Publications by authors named "Hassan Behlouli"

47 Publications

Impact of Race on the In-Hospital Quality of Care Among Young Adults With Acute Myocardial Infarction.

J Am Heart Assoc 2021 Sep 25;10(17):e021408. Epub 2021 Aug 25.

Department of Emergency Medicine University School of Medicine New Haven CT.

Background The extent to which race influences in-hospital quality of care for young adults (≤55 years) with acute myocardial infarction (AMI) is largely unknown. We examined racial disparities in in-hospital quality of AMI care and their impact on 1-year cardiac readmission. Methods and Results We used data from the VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study enrolling young Black and White US adults with AMI (2008-2012). An in-hospital quality of care score (QCS) was computed (standard AMI quality indicators divided by the total a patient is eligible for). Multivariable logistic regression was performed to identify factors associated with the lowest QCS tertile, including interactions between race and social determinants of health. Among 2846 young adults with AMI (median 48 years [interquartile range 44-52], 67.4% women, 18.8% Black race), Black individuals, especially women, exhibited a higher prevalence of cardiac risk factors and social determinants of health and were more likely to experience a non-ST-segment-elevation myocardial infarction than White individuals. Black individuals were more likely in the lowest QCS tertile than White individuals (40.8% versus 34.7%; =0.003). The association between Black race and low QCS (odds ratio [OR], 1.25; 95% CI, 1.02-1.54) was attenuated by adjustment for confounders. Employment was independently associated with better QCS, especially among Black participants (OR, 0.76; 95% CI, 0.62-0.92; P-=0.02). Black individuals experienced a higher rate of 1-year cardiac readmission (29.9% versus 20.0%; <0.0001). Conclusions Black individuals with AMI received lower in-hospital quality of care and exhibited a higher rate of cardiac readmissions than White individuals. Black individuals had a lower quality of care if unemployed, highlighting the intersection of race and social determinants of health.
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http://dx.doi.org/10.1161/JAHA.121.021408DOI Listing
September 2021

Gender score development in the Berlin Aging Study II: a retrospective approach.

Biol Sex Differ 2021 01 18;12(1):15. Epub 2021 Jan 18.

Berlin Institute for Gender in Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany.

In addition to biological sex, gender, defined as the sociocultural dimension of being a woman or a man, plays a central role in health. However, there are so far few approaches to quantify gender in a retrospective manner in existing study datasets. We therefore aimed to develop a methodology that can be retrospectively applied to assess gender in existing cohorts. We used baseline data from the Berlin Aging Study II (BASE-II), obtained in 2009-2014 from 1869 participants aged 60 years and older. We identified 13 gender-related variables and used them to construct a gender score by using primary component and logistic regression analyses. Of these, nine variables contributed to a gender score: chronic stress, marital status, risk-taking behaviour, personality attributes: agreeableness, neuroticism, extraversion, loneliness, conscientiousness, and level of education. Females and males differed significantly in the distribution of the gender score, but a significant overlap was also found. Thus, we were able to develop a gender score in a retrospective manner from already collected data that characterized participants in addition to biological sex. This approach will allow researchers to introduce the notion of gender retrospectively into a large number of studies.
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http://dx.doi.org/10.1186/s13293-020-00351-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7814714PMC
January 2021

Anticoagulant Use and the Risk of Thromboembolism and Bleeding in Postoperative Atrial Fibrillation After Noncardiac Surgery.

Can J Cardiol 2021 03 4;37(3):391-399. Epub 2020 Sep 4.

Research Institute McGill University Health Centre, Montréal, Québec, Canada; Division of General Internal Medicine, Department of Medicine, McGill University, Montréal, Québec, Canada. Electronic address:

Background: An effective and safe oral anticoagulation (OAC) strategy for patients with new postoperative AF (POAF) after noncardiac surgery remains unclear. We aimed to determine the association between OAC use and 1) thromboembolic events and 2) major bleeding in patients with POAF after noncardiac surgery.

Methods: A retrospective cohort (1999-2015) was used to identify patients with new POAF after inpatient noncardiac surgery. Initiation of OAC was defined as prescription of an OAC within 30 days following hospital discharge. Times to first hospital admission or emergency department visit for a thromboembolic or major bleeding event were compared using Cox proportional hazards models.

Results: We identified 22,007 patients with new POAF after inpatient noncardiac surgery. The majority of patients had intermediate (CHADS-VASc 2-3: 45%) to high (CHADS-VASc ≥ 4: 42%) thromboembolic risk. During a mean follow-up of 4 years, a total of 1099 (5%) thromboembolic and 3250 (15%) bleeding events occurred. Compared with patients not on anticoagulation, anticoagulation did not reduce the risk for thromboembolic events (adjusted hazard ratio [aHR] 0.89, 95% CI 0.73-1.07). In patients initiated on anticoagulation, there was an association with a higher risk for major bleeding (aHR 1.14, 95% CI 1.04-1.25).

Conclusions: In patients with new POAF after noncardiac surgery, anticoagulation was not associated with a reduction in long-term thromboembolic events; however, this was accompanied by an overall increased risk for major bleeding. Future prospective clinical studies are needed to better address the role for anticoagulation therapy in the setting of POAF after noncardiac surgery to understand the efficacy and safety of treatment.
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http://dx.doi.org/10.1016/j.cjca.2020.08.023DOI Listing
March 2021

Novel glucose lowering agents are associated with a lower risk of cardiovascular and adverse events in type 2 diabetes: A population based analysis.

Int J Cardiol 2020 07 15;310:147-154. Epub 2020 Apr 15.

Department of Experimental Medicine, McGill University, Montreal, Qc, Canada; Research Institute, McGill University Health Centre, Montreal, QC, Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada. Electronic address:

Background: Recent randomized control trials have described a protective cardiovascular effect of novel glucose lowering drugs in patients at high cardiovascular risk. Whether these second-line agents have similar effects in the general population is unknown. We aimed to compare the risk of major cardiovascular and adverse events in new users of sodium-glucose cotransporter-2 inhibitors (SGLT-2i), dipeptidyl peptidase-4 inhibitor (DPP-4i), glucagon-like peptide 1 agonist (GLP-1a), and sulfonylurea in T2DM patients not controlled on metformin therapy.

Methods: Retrospective cohort study using the MarketScan database (2011-2015). We selected T2DM individuals who were newly dispensed sulfonylureas, SGLT-2i, DPP-4i, or GLP-1a, as second-line therapy, added to metformin. Cohort entry was defined by date of first prescription of the second-line agent. Time to first non-fatal cardiovascular or adverse event was compared using Cox regression models adjusted for confounders.

Results: Among 118,341 T2DM patients using metformin (mean age: 56), most were at low cardiovascular risk (4% with previous cardiovascular or cerebrovascular event). During a median follow-up of 10 months compared with sulfonylureas users, cardiovascular risk was lower in users of SGLT-2i (aHR = 0.61; 95% CI: 0.40-0.97), DPP-4i (aHR = 0.79; 95% CI: 0.69-0.90) and GLP-1a (aHR = 0.65; 95% CI: 0.48-0.89). Serious adverse events were rare but compared with sulfonylurea, the risk was lower in new users of novel glucose lowering agents.

