Publications by authors named "Stephanie L Harrison"

73 Publications

Exercise rehabilitation associates with lower mortality and hospitalisation in cardiovascular disease patients with COVID-19.

Eur J Prev Cardiol 2021 Jul 5. Epub 2021 Jul 5.

Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, William Henry Duncan Building, Liverpool L7 8TX, UK.

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http://dx.doi.org/10.1093/eurjpc/zwaa135DOI Listing
July 2021

Direct-acting oral anticoagulants use prior to COVID-19 diagnosis and associations with 30-day clinical outcomes.

Thromb Res 2021 Jun 27;205:1-7. Epub 2021 Jun 27.

Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark. Electronic address:

Background: It is unclear if direct-acting oral anticoagulants (DOACs) use before hospitalization due to COVID-19 diagnosis would potentially impact the severity and clinical outcomes thereafter. We compared 30-day hospitalization/re-hospitalization and clinical outcomes between patients on chronic DOAC therapy and patients not on oral anticoagulation (OAC) therapy at time of COVID-19 diagnosis.

Methods: We used data from TriNetX, a global federated health research network. Patients aged ≥18 years who were treated with DOACs at time of COVID-19 diagnosis between 20 January 2020 and 28 February 2021 were included, and matched with patients not on OAC therapy from the same period. All patients were followed-up at 30-days after COVID-19 diagnosis. The primary outcomes were all-cause mortality, hospitalization/re-hospitalization, venous thromboembolism (VTE) and intracranial hemorrhage (ICH).

Results: 738,423 patients were included. After propensity score matching (PSM), 26,006 patients remained in the study (13,003 on DOACs; 13,003 not on OAC). DOAC-treated patients (mean age 67.1 ± 15.4 years, 52.2% male) had higher relative risks (RRs) and lower 30-days event-free survival as compared to patients not on OAC for all-cause mortality (RR 1.27, 95% CI 1.12-1.44; Log-Rank test p = 0.010), hospitalization/re-hospitalization (RR 1.72, 95% CI 1.64-1.82; Log-Rank test p < 0.001) and VTE (RR 4.51, 95% CI 3.91-5.82; Log-Rank test p < 0.001), but not for ICH (RR 0.90, 95% CI 0.54-1.51; Log-Rank test p = 0.513).

Conclusion: In COVID-19 patients, previous DOAC therapy at time of diagnosis was not associated with improved clinical outcomes or lower hospitalization/re-hospitalization rate compared to patients not taking OAC therapy.
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http://dx.doi.org/10.1016/j.thromres.2021.06.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8236305PMC
June 2021

Exercise-based cardiac rehabilitation for cardiac implantable electronic device recipients.

Eur J Prev Cardiol 2021 Jun 21. Epub 2021 Jun 21.

Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.

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http://dx.doi.org/10.1093/eurjpc/zwab103DOI Listing
June 2021

The Atrial Fibrillation Better Care pathway for managing atrial fibrillation: a review.

Europace 2021 Jun 14. Epub 2021 Jun 14.

Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, 6 West Derby Street, Liverpool L7 8TX, UK.

The 2020 European Society of Cardiology guidelines endorse the Atrial Fibrillation Better Care (ABC) pathway as a structured approach for the management of atrial fibrillation (AF), addressing three principal elements: 'A' - avoid stroke (with oral anticoagulation), 'B' - patient-focused better symptom management, and 'C' - cardiovascular and comorbidity risk factor reduction and management. This review summarizes the definitions used for the ABC criteria in different studies and the impact of adherence/non-adherence on clinical outcomes, from 12 studies on seven different cohorts. All studies consistently showed statistically significant reductions in the risk of stroke, myocardial infarction, and mortality among those with ABC pathway adherent treatment. The ABC pathway provides a simple decision-making framework to enable consistent equitable care from clinicians in primary and secondary/tertiary care. Further research examining the impact of ABC pathway implementation in prospective cohorts utilizing consistent inclusion criteria and definitions of 'A', 'B', and 'C' adherent care is warranted.
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http://dx.doi.org/10.1093/europace/euab092DOI Listing
June 2021

Cardiovascular risk factors, cardiovascular disease, and COVID-19: an umbrella review of systematic reviews.

Eur Heart J Qual Care Clin Outcomes 2021 07;7(4):330-339

Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, William Henry Duncan Building, 6 West Derby Street, Liverpool L7 8TX, UK.

Aims: To consolidate evidence to determine (i) the association between cardiovascular risk factors and health outcomes with coronavirus 2019 (COVID-19); and (ii) the impact of COVID-19 on cardiovascular health.

