) and was found to have severe left ventricular dysfunction. Cardiac MRI demonstrated acute myocarditis, and endomyocardial biopsy showed giant cell myocarditis. She was treated with combined immunosuppressive therapy as well as guideline-directed medical therapy. A secondary prevention implantable cardioverter defibrillator (ICD) was implanted.

Discussion: GCM is a rare, lethal myocarditis subtype but is potentially treatable. Combined immunosuppression may achieve partial clinical remission in two-thirds of patients. VA is common, and patients should undergo ICD implantation. More research is needed to better understand this complex disease.

Learning Objectives: Giant cell myocarditis is an incompletely understood, rare cause of myocarditis. Patients present predominately with heart failure and dysrhythmia. Diagnosis is confirmed by histopathology, and immunosuppression may improve outcomes. ICD implantation should be considered. In the absence of treatment, prognosis is poor with a median survival of three months.
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http://dx.doi.org/10.1155/2019/7276516DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6607713PMC
June 2019

Evaluating and managing postural tachycardia syndrome.

Cleve Clin J Med 2019 May;86(5):333-344

Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada.

Postural tachycardia syndrome (POTS) is a disorder of the autonomic nervous system with many possible causes, characterized by an unexplained increase in heartbeat without change in blood pressure upon standing. Associated cardiac and noncardiac symptoms can severely affect quality of life. Therapy, using a combined approach of diet and lifestyle changes, plus judicious use of medications if needed, can usually improve symptoms and function.
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http://dx.doi.org/10.3949/ccjm.86a.18002DOI Listing
May 2019

Clinical practice guidelines for creating an acute care hospital-based antimicrobial stewardship program: A systematic review.

Am J Infect Control 2019 08 21;47(8):979-993. Epub 2019 Mar 21.

Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada; Canadian Agency for Drugs and Technologies in Health, Ontario, Canada.

Background: Antimicrobial stewardship programs (ASPs) are dedicated to improving antimicrobial use. Although clinical practice guidelines (CPGs) are available for the development of ASPs, it is unclear what the quality of these guidelines are. We therefore systematically reviewed published CPGs for the development of acute care hospital-based ASPs.

Methods: Primary literature, CPG and health technology assessment databases, and infectious diseases society websites were searched. Abstract and full-text review of the search results for inclusion were performed independently by 2 assessors. Overall quality of included CPGs was assessed using the Appraisal of Guidelines for Research and Evaluation II instrument.

Results: We identified 1,064 unique publications; 18 warranted full-text review. Five publications were included in the final review. The National Institute for Care and Excellence from the United Kingdom, the Dutch Working Party on Antibiotic Policy, and the Infectious Diseases Society of America/Society for Healthcare Epidemiology of America from the United States all had high quality guidelines on the Appraisal of Guidelines for Research and Evaluation II scale.

Discussion: We identified 5 CPGs for creating a hospital-based ASP. Prior authorization and/or restriction policies that appeared in all 5 guidelines should be considered essential for the development of an effective hospital-based ASP.

Conclusions: High quality CPGs are available for implementation of ASPs in acute care hospitals.
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http://dx.doi.org/10.1016/j.ajic.2019.02.010DOI Listing
August 2019

Economic analysis of osimertinib in previously untreated EGFR-mutant advanced non-small cell lung cancer in Canada.

Lung Cancer 2018 11 30;125:1-7. Epub 2018 Aug 30.

Princess Margaret Cancer Centre/University Health Network, Toronto, Ontario, Canada.

Introduction: Osimertinib improves progression-free survival in previously untreated EGFR-positive advanced non-small cell lung cancer (NSCLC) patients, with marked intracranial response rates. However, its cost-effectiveness in a publically funded health care system has not been established. We assessed the cost-effectiveness of first-line osimertinib from the public payer perspective in the Canadian health care system.

Methods: A Markov model was developed to project the outcomes and direct medical costs of initial treatment with osimertinib or current standard-of-care (SoC) EGFR TKIs, gefinitib or afatinib, in patients with previously untreated EGFR-mutant advanced NSCLC. Clinical and cost input estimates were informed from the available literature. Model outcomes included costs (in 2018 Canadian dollars), life years (LYs), quality-adjusted life-years (QALYs), and the cost utility of osimertinib compared to SoC EGFR TKI, or incremental cost per QALY gained.