Conclusion: In our analyses, which included patients with and without prior cardiovascular disease, initiating novel glucose lowering drugs as second-line therapy for T2DM was associated with a lower risk of cardiovascular and adverse events than sulfonylurea initiation.
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http://dx.doi.org/10.1016/j.ijcard.2020.03.025DOI Listing
July 2020

Sex Differences in Cardiovascular Effectiveness of Newer Glucose-Lowering Drugs Added to Metformin in Type 2 Diabetes Mellitus.

J Am Heart Assoc 2020 01 4;9(1):e012940. Epub 2020 Jan 4.

Department of Medicine McGill University Montreal QC Canada.

Background Randomized controlled trials showed that newer glucose-lowering agents are cardioprotective, but most participants were men. It is unknown whether benefits are similar in women. Methods and Results Among adults with type 2 diabetes mellitus not controlled with metformin with no prior use of insulin, we assessed for sex differences in the cardiovascular effectiveness and safety of sodium-glucose-like transport-2 inhibitors (SGLT-2i), glucagon-like peptide-1 receptor agonists (GLP-1RA), dipeptidyl peptidase-4 inhibitors, initiated as second-line agents relative to sulfonylureas (reference-group). We studied type 2 diabetes mellitus American adults with newly dispensed sulfonylureas, SGLT-2i, GLP-1RA, or dipeptidyl peptidase-4 inhibitors (Marketscan-Database: 2011-2017). We used multivariable Cox proportional hazards models with time-varying exposure to compare time to first nonfatal cardiovascular event (myocardial infarction/unstable angina, stroke, and heart failure), and safety outcomes between drugs users, and tested for sex-drug interactions. Among 167 254 type 2 diabetes mellitus metformin users (46% women, median age 59 years, at low cardiovascular risk), during a median 4.5-year follow-up, cardiovascular events incidence was lower in women than men (14.7 versus 16.7 per 1000-person-year). Compared with sulfonylureas, hazard ratios (HRs) for cardiovascular events were lower with GLP-1RA (adjusted HR-women: 0.57, 95% CI: 0.48-0.68; aHR-men: 0.82, 0.71-0.95), dipeptidyl peptidase-4 inhibitors (aHR-women: 0.83, 0.77-0.89; aHR-men: 0.85, 0.79-0.91) and SGLT-2i (aHR-women: 0.58, 0.46-0.74; aHR-men: 0.69, 0.57-0.83). A sex-by-drug interaction was statistically significant only for GLP-1RA (=0.002), suggesting greater cardiovascular effectiveness in women. Compared with sulfonylureas, risks of adverse events were similarly lower in both sexes for GLP-1RA (aHR-women: 0.81, 0.73-0.89; aHR-men: 0.80, 0.71-0.89), dipeptidyl peptidase-4 inhibitors (aHR-women: 0.82, 0.78-0.87; aHR-men: 0.83, 0.78-0.87) and SGLT-2i (aHR-women: 0.68, 0.59-0.78; aHR-men: 0.67, 0.59-0.78) (all sex-drug interactions for adverse events >0.05). Conclusions Newer glucose-lowering drugs were associated with lower risk of cardiovascular events than sulfonylureas, with greater effectiveness of GLP-1RA in women than men. Overall, they appeared safe, with a better safety profile for SGLT-2i than for GLP-1RA regardless of sex.
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http://dx.doi.org/10.1161/JAHA.119.012940DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6988160PMC
January 2020

Association of Chromosome 9p21 With Subsequent Coronary Heart Disease Events.

Circ Genom Precis Med 2019 04 21;12(4):e002471. Epub 2019 Mar 21.

Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital (M.H.).

Background: Genetic variation at chromosome 9p21 is a recognized risk factor for coronary heart disease (CHD). However, its effect on disease progression and subsequent events is unclear, raising questions about its value for stratification of residual risk.

Methods: A variant at chromosome 9p21 (rs1333049) was tested for association with subsequent events during follow-up in 103 357 Europeans with established CHD at baseline from the GENIUS-CHD (Genetics of Subsequent Coronary Heart Disease) Consortium (73.1% male, mean age 62.9 years). The primary outcome, subsequent CHD death or myocardial infarction (CHD death/myocardial infarction), occurred in 13 040 of the 93 115 participants with available outcome data. Effect estimates were compared with case/control risk obtained from the CARDIoGRAMplusC4D consortium (Coronary Artery Disease Genome-wide Replication and Meta-analysis [CARDIoGRAM] plus The Coronary Artery Disease [C4D] Genetics) including 47 222 CHD cases and 122 264 controls free of CHD.

Results: Meta-analyses revealed no significant association between chromosome 9p21 and the primary outcome of CHD death/myocardial infarction among those with established CHD at baseline (GENIUS-CHD odds ratio, 1.02; 95% CI, 0.99-1.05). This contrasted with a strong association in CARDIoGRAMPlusC4D odds ratio 1.20; 95% CI, 1.18-1.22; P for interaction <0.001 compared with the GENIUS-CHD estimate. Similarly, no clear associations were identified for additional subsequent outcomes, including all-cause death, although we found a modest positive association between chromosome 9p21 and subsequent revascularization (odds ratio, 1.07; 95% CI, 1.04-1.09).

Conclusions: In contrast to studies comparing individuals with CHD to disease-free controls, we found no clear association between genetic variation at chromosome 9p21 and risk of subsequent acute CHD events when all individuals had CHD at baseline. However, the association with subsequent revascularization may support the postulated mechanism of chromosome 9p21 for promoting atheroma development.
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http://dx.doi.org/10.1161/CIRCGEN.119.002471DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6625876PMC
April 2019

Anticoagulant Use and Risk of Ischemic Stroke and Bleeding in Patients With Secondary Atrial Fibrillation Associated With Acute Coronary Syndromes, Acute Pulmonary Disease, or Sepsis.

JACC Clin Electrophysiol 2018 03 27;4(3):386-393. Epub 2017 Sep 27.

Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada; Divisions of General Internal Medicine and of Clinical Epidemiology, Department of Medicine, The Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada. Electronic address:

Objectives: The purpose of this study was to determine if anticoagulation of patients with new onset secondary atrial fibrillation (AF) occurring with acute coronary syndromes (ACS), acute pulmonary disease, or sepsis is associated with a reduction in ischemic stroke or an increase in bleeding risk.

Background: Studies evaluating the benefits and risks of anticoagulation in secondary AF are infrequent, and the optimal management of these patients is not well understood.

Methods: A retrospective study cohort was identified of 2,304 patients age 65 years or older, hospitalized with a primary diagnosis of ACS, acute pulmonary disease (chronic obstructive pulmonary disease, pneumonia/influenza, pulmonary embolism, or pleural effusion) or sepsis, and a complication of new-onset AF during admission from 1999 to 2015.