Methods And Results: An umbrella review of systematic reviews was conducted. Fourteen medical databases and pre-print servers were searched from 1 January 2020 to 5 November 2020. The review focused on reviews rated as moderate or high-quality using the AMSTAR 2 tool. Eighty-four reviews were identified; 31 reviews were assessed as moderate quality and one was high-quality. The following risk factors were associated with higher mortality and severe COVID-19: renal disease [odds ratio (OR) (95% confidence interval) for mortality 3.07 (2.43-3.88)], diabetes mellitus [OR 2.09 (1.80-2.42)], hypertension [OR 2.50 (2.02-3.11)], smoking history [risk ratio (RR) 1.26 (1.20-1.32)], cerebrovascular disease [RR 2.75 (1.54-4.89)], and cardiovascular disease [OR 2.65 (1.86-3.78)]. Liver disease was associated with higher odds of mortality [OR 2.81 (1.31-6.01)], but not severe COVID-19. Current smoking was associated with a higher risk of severe COVID-19 [RR 1.80 (1.14-2.85)], but not mortality. Obesity associated with higher odds of mortality [OR 2.18 (1.10-4.34)], but there was an absence of evidence for severe COVID-19. In patients hospitalized with COVID-19, the following incident cardiovascular complications were identified: acute heart failure (2%), myocardial infarction (4%), deep vein thrombosis (7%), myocardial injury (10%), angina (10%), arrhythmias (18%), pulmonary embolism (19%), and venous thromboembolism (25%).

Conclusion: Many of the risk factors identified as associated with adverse outcomes with COVID-19 are potentially modifiable. Primary and secondary prevention strategies that target cardiovascular risk factors may improve outcomes for people following COVID-19.
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http://dx.doi.org/10.1093/ehjqcco/qcab029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8294691PMC
July 2021

Exercise-Based Cardiac Rehabilitation and All-Cause Mortality Among Patients With Atrial Fibrillation.

J Am Heart Assoc 2021 Jun 5;10(12):e020804. Epub 2021 Jun 5.

Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart & Chest Hospital Liverpool United Kingdom.

Background There is limited evidence of long-term impact of exercise-based cardiac rehabilitation (CR) on clinical end points for patients with atrial fibrillation (AF). We therefore compared 18-month all-cause mortality, hospitalization, stroke, and heart failure in patients with AF and an electronic medical record of exercise-based CR to matched controls. Methods and Results This retrospective cohort study included patient data obtained on February 3, 2021 from a global federated health research network. Patients with AF undergoing exercise-based CR were propensity-score matched to patients with AF without exercise-based CR by age, sex, race, comorbidities, cardiovascular procedures, and cardiovascular medication. We ascertained 18-month incidence of all-cause mortality, hospitalization, stroke, and heart failure. Of 1 366 422 patients with AF, 11 947 patients had an electronic medical record of exercise-based CR within 6-months of incident AF who were propensity-score matched with 11 947 patients with AF without CR. Exercise-based CR was associated with 68% lower odds of all-cause mortality (odds ratio, 0.32; 95% CI, 0.29-0.35), 44% lower odds of rehospitalization (0.56; 95% CI, 0.53-0.59), and 16% lower odds of incident stroke (0.84; 95% CI, 0.72-0.99) compared with propensity-score matched controls. No significant associations were shown for incident heart failure (0.93; 95% CI, 0.84-1.04). The beneficial association of exercise-based CR on all-cause mortality was independent of sex, older age, comorbidities, and AF subtype. Conclusions Exercise-based CR among patients with incident AF was associated with lower odds of all-cause mortality, rehospitalization, and incident stroke at 18-month follow-up, supporting the provision of exercise-based CR for patients with AF.
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http://dx.doi.org/10.1161/JAHA.121.020804DOI Listing
June 2021

Impact of interdisciplinary approaches to deprescribing psychotropics on clinical outcomes in older residents of long-term care facilities.

Int Psychogeriatr 2021 Jun;33(6):543-546

University of South Australia, UniSA Allied Health and Human Performance, Adelaide, South Australia, Australia.

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http://dx.doi.org/10.1017/S1041610220001453DOI Listing
June 2021

Body Weight, BMI, Percent Fat and Associations with Mortality and Incident Mobility Limitation in Older Men.

Geriatrics (Basel) 2021 May 18;6(2). Epub 2021 May 18.

Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN 55454, USA.

How different measures of adiposity are similarly or differentially related to mobility limitation and mortality is not clear. In total, 5849 community-dwelling men aged ≥65 years (mean age: 72 years) were followed mortality over 10 years and self-reported mobility limitations (any difficulty walking 2-3 blocks or with climbing 10 steps) at six contacts over 14 years. Baseline measures of adiposity included weight, BMI and percent fat by DXA. Appendicular lean mass (ALM, by DXA) was analyzed as ALM/ht2. Proportional hazards models estimated the risk of mortality, and repeated measures generalized estimating equations estimated the likelihood of mobility limitation. Over 10 years, 27.9% of men died; over 14 years, 48.0% of men reported at least one mobility limitation. We observed U-shaped relationships between weight, BMI, percent fat and ALM/ht2 with mortality. There was a clear log-linear relationship between weight, BMI and percent fat with incident mobility limitation, with higher values associated with a greater likelihood of mobility limitation. In contrast, there was a U-shaped relationship between ALM/ht2 and incident mobility limitation. These observational data suggest that no single measure of adiposity or body composition reflects both the lowest risk of mortality and the lowest likelihood for developing mobility limitation in older men.
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http://dx.doi.org/10.3390/geriatrics6020053DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8162350PMC
May 2021

Prevalence of atrial fibrillation and outcomes in older long-term care residents: a systematic review.