Results: Initial treatment with osimertinib was associated with a gain of 0.79 QALY [95% confidence interval (CI), 0.74 to 0.83] at an incremental cost of $176,394 CAD (95% CI, 176,383 to 176,405) vs. SoC EGFR TKI (incremental cost-effectiveness ratio [ICER]: $223,133/QALY gained; 95%CI, 198,144 to 252,805). Osimertinib had a 0% probability of being cost-effective at a willingness-to-pay threshold of $100,000 per QALY. Deterministic sensitivity analysis showed that the cost of osimertinib had the largest impact on ICER results.

Conclusion: At the current marketed price, first-line osimertinib therapy in patients with advanced EGFR-mutant lung adenocarcinoma is not cost-effective in Canada. Reduction of osimertinib cost, for example by 25%, can significantly improve the cost-effectiveness profile.
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http://dx.doi.org/10.1016/j.lungcan.2018.08.024DOI Listing
November 2018

Effects of a reminder to initiate oral anticoagulation in patients with atrial fibrillation/atrial flutter discharged from the emergency department: REMINDER study.

CJEM 2018 11 8;20(6):841-849. Epub 2018 Oct 8.

*Libin Cardiovascular Institute of Alberta,Department of Cardiac Sciences,University of Calgary,Calgary,AB.

Objective: Oral anticoagulation (OAC) reduces stroke risk in patients with atrial fibrillation (AF) or atrial flutter (AFL). However, OAC initiation rates in patients discharged directly from the emergency department (ED) are low. We aimed to address this care gap by implementing a quality improvement intervention.

Methods: The study was performed in four Canadian urban EDs between 2015 and 2016. Patients were included if they had an electrocardiogram (ECG) documenting AF/AFL in the ED, were directly discharged from the ED, and were alive after 90 days. Baseline rates of OAC initiation were determined prior to the intervention. Between June and December 2016, we implemented our intervention in two EDs (ED-intervention), with the remaining sites acting as controls (ED-control). The intervention included a reminder statement prompting OAC initiation according to guideline recommendations, manually added to ECGs with a preliminary interpretation of AF/AFL, along with a decision-support algorithm that included a referral sheet. The primary outcome was the rate of OAC initiation within 90 days of the ED visit.

Results: Prior to the intervention, 37.2% OAC-naïve patients with ECG-documented AF/AFL were initiated on OAC. Following implementation of the intervention, the rate of OAC initiation increased from 38.6% to 47.5% (absolute increase of 8.5%; 95% CI, 0.3% to 16.7%, p=0.04) among the ED-intervention sites, whereas the rate remained unchanged in ED-control sites (35.3% to 35.9%, p=0.9).

Conclusions: Implementation of a quality improvement intervention consisting of a reminder and decision-support tool increased initiation of OAC in high-risk patients. This support package can be readily implemented in other jurisdictions to improve OAC rates for AF/AFL.
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http://dx.doi.org/10.1017/cem.2018.415DOI Listing
November 2018

Fragmented QRS complexes after acute myocardial infarction are independently associated with unfavorable left ventricular remodeling.

J Electrocardiol 2018 Jul - Aug;51(4):607-612. Epub 2018 Apr 12.

Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada. Electronic address:

Background: Recovery of left ventricular ejection fraction (LVEF) after acute myocardial infarction (MI) is not universal and is difficult to predict. Fragmented QRS (fQRS) complexes are thought to be markers of myocardial scar. We hypothesized that fQRS complexes on 12‑lead surface ECGs during the initial post-MI period would be associated with adverse LV remodeling over the following year.

Methods: Change in LVEF between the early (0-2 month) and later (2-12 month) post-MI periods was assessed in two independent cohorts of post-MI patients with initial LV dysfunction. A decline or no recovery in LVEF (ΔLVEF ≤0%) was used as a primary outcome. fQRS complexes were measured on 12‑lead ECGs within a week of acute MI. A subset of patients underwent cardiac magnetic resonance imaging (CMR) for scar quantification.

Results: Of 705 patients in the combined cohort, 27% experienced the primary outcome (average ΔLVEF of -4%). fQRS complexes were associated with a two-fold higher risk of no LVEF recovery, independent of prior MI or CABG, baseline LVEF, MI location and QRS duration or axis. Of 113 patients undergoing CMR, fQRS was associated with increased peri-infarct zone late gadolinium enhancement (13 ± 5% vs 11 ± 4%, p = 0.02), but not core infarct.

Conclusions: Despite contemporary post-MI therapy, >1 in 4 patients will show a decline in LVEF during follow-up. Fragmented QRS complexes on 12‑lead surface ECG early post-MI may be a valuable marker of unfavorable LV remodeling and correlate to increased peri-infarct scar on CMR imaging.
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http://dx.doi.org/10.1016/j.jelectrocard.2018.04.004DOI Listing
May 2019
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