Results: Over a follow-up of ∼3 years, we did not identify any association between anticoagulation and a lower incidence of ischemic stroke in patients with new-onset AF occurring with ACS, acute pulmonary disease, or sepsis (odds ratio [OR]: 1.22 [95% confidence interval (CI): 0.65 to 2.27], OR: 0.97 [95% CI: 0.53 to 1.77], and OR: 1.98 [95% CI: 0.29 to 13.47]), after adjusting for confounders. However, anticoagulation was associated with a higher risk of bleeding in patients with AF associated with acute pulmonary disease (OR: 1.72 [95% CI: 1.23 to 2.39]), but not in ACS or sepsis (OR: 1.42 [95% CI: 0.94 to 2.14], OR: 0.96 [95% CI: 0.29 to 3.21]).

Conclusions: Our study demonstrates that the benefit of anticoagulation in secondary AF is not strong and can be associated with a higher risk of bleeding. Careful individual assessment regarding decisions on anticoagulation is warranted in these patients.
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http://dx.doi.org/10.1016/j.jacep.2017.08.003DOI Listing
March 2018

Long-term risk of stroke and bleeding post-atrial fibrillation ablation.

J Cardiovasc Electrophysiol 2018 10 12;29(10):1355-1362. Epub 2018 Oct 12.

Division of Cardiology, McGill University Health Centre and McGill Research Institute, Montreal, Canada.

Background: Catheter ablation (CA) is an established therapy for atrial fibrillation (AF). Studies regarding long-term real-world outcomes post-CA have inconsistently accounted for oral anticoagulation (OAC).

Objectives: To describe patterns of OAC use post-CA and to compare the OAC-adjusted long-term risk of stroke and major bleeding in AF patients with and without CA.

Methods: A population-based cohort of AF patients was constructed in Quebec and Ontario, Canada (1999-2014). Propensity score matching was performed to determine the incidence rates of stroke and major bleeding among those undergoing CA, adjusted for time-dependent OAC use.

Results: From the entire cohort, 6391 patients were identified as having undergone CA as compared to 482 977 patients who did not. Of these, 1240 patients with government medical insurance undergoing CA were matched with 2427 patients without CA. Post-CA, 78%, 65%, and 61% remained on an OAC at 1, 2, and 5 years, while 75%, 71%, and 68% of patients not undergoing CA were on OACs at 1, 2, and 5 years. At follow-up, there was no statistically significant difference for stroke (adjusted hazard ratio [HR], 0.88; 95% CI, 0.63 to 1.21) or major bleeding (adjusted HR, 0.88; 95% CI, 0.73 to 1.06).

Conclusion: No evidence was found that CA significantly decreases the risk of stroke or major bleeding when adjusting for OAC use over time. It may be prudent to continue anticoagulation post-CA based on patient-risk profile until randomized trials demonstrate both reduced stroke rates with CA, and improved safety (balancing stroke and bleeding risk) with OAC discontinuation post-CA.
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http://dx.doi.org/10.1111/jce.13702DOI Listing
October 2018

Population-Based Evaluation of Major Adverse Events After Catheter Ablation for Atrial Fibrillation.

JACC Clin Electrophysiol 2017 12 30;3(12):1425-1433. Epub 2017 Aug 30.

Division of Cardiology, McGill University Health Centre Research Institute, Montreal, Quebec, Canada.

Objectives: The purpose of this study was to evaluate the safety and incidence of periprocedural adverse events (AEs) among patients who underwent catheter ablation (CA) for atrial fibrillation (AF) in Quebec and Ontario, Canada.

Background: CA is evolving into the mainstay therapy for patients with symptomatic AF refractory to antiarrhythmic medication. However, the safety of CA at the population level over time requires further evaluation.

Methods: A population-based cohort was constructed using administrative databases of all patients who underwent CA between 1999 and 2014 in Quebec and Ontario, Canada. Incidence and predictors of AEs were assessed within 30 days of CA. Major AEs included all-cause mortality, cerebrovascular accident (CVA) including transient ischemic attack, pericardial effusion requiring drainage (PERD), vascular AEs, hemorrhage/hematoma, and pulmonary embolism.

Results: Of 6,388 patients who had a CA (mean age 57.3 years; mean CHADS-VASc 1.1 ± 1.4; 27.6% female), 221 (3.5%) patients developed major AEs within 30 days of index CA. Hemorrhage/hematoma was the most frequent (1.4%), followed by PERD (1.0%) and CVA (0.6%). PERD was more likely to occur post-discharge than during the index CA (p < 0.05). CVA decreased by more than 50% in patients with recent compared with remote CA (p < 0.05). Compared with index CA, the incidence of PERD and hemorrhage/hematoma was greater at first repeat CA (p < 0.05 for both).

Conclusions: CA is a relatively safe procedure with low incidence of major AEs. The incidence of procedure-related CVA appeared to decline significantly over time. Incidence of PERD remained relatively stable and was more likely to be diagnosed after discharge and following repeat CA.
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http://dx.doi.org/10.1016/j.jacep.2017.04.010DOI Listing
December 2017

Treatment Discontinuation and Clinical Events in Type 2 Diabetes Patients Treated with Dipeptidyl Peptidase-4 Inhibitors or NPH Insulin as Third-Line Therapy.

J Diabetes Res 2018 11;2018:4817178. Epub 2018 Mar 11.

Centre for Outcome Research & Evaluation (CORE), McGill University, Montréal, QC, Canada H3A 0G4.

Objective: To compare dipeptidyl peptidase-4 (DPP-4) inhibitors with neutral protamine Hagedorn (NPH) insulin, in terms of effectiveness and safety for the management of patients with type 2 diabetes mellitus (DM2) not controlled on metformin and sulfonylureas.

Methods: A retrospective cohort study of individuals with DM2 newly dispensed with either DPP-4 inhibitors or NPH as third-line therapy, after metformin and sulfonylurea. Treatment discontinuation, macrovascular outcomes, and hypoglycemia were compared using multivariable Cox regression models, adjusted for sex, age, year of cohort entry, place of residence, hypertension, past history of hypoglycemia, diabetic ketoacidosis, comorbidities, and number of visits to emergency departments, outpatient physician, and hospitalizations.

Results: Treatment discontinuation and hypoglycemia occurred more frequently with NPH than with DPP-4 inhibitor users. In the adjusted Cox model, the use of NPH compared to that of DPP-4 inhibitors was associated with a higher risk of discontinuation (HR: 1.33; 95% CI 1.27-1.40) and hypoglycemia (HR: 2.98; 95% CI 2.72-3.28). Risk of cardiovascular events was similar across groups.

Conclusions: This real-world analysis suggests that DM2 patients initiating third-line therapy with NPH have poorer control of diabetes when compared to DPP-4 inhibitor initiators.
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http://dx.doi.org/10.1155/2018/4817178DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5866860PMC
October 2018

An exploration of the subjective social status construct in patients with acute coronary syndrome.

BMC Cardiovasc Disord 2018 02 6;18(1):22. Epub 2018 Feb 6.

Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada.