Age Ageing 2021 May;50(3):744-757

Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.

Background: anticoagulation is integral to stroke prevention for atrial fibrillation (AF), but there is evidence of under-treatment in older people in long-term care (LTC).

Objective: to synthesise evidence on the prevalence and outcomes (stroke, mortality or bleeding) of AF in LTC and the factors associated with the prescription of anticoagulation.

Methods: studies were identified from Medline, CINAHL, PsycINFO, Scopus and Web of Science from inception to 31 October 2019. Two reviewers independently applied the selection criteria and assessed the quality of studies using the Newcastle Ottawa Scale.

Results: twenty-nine studies were included. Prevalence of AF was reported in 21 studies, ranging from 7 to 38%. Two studies reported on outcomes based on the prescription of anticoagulation or not; one reported a reduction in the ischaemic stroke event rate associated with anticoagulant (AC) prescription (2.84 per 100 person years, 95% confidence interval [CI]: 1.98-7.25 versus 3.95, 95% CI: 2.85-10.08) and a non-significant increase in intracranial haemorrhage rate (0.71 per 100 person years, 95% CI: 0.29-2.15 versus 0.65, 95% CI: 0.29-1.93). The second study reported a 76% lower chance of ischaemic stroke with AC prescription and a low incidence of bleeding (n = 4 events). Older age, dementia/cognitive impairment and falls/falls risk were independently associated with the non-prescription of anticoagulation. Conversely, previous stroke/transient ischaemic attack and thromboembolism were independently associated with an increased prescription of anticoagulation.

Conclusion: estimates of AF prevalence and factors associated with AC prescription varied extensively. Limited data on outcomes prevent the drawing of definitive conclusions. We recommend panel data collection and systems for linkage to create longitudinal cohorts to provide more robust evidence.
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http://dx.doi.org/10.1093/ageing/afaa268DOI Listing
May 2021

Frailty and cognitive impairment are not reasons to withhold anticoagulation in people with atrial fibrillation but screening could guide management.

J Am Geriatr Soc 2021 Jul 24;69(7):1807-1810. Epub 2021 Apr 24.

Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.

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http://dx.doi.org/10.1111/jgs.17142DOI Listing
July 2021

Higher Mortality of Ischaemic Stroke Patients Hospitalized with COVID-19 Compared to Historical Controls.

Cerebrovasc Dis 2021 26;50(3):326-331. Epub 2021 Mar 26.

Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.

Introduction: Increasing evidence suggests patients with coronavirus disease 2019 (COVID-19) may develop thrombosis and thrombosis-related complications. Some previous evidence has suggested COVID-19-associated strokes are more severe with worse outcomes for patients, but further studies are needed to confirm these findings. The aim of this study was to determine the association between COVID-19 and mortality for patients with ischaemic stroke in a large multicentre study.

Methods: A retrospective cohort study was conducted using electronic medical records of inpatients from 50 healthcare organizations, predominately from the USA. Patients with ischaemic stroke within 30 days of COVID-19 were identified. COVID-19 was determined from diagnosis codes or a positive test result identified with CO-VID-19-specific laboratory codes between January 20, 2020, and October 1, 2020. Historical controls with ischaemic stroke without COVID-19 were identified in the period January 20, 2019, to October 1, 2019. 1:1 propensity score matching was used to balance the cohorts with and without CO-VID-19 on characteristics including age, sex, race and comorbidities. Kaplan-Meier survival curves for all-cause 60-day mortality by COVID-19 status were produced.

Results: During the study period, there were 954 inpatients with ischaemic stroke and COVID-19. During the same time period in 2019, there were 48,363 inpatients with ischaemic stroke without COVID-19 (historical controls). Compared to patients with ischaemic stroke without COVID-19, patients with ischaemic stroke and COVID-19 had a lower mean age, had a lower prevalence of white patients, a higher prevalence of black or African American patients and a higher prevalence of hypertension, previous cerebrovascular disease, diabetes mellitus, ischaemic heart disease, atrial fibrillation, chronic kidney disease, chronic obstructive pulmonary disease, liver disease, neoplasms, and mental disorders due to known physiological conditions. After propensity score matching, there were 952 cases and 952 historical controls; cases and historical controls were better balanced on all included characteristics (all p > 0.05). After propensity score matching, Kaplan-Meier survival analysis showed the survival probability was significantly lower in ischaemic stroke patients with COVID-19 (78.3% vs. 91.0%, log-rank test p < 0.0001). The odds of 60-day mortality were significantly higher for patients with ischaemic stroke and COVID-19 compared to the propensity score-matched historical controls (odds ratio: 2.51 [95% confidence interval 1.88-3.34]).