Background: Perception of low subjective social status (SSS) relative to others in society or in the community has been associated with increased risk of cardiovascular disease. Our objectives were to determine whether low SSS in society was associated with barriers to access to care or hospital readmission in patients with established cardiovascular disease, and whether perceptions of discordantly high SSS in the community modified this association.

Methods: We conducted a prospective cohort study from 2009 to 2013 in Canada, United States, and Switzerland in patients admitted to hospital with acute coronary syndrome (ACS). Data on access to care and SSS variables were obtained at baseline. Readmission data were obtained 12 months post-discharge. We conducted multivariable logistic regression to model the odds of access to care and readmission outcomes in those with low versus high societal SSS.

Results: One thousand ninety patients admitted with ACS provided both societal and community SSS rankings. The low societal SSS cohort had greater odds of reporting that their health was affected by lack of health care access (OR 1.48, 95% CI 1.11, 1.97) and of experiencing cardiac readmissions (1.88, 95% CI 1.15, 3.06). Within the low societal SSS cohort, there was a trend toward fewer access to care barriers for those with discordantly high community SSS though findings varied based on the outcome variable. There were no statistically significant differences in readmissions based on community SSS rankings.

Conclusion: Low societal SSS is associated with increased barriers to access to care and cardiac readmissions. Though attenuated, these trends remained even when adjusting for clinical and sociodemographic factors, suggesting that perceived low societal SSS has health effects above and beyond objective socioeconomic factors. Furthermore, high community SSS may potentially mitigate the risk of experiencing barriers to access to health care in those with low societal SSS, though these associations were not statistically significant. Subjective social status relative to society versus relative to the community seem to represent distinct concepts. Insight into the differences between these two SSS constructs is imperative in the understanding of cardiovascular health and future development of public health policies.
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http://dx.doi.org/10.1186/s12872-018-0759-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5801903PMC
February 2018

Comparative effectiveness of antihypertensive drugs in nondiabetic patients with hypertension: A population-based study.

J Clin Hypertens (Greenwich) 2017 Oct 29;19(10):999-1009. Epub 2017 Jul 29.

Divisions of General Internal Medicine and Clinical Epidemiology, Department of Medicine, McGill University and McGill University Health Center Research Institute, Montreal, Quebec, Canada.

The authors compared the effectiveness of thiazide diuretic (TD), angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), and calcium channel blocker (CCB) monotherapies for the treatment of nondiabetic hypertension using MarketScan Databases 2010-2014. Multivariable Cox regression models assessed whether the addition of a new antihypertensive drug, treatment discontinuation, or switch and major cardiovascular or cerebrovascular events varied across groups. A total of 565 009 patients started monotherapy with ACEIs (43.6%), CCBs (23.6%), TDs (18.8%), or ARBs (14.0%). Patients who took TDs had a higher risk for either drug addition or discontinuation than patients who took ACEIs (hazard ratio [HR], 0.69 [95% CI, 0.68-0.70] vs HR, 0.81 [95% CI, 0.80-0.81]), ARBs (HR, 0.67 [95% CI, 0.66-0.68] vs HR, 0.66 [95% CI, 0.65-0.67]), and CCBs (HR, 0.85 [95% CI, 0.84-0.87] vs HR, 0.94 [95% CI, 0.93-0.95]). Conversely, patients who took TDs experienced a lower risk of clinical events compared with patients who took ACEIs (HR, 1.24 [95% CI, 1.15-1.33]), ARBs (HR, 1.28 [95% CI, 1.18-1.39]), and CCBs (HR, 1.35 [95% CI, 1.25-1.46]). Our results provide a strong rationale for choosing TDs as first-line monotherapy for the control of hypertension.
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http://dx.doi.org/10.1111/jch.13055DOI Listing
October 2017

Catheter ablation for the treatment of atrial fibrillation is associated with a reduction in health care resource utilization.

J Cardiovasc Electrophysiol 2017 Jul 8;28(7):733-741. Epub 2017 Jun 8.

Division of Clinical Epidemiology, McGill University Health Centre Research Institute, Montreal, Quebec, Canada.

Background: Catheter ablation (CA) is superior to antiarrhythmic therapy at reducing recurrence of atrial fibrillation (AF); however, there are limited data regarding whether this decrease translates into a reduction in health care resource utilization.

Objective: To evaluate the impact of AF ablation on long-term health care resource utilization.

Methods: A population-based cohort was constructed to include patients who underwent CA for AF in Quebec, Canada, between April 2005 and March 2011. Resource utilization was evaluated 24 months pre- and postindex CA procedure.

Results: In a cohort of 1,556 patients, resource utilization increased progressively over the 24-month period leading to index CA (P for trend <0.05 for hospitalizations, ER visits, outpatient visits, cardioversions, and echocardiograms). After index CA, all-cause hospitalizations, hospitalizations for AF, ER visits, cardioversions, and echocardiograms were reduced 12 months post-CA compared to 12 months prior (all-cause hospitalizations 0.8-0.6 per patient per year; hospitalizations for AF 0.4-0.3; ER visits 2.9-1.8; cardioversions 0.5-0.2; echocardiograms 0.8-0.5; P < 0.05 for all trends). Resource utilization continued to decline at 24 months post-CA (vs. 12 months prior) for all-cause hospitalizations (0.4), cardioversions (0.1), and echocardiograms (0.3) (per patient year; P < 0.05 for all trends).

Conclusion: In conclusion, the pattern of increasing health care resource utilization preceding CA for AF reverses after CA to lower than preablation levels up to 24 months post-CA.
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http://dx.doi.org/10.1111/jce.13225DOI Listing
July 2017

Early non-persistence with dabigatran and rivaroxaban in patients with atrial fibrillation.

Heart 2017 09 12;103(17):1331-1338. Epub 2017 Mar 12.

Division of Cardiology, McGill University Health Centre, Montreal, Quebec, Canda.

Objective: Dabigatran and rivaroxaban are novel oral anticoagulants (NOACs) approved for stroke prevention in atrial fibrillation (AF). Although NOACs are more convenient than warfarin, their lack of monitoring may predispose patients to non-persistence. Limited information is available on NOAC non-persistence rates and related clinical outcomes in clinical practice.

Methods: We conducted a retrospective cohort study using administrative data from Ontario, Canada, from January 1998 to March 2014 of patients with AF who were dispensed dabigatran or rivaroxaban. Non-persistence was defined as a gap in dabigatran or rivaroxaban prescriptions ≥14 days. A multivariable Cox proportional hazards model was used to estimate the primary composite outcome of stroke, transient ischaemic attack (TIA) and mortality associated with non-persistence.

Results: The cohort consisted of 15 857 dabigatran (age 80.7±6.7 year) and 10 119 rivaroxaban users (age 77.0±7.1 year) with women comprising 52% of each medication group. At 6 months, 36.4% of patients were non-persistent to dabigatran, while 31.9% of patients were non-persistent to rivaroxaban. Stroke/TIA/death was significantly higher for those non-persistent to dabigatran (HR 1.76 (95% CI 1.60 to 1.94); p<0.0001) or rivaroxaban (HR 1.89 (95% CI 1.64 to 2.19); p<0.0001) compared with those who were persistent. Risk of stroke/TIA was markedly higher in non-persistent patients to dabigatran (HR 3.75 (95% CI 2.59 to 5.43); p<0.0001) and rivaroxaban (HR 6.25 (95% CI 3.37 to 11.58); p<0.0001) than those persistent.

Conclusions: NOAC non-persistence rates are high in clinical practice, with approximately one in three patients becoming non-persistent to dabigatran or rivaroxaban within 6 months after drug initiation. Non-persistence with either dabigatran or rivaroxaban is significantly associated with worse clinical outcomes of stroke/TIA/death.
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http://dx.doi.org/10.1136/heartjnl-2016-310672DOI Listing
September 2017

Sex Versus Gender-Related Characteristics: Which Predicts Outcome After Acute Coronary Syndrome in the Young?

J Am Coll Cardiol 2016 Jan;67(2):127-135

Divisions of General Internal Medicine and of Clinical Epidemiology, Department of Medicine, The Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada; Division of Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada. Electronic address:

Background: "Gender" reflects social norms for women and men, whereas "sex" defines biological characteristics. Gender-related characteristics explain some differences in access to care for premature acute coronary syndrome (ACS); whether they are associated with cardiovascular outcomes is unknown.

Objectives: This study estimated associations between gender and sex with recurrent ACS and major adverse cardiac events (MACE) (e.g., ACS, cardiac mortality, revascularization) over 12 months in patients with ACS.

Methods: We studied 273 women and 636 men age 18 to 55 years from GENESIS-PRAXY (GENdEr and Sex determInantS of cardiovascular disease: from bench to beyond-Premature Acute Coronary SYndrome), a prospective observational cohort study, who were hospitalized for ACS between January 2009 and April 2013. Gender-related characteristics (e.g., social roles) were assessed using a self-administered questionnaire, and a composite measure of gender was derived. Outcomes included recurrent ACS and MACE over 12 months.

Results: Feminine roles and personality traits were associated with higher rates of recurrent ACS and MACE compared with masculine characteristics. This difference persisted for recurrent ACS, after multivariable adjustment (hazard ratio from score 0 to 100: 4.50; 95% confidence interval: 1.05 to 19.27), and was a nonstatistically significant trend for MACE (hazard ratio: 1.54; 95% confidence interval: 0.90 to 2.66). A possible explanation is increased anxiety, the only condition that was more prevalent in patients with feminine characteristics and that rendered the association between gender and recurrent ACS nonstatistically significant (hazard ratio: 3.56; 95% confidence interval: 0.81 to 15.61). Female sex was not associated with outcomes post-ACS.

Conclusions: Younger adults with ACS with feminine gender are at an increased risk of recurrent ACS over 12 months, independent of female sex.
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http://dx.doi.org/10.1016/j.jacc.2015.10.067DOI Listing
January 2016

Potential factors associated with fruit and vegetable intake after premature acute coronary syndrome: a prospective cohort study.

Int J Food Sci Nutr 2015 3;66(8):943-9. Epub 2015 Nov 3.

b Division of Clinical Epidemiology , Research Institute of McGill University Health Centre , Montreal , Quebec , Canada .

Studies on dietary changes and their associated factors are limited, particularly with respect to younger cardiovascular patients. Our objective was to evaluate the factors associated with fruit and vegetable intake among adults with premature acute coronary syndrome (ACS) 1 year after the event. We used data from GENESIS-PRAXY, a multicentre prospective study of adults aged 18-55 years, hospitalised for ACS. Participants were 704 adults from 24 centres in Canada, 1 in USA and 1 in Switzerland. Data were collected through questionnaires and chart reviews at baseline and 1 year post-ACS. Fruit and vegetable intake was low among adults with premature ACS, and remained suboptimal at 1 year post-ACS, with only 21% meeting the minimum recommendations of at least 5 daily servings. The findings suggest that patient lifestyle characteristics, such as the number of hours spent at work and baseline intake are factors that may be associated with the intake of fruits and vegetables. More research is needed to assess effective strategies to increase fruit and vegetable intake among patients with premature ACS so that they meet dietary recommendations.
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http://dx.doi.org/10.3109/09637486.2015.1102873DOI Listing
September 2016

Dabigatran use in elderly patients with atrial fibrillation.

Thromb Haemost 2016 Jan 10;115(1):152-60. Epub 2015 Sep 10.

Louise Pilote, MD, MPH, PhD, McGill University Health Centre, 687 Pine Ave West, V Building, Montreal, Quebec, H3A 1A1 Canada, Tel.: +1 514 934 1934 ext. 44722, Fax: +1 514 934 8293, E-mail:

In elderly patients (≥ 75 years), evidence of dabigatran efficacy is lacking and increased vigilance is warranted. We aimed to assess dabigatran effectiveness and safety in elderly patients in real-world practice. We conducted a population-based study using administrative databases, in Quebec (1999-2013). Dabigatran users (110/150 mg) were compared with matched warfarin users with regard to stroke and bleeding events. Age was categorised into < 75 or ≥ 75 years. Propensity score adjusted models were used. The cohort consisted of 15,918 dabigatran users and 47,192 matched warfarin users, with 67.3% being elderly patients. The elderly predominantly used the lower dose (80.1%) while younger patients mainly used the higher dose (80.0%). In multivariable analyses adjusted for propensity score, the risk of stroke in elderly patients using dabigatran, was no different than the risk in warfarin users (HR 1.05, 95% CI: 0.93, 1.19) regardless of dabigatran dose. However, dabigatran was associated with lower rates of intracranial haemorrhage (HR 0.60, 95% CI: 0.47-0.76) and higher rates of gastrointestinal bleeding (HR 1.30 95% CI: 1.14-1.50) when compared to warfarin. Based on real-life experience, dabigatran can offer an alternative to warfarin in elderly patients, with fewer intracranial bleeding events. However, caution is warranted for gastrointestinal bleeding.
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http://dx.doi.org/10.1160/TH15-03-0247DOI Listing
January 2016

Sex differences in health behavior change after premature acute coronary syndrome.

Am Heart J 2015 Aug 17;170(2):242-8. Epub 2015 Apr 17.

Division of Clinical Epidemiology, Research Institute of McGill University Health Centre, Montreal, Quebec, Canada; Division of General Internal Medicine, McGill University Health Centre, Montreal, Quebec, Canada. Electronic address:

Background: Limited information is available on the health behavior profile of patients with premature acute coronary syndrome (ACS). The purpose of this study is to desribe the health bahvior of young patients with ACS at the baseline and 1 year post-ACS and examine sex differences.

Methods: GENESIS-PRAXY is a prospective cohort study of adults (18-55 years old) hospitalized with ACS from 26 centers located in Canada, United States, and Switzerland. Data on diet, physical activity, smoking, alcohol consumption, and recreational drug use were collected through self-administered questionnaires at baseline and 1 year post-ACS.