Discussion/conclusions: Ischaemic stroke patients with COVID-19 had significantly higher 60-day all-cause mortality compared to propensity score-matched historical controls (ischaemic stroke patients without COVID-19).
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http://dx.doi.org/10.1159/000514137DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8089422PMC
June 2021

Associations between COVID-19 and 30-day thromboembolic events and mortality in people with dementia receiving antipsychotic medications.

Pharmacol Res 2021 05 4;167:105534. Epub 2021 Mar 4.

Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.

Background: Antipsychotic medications are frequently prescribed to people with dementia to manage behavioural and psychological symptoms. Using a global federated research network, the objectives were to determine: 1) if COVID-19 is associated with 30-day thromboembolic events and mortality for people with dementia receiving antipsychotic medications; and 2) if the proportion of people with dementia receiving antipsychotics is higher during the COVID-19 pandemic compared to 2019.

Methods: A retrospective cohort study was conducted using TriNetX, a global federated health research network. The network was searched for people aged ≥ 65 years with dementia, COVID-19 and use of antipsychotics in the 30-days prior to COVID-19 recorded in electronic medical records between 20/01/2020 and 05/12/2020. These individuals were compared to historical controls from 2019 with dementia and use of antipsychotics in the 30-days before a visit to a participating healthcare organisation. Propensity score matching for age, sex, race, co-morbidities and use of antidepressants and anticonvulsants was used to balance cohorts with and without COVID-19.

Results: Within the TriNetX network, 8414 individuals with COVID-19, dementia and use of antipsychotics and 31,963 historical controls were identified. After propensity score matching there were 8396 individuals with COVID-19 and 8396 historical controls. The cohorts were well balanced for age, sex, race, co-morbidities and use of antidepressants and anticonvulsants. The odds of 30-day thromboembolic events and all-cause mortality were significantly higher in adults with COVID-19 (Odds Ratios: 1.36 (95% confidence interval (CI): 1.21-1.52) and 1.93 (1.71-2.17), respectively). The number of people with dementia with a visit to a participating healthcare organisation was lower between 20/01/2020 and 05/12/2020 (n = 165,447) compared to the same period in 2019 (n = 217,391), but the proportion receiving antipsychotics increased from 14.7% (95%CI: 14.6-14.9%) to 16.4% (95%CI: 16.2-16.5%), P < .0001.

Conclusions: These findings add to the evidence base that during the COVID-19 pandemic there was an increase in the proportion of people with dementia receiving antipsychotics. The negative effects of antipsychotics in patients with dementia may be compounded by concomitant COVID-19.
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http://dx.doi.org/10.1016/j.phrs.2021.105534DOI Listing
May 2021

Atrial fibrillation and the risk of 30-day incident thromboembolic events, and mortality in adults ≥ 50 years with COVID-19.

J Arrhythm 2021 Feb 11;37(1):231-237. Epub 2020 Dec 11.

Liverpool Centre for Cardiovascular Science University of Liverpool and Liverpool Heart & Chest Hospital Liverpool UK.

Background: There are limited data on the outcomes of adults with coronavirus disease 2019 (COVID-19) and atrial fibrillation (AF). The objectives were to (i) examine associations between AF, 30-day thromboembolic events and mortality in adults with COVID-19 and (ii) examine associations between COVID-19, 30-day thromboembolic events and mortality in adults with AF.

Methods: A study was conducted using a global federated health research network. Adults aged ≥50 years who presented to 41 participating healthcare organizations between 20 January 2020 and 1 September 2020 with COVID-19 were included.

Results: For the first objective, 6589 adults with COVID-19 and AF were propensity score matched for age, gender, race, and comorbidities to 6589 adults with COVID-19 without AF. The survival probability was significantly lower in adults with COVID-19 and AF compared to matched adults without AF (82.7% compared to 88.3%, Log-Rank test  < .0001; Risk Ratio (95% confidence interval) 1.61 (1.46, 1.78)) and risk of thromboembolic events was higher in patients with AF (9.9% vs 7.0%, Log-Rank test  < .0001; Risk Ratio (95% confidence interval) 1.41 (1.26, 1.59)). For the second objective, 2454 adults with AF and COVID-19 were propensity score matched to 2454 adults with AF without COVID-19. The survival probability was significantly lower for adults with AF and COVID-19 compared to adults with AF without COVID-19, but there was no significant difference in risk of thromboembolic events.

Conclusions: AF could be an important risk factor for short-term mortality with COVID-19, and COVID-19 may increase risk of short-term mortality amongst adults with AF.
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http://dx.doi.org/10.1002/joa3.12458DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7896479PMC
February 2021

Association of Exercise-Based Cardiac Rehabilitation with Progression of Paroxysmal to Sustained Atrial Fibrillation.

J Clin Med 2021 Jan 23;10(3). Epub 2021 Jan 23.

Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Faculty of Health & Life Sciences, William Henry Duncan Building, Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool L7 8TX, UK.

Progression of atrial fibrillation (AF) is associated with worsened prognosis for cardiovascular events and mortality. Exercise-based-cardiac rehabilitation programmes have shown preliminary promise for primary and secondary prevention of AF. Yet, such interventions are typically reserved for patients with acute coronary syndrome or undergoing revascularization. Using a retrospective cohort design, the present study investigated the association of exercise-based cardiac rehabilitation on the progression of paroxysmal to sustained AF, compared to propensity-matched controls. Patients with a diagnosis of paroxysmal AF were compared between those with and without an electronic medical record of exercise-based cardiac rehabilitation within 6-months of diagnosis. Using cox regression models, we ascertained odds of 2-year incidence for AF progression. This cohort of 9808 patients with paroxysmal AF demonstrated that exercise-based cardiac rehabilitation was associated with 26% lower odds of AF progression (odds ratio 0.74, 95% CI 0.66-0.83) compared to propensity-matched controls. This beneficial effect seemed to vary across patient subgroups. In conclusion, findings revealed that exercise-based cardiac rehabilitation was associated with significantly lower odds of progression from paroxysmal to sustained AF at 2-years follow-up compared to propensity-matched controls.
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http://dx.doi.org/10.3390/jcm10030435DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7865453PMC
January 2021

Prevalence of atrial fibrillation and outcomes in older long-term care residents: a systematic review.

Age Ageing 2020 Dec 31. Epub 2020 Dec 31.

Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.

Background: anticoagulation is integral to stroke prevention for atrial fibrillation (AF), but there is evidence of under-treatment in older people in long-term care (LTC).

Objective: to synthesise evidence on the prevalence and outcomes (stroke, mortality or bleeding) of AF in LTC and the factors associated with the prescription of anticoagulation.

Methods: studies were identified from Medline, CINAHL, PsycINFO, Scopus and Web of Science from inception to 31 October 2019. Two reviewers independently applied the selection criteria and assessed the quality of studies using the Newcastle Ottawa Scale.

Results: twenty-nine studies were included. Prevalence of AF was reported in 21 studies, ranging from 7 to 38%. Two studies reported on outcomes based on the prescription of anticoagulation or not; one reported a reduction in the ischaemic stroke event rate associated with anticoagulant (AC) prescription (2.84 per 100 person years, 95% confidence interval [CI]: 1.98-7.25 versus 3.95, 95% CI: 2.85-10.08) and a non-significant increase in intracranial haemorrhage rate (0.71 per 100 person years, 95% CI: 0.29-2.15 versus 0.65, 95% CI: 0.29-1.93). The second study reported a 76% lower chance of ischaemic stroke with AC prescription and a low incidence of bleeding (n = 4 events). Older age, dementia/cognitive impairment and falls/falls risk were independently associated with the non-prescription of anticoagulation. Conversely, previous stroke/transient ischaemic attack and thromboembolism were independently associated with an increased prescription of anticoagulation.

Conclusion: estimates of AF prevalence and factors associated with AC prescription varied extensively. Limited data on outcomes prevent the drawing of definitive conclusions. We recommend panel data collection and systems for linkage to create longitudinal cohorts to provide more robust evidence.
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http://dx.doi.org/10.1093/ageing/afaa268DOI Listing
December 2020

End-Stage renal disease and 30-day mortality for adults with and without COVID-19.

Eur J Intern Med 2021 01 9;83:93-95. Epub 2020 Nov 9.

Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.

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http://dx.doi.org/10.1016/j.ejim.2020.11.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7649657PMC
January 2021

High-Risk Medication Use in Older Residents of Long-Term Care Facilities: Prevalence, Harms, and Strategies to Mitigate Risks and Enhance Use.

Sr Care Pharm 2020 Oct;35(10):419-433

Older residents of long-term care facilities (LTCFs), also known as nursing homes, care homes, or residential aged care facilities, often have multiple health conditions and are exposed to polypharmacy. Use of high-risk medications such as opioids, glucose-lowering medications, antithrombotics, and antipsychotics is prevalent among residents of LTCFs. Ensuring appropriate use of high-risk medications is important to minimize the risk of medication-related harm in this vulnerable population. This paper provides an overview of the prevalence and factors associated with high-risk medication use among residents of LTCFs. Evidencebased strategies to optimize the use of high-risk medications and enhance resident outcomes are also discussed.
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http://dx.doi.org/10.4140/TCP.n.2020.419.DOI Listing
October 2020

Lipid levels, atrial fibrillation and the impact of age: Results from the LIPIDOGRAM2015 study.

Atherosclerosis 2020 11 6;312:16-22. Epub 2020 Sep 6.

Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital & University of Liverpool, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.

Background And Aims: An inverse relationship between lipid levels and atrial fibrillation (AF) has been suggested, but whether the association is upheld for all age groups remains unclear. The aim of the study was to examine associations between lipid levels and AF by age groups in a nationwide study in Poland.

Methods: Multivariate Poisson regression models were used to estimate prevalence ratios (PRs) for AF by lipid levels. Low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides (TG), total cholesterol (TC), non-HDL-C and LDL-C/HDL-C ratios were grouped into quartiles.