Results: Our analysis included 740 patients with complete data. At baseline, the health behavior profile of young patients with ACS was worse than that of the general population. Men had a lower fruit and vegetable intake, consumed alcohol more, and used recreational drugs more than women. Conversely, fewer men than women were smokers (34% vs 42%). At 1 year post-ACS, the proportion of those consuming ≥5 daily servings of fruits and vegetables increased modestly (+5% vs +1%, for men vs women) but remained lower than the general population. Among women, the prevalence of smoking remained about twice as high as the general population. Recreational drug use also remained higher than in the general population.

Conclusions: Despite small improvements at 1 year post-ACS, the health behavior profile of young patients remained worse than that of the general population. Greater efforts to improve health behaviors post-ACS among young patients are needed, and a sex-based approach may be required to ensure successful behavioral changes.
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http://dx.doi.org/10.1016/j.ahj.2015.04.016DOI Listing
August 2015

Temporal trends and sex differences in pulmonary vein isolation for patients with atrial fibrillation.

Heart Rhythm 2015 Sep 18;12(9):1979-86. Epub 2015 Jun 18.

Division of Clinical Epidemiology; Division of General Internal Medicine, McGill University Health Centre, Montreal, Quebec, Canada. Electronic address:

Background: Indications for pulmonary vein isolation for the treatment of atrial fibrillation (AF) have expanded over the years.

Objective: We aimed to describe trends in demographic and clinical characteristics of patients undergoing ablation, with a particular focus on sex differences.

Methods: Patients who underwent first AF ablation between 2003 and 2012 were identified within an AF cohort by using Quebec administrative databases. Descriptive statistics and multivariable analysis were used to examine sex differences and temporal trends in demographic and clinical characteristics, as well as independent predictors of the ablation procedure.

Results: A total of 2438 of 173,689 patients in the AF cohort underwent AF ablation. In the span of 10 years, the rate of AF ablation increased from 8.5 to 57.2 per million persons-an almost 7-fold increase. Patients undergoing ablation were younger than patients in the general AF cohort (57.4 ± 12.2 years vs 75.3 ± 12.0 years) and had fewer baseline comorbidities (56.7% vs 88.4%). Representing 42.9% of the general AF cohort, the annual proportion of women in the AF ablation cohort has not surpassed 30%, and men had a higher likelihood of undergoing ablation than did women (odds ratio 1.54; 95% confidence interval 1.40-1.69). Over the decade of observation, there were slight increases in patient age, comorbidities, and CHADS2 score, some of which reached clinical significance for men and/or women.

Conclusion: The uptake of AF ablation over 10 years has expanded, with an increasingly greater number of older patients and with increased presence of comorbidities; however, there has been no increase in the relatively low proportion of women undergoing AF ablation.
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http://dx.doi.org/10.1016/j.hrthm.2015.06.029DOI Listing
September 2015

Health-related quality of life in premature acute coronary syndrome: does patient sex or gender really matter?

J Am Heart Assoc 2014 Jul 28;3(4). Epub 2014 Jul 28.

Division of Clinical Epidemiology, McGill University Health Centre, Montreal, Quebec, Canada (S.L.L.Y., R.P., H.B., L.P.) Division of General Internal Medicine, McGill University Health Centre, Montreal, Quebec, Canada (L.P.).

Background: Limited data exist as to the relative contribution of sex and gender on health-related quality of life (HRQL) among patients with acute coronary syndrome (ACS). This study aims to evaluate the effect of sex and gender-related variables on long-term HRQL among young adults with ACS.

Methods And Results: GENESIS-PRAXY (GENdEr and Sex determInantS of cardiovascular disease: from bench to beyond-Premature Acute Coronary SYndrome) is a multicenter, prospective cohort study (January 2009 to August 2013) of adults aged 18 to 55 years, hospitalized with ACS. HRQL was measured at baseline, 1, 6, and 12 months using the Short Form-12 and Seattle Angina Questionnaire (SAQ) among 1213 patients. Median age was 49 years. Women reported worse HRQL than men over time post-ACS, both in terms of physical and mental functioning. Gender-related factors were more likely to be predictors of HRQL than sex. Femininity score, social support, and housework responsibility were the most common gender-related predictors of HRQL at 12 months. We observed an interaction between female sex and social support (β=0.44 [95% confidence interval, 0.01, 0.88]; P=0.047) for the physical limitation subscale of the SAQ.

Conclusions: Young women with ACS report significantly poorer HRQL than young men. Gender appears to be more important than sex in predicting long-term HRQL post-ACS. Specific gender-related factors, such as social support, may be amenable to interventions and could improve the HRQL of patients with premature ACS.
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http://dx.doi.org/10.1161/JAHA.114.000901DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4310372PMC
July 2014

Relation of digoxin use in atrial fibrillation and the risk of all-cause mortality in patients ≥65 years of age with versus without heart failure.

Am J Cardiol 2014 Aug 16;114(3):401-6. Epub 2014 May 16.

Division of Clinical Epidemiology, McGill University Health Center, Montreal, Quebec, Canada; Division of Internal Medicine, McGill University Health Center, Montreal, Quebec, Canada. Electronic address:

Previous studies on digoxin use in patients with atrial fibrillation (AF) and the risk of all-cause mortality found conflicting results. We conducted a population-based, retrospective, cohort study of patients aged ≥65 years admitted to a hospital with a primary or secondary diagnosis of AF, in Quebec province, Canada, from 1998 to 2012. The AF cohort was grouped into patients with and without heart failure (HF) and into digoxin and no-digoxin users according to the first prescription filled for digoxin within 30 days after AF hospital discharge. We derived propensity score-matched digoxin and no-digoxin treatment groups for the groups of patients with and without HF, respectively, and conducted multivariable Cox proportional hazards regression analyses to determine association between digoxin use and all-cause mortality. The AF propensity score-matched cohorts of patients with and without HF were well balanced on baseline characteristics. In the propensity score-matched HF group, digoxin use was associated with a 14% greater risk of all-cause mortality (adjusted hazard ratio 1.14, 95% confidence interval 1.10 to 1.17). In the propensity score-matched no-HF group, digoxin use was associated with a 17% greater risk of all-cause mortality (adjusted hazard ratio 1.17, 95% confidence interval 1.14 to 1.19). In conclusion, our retrospective analyses found that digoxin use was associated with a greater risk for all-cause mortality in patients aged ≥65 years with AF regardless of concomitant HF. Large, multicenter, randomized controlled trials or prospective cohort studies are required to clarify this issue.
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http://dx.doi.org/10.1016/j.amjcard.2014.05.013DOI Listing
August 2014

Warfarin use and the risk for stroke and bleeding in patients with atrial fibrillation undergoing dialysis.

Circulation 2014 Mar 22;129(11):1196-203. Epub 2014 Jan 22.