Results: Of the 13,724 participants, 5.2% (n = 708) had AF. People with AF were older with more comorbidities, but lower lipid levels (all p < 0.05). The prevalence of AF was inversely associated with LDL-C (Adjusted PR (95% Confidence Interval) highest versus lowest quartile: 0.60 (0.48, 0.75)), TC (0.61 (0.49, 0.75)) and non-HDL-C (0.63 (0.51, 0.78)). The prevalence of AF was inversely associated with HDL-C (0.58 (0.46, 0.74)), but this was not statistically significant for people aged 75 years and older. For the LDL-C/HDL-C ratio, the prevalence of AF was only inversely associated with higher levels for people aged 75 years and older (0.75 (0.61, 0.94)). There was no statistically significant difference in prevalence of AF by TG levels.

Conclusions: The results suggest an inverse relationship between lipid levels and AF. The inverse association between higher HDL-C and AF was only significant for people aged <75 years, whereas the inverse association between higher LDL-C/HDL-C ratio and AF was only significant for people aged 75 years and older.
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http://dx.doi.org/10.1016/j.atherosclerosis.2020.08.026DOI Listing
November 2020

Comorbidities associated with mortality in 31,461 adults with COVID-19 in the United States: A federated electronic medical record analysis.

PLoS Med 2020 09 10;17(9):e1003321. Epub 2020 Sep 10.

Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.

Background: At the beginning of June 2020, there were nearly 7 million reported cases of coronavirus disease 2019 (COVID-19) worldwide and over 400,000 deaths in people with COVID-19. The objective of this study was to determine associations between comorbidities listed in the Charlson comorbidity index and mortality among patients in the United States with COVID-19.

Methods And Findings: A retrospective cohort study of adults with COVID-19 from 24 healthcare organizations in the US was conducted. The study included adults aged 18-90 years with COVID-19 coded in their electronic medical records between January 20, 2020, and May 26, 2020. Results were also stratified by age groups (<50 years, 50-69 years, or 70-90 years). A total of 31,461 patients were included. Median age was 50 years (interquartile range [IQR], 35-63) and 54.5% (n = 17,155) were female. The most common comorbidities listed in the Charlson comorbidity index were chronic pulmonary disease (17.5%, n = 5,513) and diabetes mellitus (15.0%, n = 4,710). Multivariate logistic regression analyses showed older age (odds ratio [OR] per year 1.06; 95% confidence interval [CI] 1.06-1.07; p < 0.001), male sex (OR 1.75; 95% CI 1.55-1.98; p < 0.001), being black or African American compared to white (OR 1.50; 95% CI 1.31-1.71; p < 0.001), myocardial infarction (OR 1.97; 95% CI 1.64-2.35; p < 0.001), congestive heart failure (OR 1.42; 95% CI 1.21-1.67; p < 0.001), dementia (OR 1.29; 95% CI 1.07-1.56; p = 0.008), chronic pulmonary disease (OR 1.24; 95% CI 1.08-1.43; p = 0.003), mild liver disease (OR 1.26; 95% CI 1.00-1.59; p = 0.046), moderate/severe liver disease (OR 2.62; 95% CI 1.53-4.47; p < 0.001), renal disease (OR 2.13; 95% CI 1.84-2.46; p < 0.001), and metastatic solid tumor (OR 1.70; 95% CI 1.19-2.43; p = 0.004) were associated with higher odds of mortality with COVID-19. Older age, male sex, and being black or African American (compared to being white) remained significantly associated with higher odds of death in age-stratified analyses. There were differences in which comorbidities were significantly associated with mortality between age groups. Limitations include that the data were collected from the healthcare organization electronic medical record databases and some comorbidities may be underreported and ethnicity was unknown for 24% of participants. Deaths during an inpatient or outpatient visit at the participating healthcare organizations were recorded; however, deaths occurring outside of the hospital setting are not well captured.

Conclusions: Identifying patient characteristics and conditions associated with mortality with COVID-19 is important for hypothesis generating for clinical trials and to develop targeted intervention strategies.
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http://dx.doi.org/10.1371/journal.pmed.1003321DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7482833PMC
September 2020

The Registry of Senior Australians outcome monitoring system: quality and safety indicators for residential aged care.

Int J Qual Health Care 2020 Nov;32(8):502-510

South Australian Health and Medical Research Institute, Adelaide, SA 5000, Australia.

Objectives: To introduce the Registry of Senior Australians (ROSA) Outcome Monitoring System, which can monitor the quality and safety of care provided to individuals accessing residential aged care. Development and examination of 12 quality and safety indicators of care and their 2016 prevalence estimates are presented.

Design: Retrospective.

Setting: 2690 national and 254 South Australian (SA) aged care facilities.

Participants: 208 355 unique residents nationally and 18 956 in SA.

Main Outcome Measures: Risk-adjusted prevalence of high sedative load, antipsychotic use, chronic opioid use, antibiotic use, premature mortality, falls, fractures, medication-related adverse events, weight loss/malnutrition, delirium and/or dementia hospitalisations, emergency department presentations, and pressure injuries.

Results: Five indicators were estimated nationally; antibiotic use (67.5%, 95% confidence interval (CI): 67.3-67.7%) had the highest prevalence, followed by high sedative load (48.1%, 95% CI: 47.9-48.3%), chronic opioid use (26.8%, 95% CI: 26.6-26.9%), antipsychotic use (23.5%, 95% CI: 23.4-23.7%) and premature mortality (0.6%, 95% CI: 0.6-0.7%). Seven indicators were estimated in SA; emergency department presentations (19.1%, 95% CI: 18.3-20.0%) had the highest prevalence, followed by falls (10.1%, 95% CI: 9.7-10.4%), fractures (4.8%, 95% CI: 4.6-5.1%), pressure injuries (2.9%, 95% CI: 2.7-3.1%), delirium and/or dementia related hospitalisations (2.3%, 95% CI: 2.1-2.6%), weight loss/malnutrition (0.7%, 95% CI: 0.6-0.8%) and medication-related events (0.6%, 95% CI: 0.5-0.7%).

Conclusions: Twelve quality and safety indicators were developed to monitor aged care provided to older Australians based on the synthesis of existing literature and expert advisory input. These indicators rely on existing data within the aged care and healthcare sectors, therefore creating a pragmatic tool to examine quality and unwarranted care variation.
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http://dx.doi.org/10.1093/intqhc/mzaa078DOI Listing
November 2020

Considerations when choosing an appropriate bleeding risk assessment tool for patients with atrial fibrillation.

J Thromb Haemost 2020 04;18(4):788-790

Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.

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http://dx.doi.org/10.1111/jth.14738DOI Listing
April 2020

Initiation of antipsychotics after moving to residential aged care facilities and mortality: a national cohort study.

Aging Clin Exp Res 2021 Jan 11;33(1):95-104. Epub 2020 Mar 11.

Registry of Senior Australians, Health Ageing Research Consortium, South Australian Health and Medical Research Institute, Adelaide, SA, 5000, Australia.

Background: There is a high burden of antipsychotic use in residential aged care facilities (RACFs) and there is concern regarding potential inappropriate prescribing of antipsychotics in response to mild behavioural symptoms. Antipsychotic use has been associated with a higher risk of mortality in community-dwelling older adults with dementia, but few studies have examined associations upon RACF entry.

Aims: To examine associations between incident antipsychotic use and risk of mortality for people with and without diagnosed dementia in RACFs.

Methods: A retrospective cohort study, employing a new-user design (individuals did not receive an antipsychotic 6 months before enrolment) of 265,820 people who accessed RACFs in Australia between 1/4/2008 and 30/6/2015 was conducted. Cox regression models were used to examine adjusted associations between antipsychotic use in the first 100 days of RACF entry and mortality.

Results: In the 100 days after entering care, 29,455 residents (11.1%) were dispensed an antipsychotic. 180,956 (68.1%) residents died [38,249 (14.4%) were related to cerebrovascular causes] over a median 2.1 years (interquartile range 1.0-3.6) follow-up. Of the residents included, 119,665 (45.0%) had a diagnosis of dementia. Incident antipsychotic use was associated with higher risk of mortality in residents with dementia (adjusted hazard ratio 1.20, 95% confidence interval 1.18-1.22) and without dementia (1.28, 1.24-1.31).

Conclusion: Initiation of antipsychotics after moving to RACFs is associated with a higher risk of mortality. Careful consideration of the potential benefits and harms should be given when starting a new prescription for antipsychotics for people moving to RACFs.
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http://dx.doi.org/10.1007/s40520-020-01518-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7897604PMC
January 2021

The potential for photoplethysmographic (PPG)-based smart devices in atrial fibrillation detection.

Expert Rev Med Devices 2020 04 12;17(4):253-255. Epub 2020 Mar 12.

Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.

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http://dx.doi.org/10.1080/17434440.2020.1740085DOI Listing
April 2020

The dispensing of psychotropic medicines to older people before and after they enter residential aged care.

Med J Aust 2020 04 11;212(7):309-313. Epub 2020 Feb 11.

Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, SA.

Objective: To examine the prevalence of psychotropic medicine dispensing before and after older people enter residential care.

Design: Retrospective national cohort study; analysis of Registry of Senior Australians (ROSA) data.

Setting, Participants: All concession card-holding residents of government-subsidised residential aged care facilities in Australia who entered residential care for at least three months between 1 April 2008 and 30 June 2015.

Main Outcome Measures: Proportions of residents dispensed antipsychotic, benzodiazepine, or antidepressant medicines during the year preceding and the year after commencing residential care, by quarter.