Divisions of Clinical Epidemiology and General Internal Medicine, McGill University Health Center, Montreal, Quebec, Canada (M.S., M.A.T., NE.R., H.B., L.P._; Department of Pharmacy Practice and Administration, College of Pharmacy, Western University of Health Sciences, Pomona, CA (C.A.J.); Division of Cardiology, McGill University Health Center, Montreal, Quebec, Canada (V.E.); Divisions of Cardiology and Clinical Epidemiology, Jewish General Hospital/McGill University, Montreal, Quebec, Canada (M.J.E.); Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada (K.H.H.); Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, Canada; Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada (J.V.T.); and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada (H.G.).

Background: Current observational studies on warfarin use and the risk for stroke and bleeding in patients with atrial fibrillation (AF) undergoing dialysis found conflicting results.

Methods And Results: We conducted a population-based retrospective cohort study of patients aged ≥65 years admitted to a hospital with a primary or secondary diagnosis of AF, in Quebec and Ontario, Canada from 1998 to 2007. The AF cohort was grouped into dialysis (hemodialysis and peritoneal dialysis) and nondialysis patients and into warfarin and no-warfarin users according to the first prescription filled for warfarin within 30 days after AF hospital discharge. We determined the association between warfarin use and the risk for stroke and bleeding in dialysis and nondialysis patients. The cohort comprised 1626 dialysis patients and 204 210 nondialysis patients. Among dialysis patients, 46% (756/1626) patients were prescribed warfarin. Among dialysis patients, warfarin users had more congestive heart failure and diabetes mellitus, but fewer prior bleeding events in comparison with the no-warfarin users. Among dialysis patients, warfarin use, in comparison with no-warfarin use, was not associated with a lower risk for stroke (adjusted hazard ratio, 1.14; 95% confidence interval, 0.78-1.67) but was associated with a 44% higher risk for bleeding (adjusted hazard ratio, 1.44; 95% confidence interval, 1.13-1.85) after adjusting for potential confounders. Propensity score-adjusted analyses yielded similar results.

Conclusions: Our results suggest that warfarin use is not beneficial in reducing stroke risk, but it is associated with a higher bleeding risk in patients with AF undergoing dialysis.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.113.004777DOI Listing
March 2014

Sex- and gender-related risk factor burden in patients with premature acute coronary syndrome.

Can J Cardiol 2014 Jan 13;30(1):109-17. Epub 2013 Nov 13.

Division of Clinical Epidemiology, McGill University Health Centre, Montreal, Québec, Canada; Division of General Internal Medicine, McGill University Health Centre, Montreal, Québec, Canada. Electronic address:

Background: Few contemporary data exist on traditional (TRF) and non-TRF (NTRF) burden in patients with premature acute coronary syndrome (ACS).

Methods: Prevalence of TRFs and NTRFs were measured in 1015 young (55 years old or younger) ACS patients recruited from 26 centres in Canada, the United States, and Switzerland. Risk factors were compared across sex and family history categories, and against a sample of the general Canadian population based on the 2000-2001 Canadian Community Health Survey. The 10- and 30-year risks of cardiovascular disease (CVD) were estimated using Framingham Risk Scores.

Results: Risk factors were more prevalent in premature ACS patients compared with the general population. Young women with a family history of coronary artery disease showed the greatest risk factor burden including TRFs of hypertension (67%), dyslipidemia (67%), obesity (53%), smoking (42%), and diabetes (33%), and NTRFs of anxiety (55%), low household income (44%), and depression (37%). The estimated median 10-year risk of CVD was 7% (interquartile range [IQR], 3%-9%) in women and 13% (IQR, 7%-17%) in men, whereas the 30-year risk of CVD was 36% (IQR, 22%-49%) in women and 44% (IQR, 31%-57%) in men.

Conclusions: Patients with premature ACS, especially women with a positive family history, are characterized by a very high risk factor burden that is poorly captured by 10-year risk estimates but better captured by 30-year estimates. Consideration of NTRFs and use of 30-year risk estimates might better estimate risk in young individuals and improve the prevention of premature ACS.
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http://dx.doi.org/10.1016/j.cjca.2013.07.674DOI Listing
January 2014

Gender and other disparities in referral to specialized heart failure clinics following emergency department visits.

J Womens Health (Larchmt) 2013 Jun;22(6):526-31

Université de Montréal, Montreal, Quebec H3C3J7, Canada.

Background: Persons with heart failure (HF) at high risk for adverse events should be followed by specialized HF clinics, since follow-up by specialized HF clinics improves outcomes for HF patients. The objective was to determine whether there were disparities for gender and other factors associated with referral of patients to specialized HF clinics.

Methods: In this prospective cohort study, patients with a confirmed primary diagnosis of HF were recruited by nurses at 8 hospital emergency departments (ED) in Québec, Canada. They were interviewed by telephone at 6 weeks post ED discharge and subsequently at 3 months and 6 months. Pertinent clinical variables were extracted from medical charts by trained nurses. Bivariate analysis and multiple logistic regression were used to identify whether gender and other potential factors were associated with referral to the HF clinic.

Results: We enrolled 549 patients (mean age 75.5±11.0 years; 51% males). By 6 months after their ED visit for HF, 37.6% of the cohort were referred to specialized HF clinics. Men were more likely to be referred (odds ratio [OR] 2.04; 95% confidence interval [CI] 1.12, 3.74). Other factors associated with referral were younger age (OR 0.95; 95% CI 0.92, 0.98), and systolic dysfunction HF (left ventricle ejection fraction <40%) (OR 3.08; 95% CI 1.77, 5.46).

Conclusion: There are disparities in referral with respect to gender, age, and type of HF. These disparities in referral need to be addressed.
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http://dx.doi.org/10.1089/jwh.2012.4107DOI Listing
June 2013

Access to heart failure care post emergency department visit: do we meet established benchmarks and does it matter?

Am Heart J 2013 May 21;165(5):725-32. Epub 2013 Mar 21.

Université de Montréal, Montreal, Quebec, Canada.

Background: The Canadian Cardiology Society recommends that patients should be seen within 2 weeks after an emergency department (ED) visit for heart failure (HF). We sought to investigate whether patients who had an ED visit for HF subsequently consult a physician within the current established benchmark, to explore factors related to physician consultation, and to examine whether delay in consultation is associated with adverse events (AEs) (death, hospitalization, or repeat ED visit).

Methods: Patients were recruited by nurses at 8 hospital EDs in Québec, Canada, and interviewed by telephone within 6 weeks of discharge and subsequently at 3 and 6 months. Clinical variables were extracted from medical charts by nurses. We used Cox regression in the analysis.

Results: We enrolled 410 patients (mean age 74.9 ± 11.1 years, 53% males) with a confirmed primary diagnosis of HF. Only 30% consulted with a physician within 2 weeks post-ED visit. By 4 weeks, 51% consulted a physician. Over the 6-month follow-up, 26% returned to the ED, 25% were hospitalized, and 9% died. Patients who were followed up within 4 weeks were more likely to be older and have higher education and a worse quality of life. Patients who consulted a physician within 4 weeks of ED discharge had a lower risk of AEs (hazard ratio 0.59, 95% CI 0.35-0.99).

Conclusion: Prompt follow-up post-ED visit for HF is associated with lower risk for major AEs. Therefore, adherence to current HF guideline benchmarks for timely follow-up post-ED visit is crucial.
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http://dx.doi.org/10.1016/j.ahj.2013.02.017DOI Listing
May 2013

Temporal trends in medication use and outcomes in atrial fibrillation.

Can J Cardiol 2013 Oct 8;29(10):1241-8. Epub 2013 Jan 8.

Division of General Internal Medicine, McGill University Health Centre, Montreal, Québec, Canada; Division of Clinical Epidemiology, McGill University Health Centre, Montreal, Québec, Canada. Electronic address:

Background: Novel therapies for anticoagulation and rhythm control for atrial fibrillation (AF) have been developed recently. To best evaluate the comparative effectiveness of newer agents, practice patterns and outcomes of existing therapies must be characterized at the population level.

Methods: We conducted a retrospective population-based cohort study of patients ≥ 65 years with a first diagnosis of AF over a 9-year period in Québec and Ontario. Using hospital and drug claims databases, trends of filled prescriptions, and rates of strokes, bleeding complications, and mortality within 1 year were estimated.

Results: From 1998 to 2006, 338, 479 patients were hospitalized with an AF diagnosis. Median age was 77.5 years and 50.4% were male. Use of rate control was 3-fold higher than rhythm control therapy. There was a modest decrease in rate control therapy until 2001 (71.9% to 70.6%, P = 0.01), followed by a progressive increase (70.6% to 76.4%, P = 0.014). An opposite trend was observed for rhythm control. Although warfarin prescriptions increased (51.0% to 64.5%, P < 0.0001), stroke rates tended to decrease (3.8% to 3.5%, P = 0.148). Bleeding complications increased mostly because of emergency room visits (4.8% to 6.1%, P = 0.007). Mortality remained high despite a small but statistically significant decline (27.6% to 25.8%, P = 0.018).

Conclusions: With increased anticoagulation use, stroke rates are declining and emergency room bleeding complications are increasing. Despite an increased use of evidence-based AF therapies, mortality remains high in this population. These findings highlight the need to focus on AF prevention in addition to minimizing its complications.
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http://dx.doi.org/10.1016/j.cjca.2012.09.021DOI Listing
October 2013

Rhythm versus rate control therapy and subsequent stroke or transient ischemic attack in patients with atrial fibrillation.

Circulation 2012 Dec 2;126(23):2680-7. Epub 2012 Nov 2.

MPH, McGill University Health Centre, 687 Pine Ave West, V Building, Montreal, Quebec, H3A 1A1 Canada.

Background: Stroke is a debilitating condition with an increased risk in patients with atrial fibrillation. Although data from clinical trials suggest that both rate and rhythm control are acceptable approaches with comparable rates of mortality in the short term, it is unclear whether stroke rates differ between patients who filled prescriptions for rhythm or rate control therapy.

Methods And Results: We conducted a population-based observational study of Quebec patients ≥65 years with a diagnosis of atrial fibrillation during the period 1999 to 2007 with the use of linked administrative data from hospital discharge and prescription drug claims databases. We compared rates of stroke or transient ischemic attack (TIA) among patients using rhythm (class Ia, Ic, and III antiarrhythmics), versus rate control (β-blockers, calcium channel blockers, and digoxin) treatment strategies (either current or new users). The cohort consisted of 16 325 patients who filled a prescription for rhythm control therapy (with or without rate control therapy) and 41 193 patients who filled a prescription for rate control therapy, with a mean follow-up of 2.8 years (maximum 8.2 years). A lower proportion of patients on rhythm control therapy than on rate control therapy had a CHADS(2) (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and previous stroke or TIA) score of ≥2 (58.1% versus 67.0%, P<0.001). Treatment with any antithrombotic drug was comparable in the 2 groups (76.8% in rhythm control versus 77.8% in rate control group). Crude stroke/TIA incidence rate was lower in patients treated with rhythm control in comparison with rate control therapy (1.74 versus 2.49, per 100 person-years, P<0.001). This association was more marked in patients in the moderate- and high-risk groups for stroke according to the CHADS(2) risk score. In multivariable Cox regression analysis, rhythm control therapy was associated with a lower risk of stroke/TIA in comparison with rate control therapy (adjusted hazard ratio, 0.80; 95% confidence interval, 0.74, 0.87). The lower stroke/TIA rate was confirmed in a propensity score-matched cohort.

Conclusions: In comparison with rate control therapy, the use of rhythm control therapy was associated with lower rates of stroke/TIA among patients with atrial fibrillation, in particular, among those with moderate and high risk of stroke.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.112.092494DOI Listing
December 2012

Improved outcomes in heart failure treated with high-dose ACE inhibitors and ARBs: a population-based study.

Arch Intern Med 2012 Sep;172(16):1263-5

Division of Internal Medicine, McGill University Health Centre, Montreal General Hospital, Quebec, Canada.

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http://dx.doi.org/10.1001/archinternmed.2012.2514DOI Listing
September 2012

Sex differences in stroke risk among older patients with recently diagnosed atrial fibrillation.

JAMA 2012 May;307(18):1952-8

Division of Clinical Epidemiology, McGill University Health Center, Montreal, Quebec, Canada.

Context: Stroke is a serious complication associated with atrial fibrillation (AF). Women with AF are at higher risk of stroke compared with men. Reasons for this higher stroke risk in women remain unclear, although some studies suggest that undertreatment with warfarin may be a cause.

Objective: To compare utilization patterns of warfarin and the risk of subsequent stroke between older men and women with AF at the population level.

Design, Setting, And Patients: Population-based cohort study of patients 65 years or older admitted to the hospital with recently diagnosed AF in the province of Quebec, Canada, 1998-2007, using administrative data with linkage between hospital discharge, physicians, and prescription drug claims databases.

Main Outcome Measures: Risk of stroke.

Results: The cohort comprised 39,398 men (47.2%) and 44,115 women (52.8%). At admission, women were older and had a higher CHADS(2) (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack) score than men (1.99 [SD, 1.10] vs 1.74 [SD, 1.13], P < .001). At 30 days postdischarge, 58.2% of men and 60.6% of women had filled a warfarin prescription. In adjusted analysis, women appeared to fill more warfarin prescriptions compared with men (odds ratio, 1.07 [95% CI, 1.04-1.11]; P < .001). Adherence to warfarin treatment was good in both sexes. Crude stroke incidence was 2.02 per 100 person-years (95% CI, 1.95-2.10) in women vs 1.61 per 100 person-years (95% CI, 1.54-1.69) in men (P < .001). The sex difference was mainly driven by the population of patients 75 years or older. In multivariable Cox regression analysis, women had a higher risk of stroke than men (adjusted hazard ratio, 1.14 [95% CI, 1.07-1.22]; P < .001), even after adjusting for baseline comorbid conditions, individual components of the CHADS(2) score, and warfarin treatment.

Conclusion: Among older patients admitted with recently diagnosed AF, the risk of stroke was greater in women than in men, regardless of warfarin use.
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http://dx.doi.org/10.1001/jama.2012.3490DOI Listing
May 2012
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