Results: Of 322 120 included aged care residents, 68 483 received at least one antipsychotic (21.3%; 95% CI, 21.1-21.4%), 98 315 at least one benzodiazepine (30.5%; 95% CI, 30.4-30.7%), and 122 224 residents at least one antidepressant (37.9%; 95% CI, 37.8-38.1%) during their first three months of residential care; 31 326 of those dispensed antipsychotics (45.7%), 38 529 of those dispensed benzodiazepines (39.2%), and 25 259 residents dispensed antidepressants (19.8%) had not received them in the year preceding their entry into care. During the first three months of residential care, the prevalence of antipsychotic (prevalence ratio [PR], 3.37; 95% CI, 3.31-3.43) and antidepressant dispensing (PR, 1.05; 95% CI, 1.04-1.07) were each higher for residents with than for those without dementia; benzodiazepine dispensing was similar for both groups (PR, 1.01; 95% CI, 0.99-1.02).

Conclusions: Dispensing of psychotropic medicines to older Australians is high before they enter residential care but increases markedly soon after entry into care. Non-pharmacological behavioural management strategies are important for limiting the prescribing of psychotropic medicines for older people in the community or in residential care.
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http://dx.doi.org/10.5694/mja2.50501DOI Listing
April 2020

Reducing risk of adverse cardiovascular and renal outcomes for patients with atrial fibrillation and type 2 diabetes.

Eur J Heart Fail 2020 01 9;22(1):136-138. Epub 2019 Dec 9.

Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.

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http://dx.doi.org/10.1002/ejhf.1685DOI Listing
January 2020

Revisiting the dynamic risks of incident atrial fibrillation: does the use of nonsteroidal anti-inflammatory drugs contribute to risk?

QJM 2020 02;113(2):77-78

From the Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.

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http://dx.doi.org/10.1093/qjmed/hcz310DOI Listing
February 2020

Residential Respite Care Use Is Associated With Fewer Overall Days in Residential Aged Care.

J Am Med Dir Assoc 2020 05 23;21(5):653-659.e2. Epub 2019 Oct 23.

Registry of Senior Australians, Health Ageing Research Consortium, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.

Objectives: To examine the use of residential respite care and determine associations between respite care and total days spent in residential care (respite days plus long-term care days).

Design: A retrospective cohort study of individuals accessing aged care services in Australia using the National Historical Cohort of the Registry of Senior Australians was conducted.

Setting: Residential respite care (short stays in residential aged care homes) and long-term residential care accessed in all government-subsidized residential aged care homes in Australia.

Participants: This study included people who were approved for government-subsidized residential respite care between January 2005 and June 2012 (n = 480,862) and included a 2-year follow-up period.

Methods: Poisson regression models were used to examine associations between use of residential respite care and number of days spent in residential care.

Results: Of people approved for residential respite care, 36.9% used their approval within 12 months (32.0% used respite once and went directly to long-term care without returning home, 40.7% used respite once and did not go directly to long-term care, and 27.3% used respite ≥2 times). Compared with people who did not use respite care, using respite care once and not going directly to long-term care was associated with less total days in residential care [incidence rate ratio (IRR) 0.68, 95% confidence interval (CI) 0.67-0.69; P < .001] and using respite care ≥2 times was also associated with fewer days (IRR 0.86, 95% CI 0.84-0.87, P < .001). Using respite care once and going directly to long-term care was associated with more days in residential care (IRR 1.11, 95% CI 1.10-1.12, P < .001).

Conclusions And Implications: Using residential respite care was associated with fewer days spent in residential care when people returned home after using respite. The findings suggest that using residential respite as intended by returning home after use achieves the goal of helping people stay living at home longer.
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http://dx.doi.org/10.1016/j.jamda.2019.08.023DOI Listing
May 2020

Alternative staffing structures in a clustered domestic model of residential aged care in Australia.

Australas J Ageing 2019 Sep;38 Suppl 2:68-74

Rehabilitation, Aged and Extended Care, College of Medicine and Public Health, Flinders University, Flinders Medical Centre, Adelaide, South Australia, Australia.

Objective: A clustered domestic model of residential aged care has been associated with better consumer-rated quality of care. Our objective was to examine differences in staffing structures between clustered domestic and standard models.

Methods: A cross-sectional study involving 541 individuals living in 17 Australian not-for-profit residential aged care homes.

Results: Four of the homes offered dementia-specific clustered domestic models of care with higher personal care attendant (PCA) hours-per-resident-per-day (mean [SD] 2.43 [0.29] vs. 1.74 [0.46], P < 0.001), slightly higher direct care hours-per-resident-per-day (2.66 [0.35] vs. 2.58 [0.44], P = 0.006), higher staff training costs ($1492 [258] vs. $989 [928], P < 0.001) and lower registered/enrolled nurse hours-per-resident-per-day (0.23 [0.10] vs. 0.85 [0.17], P < 0.001) compared to standard models.

Conclusions: An Australian clustered domestic model of care had higher PCA hours, more staff training and more direct care time compared to standard models. Further research to determine optimal staffing structures within alternative models of care is warranted.
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http://dx.doi.org/10.1111/ajag.12674DOI Listing
September 2019

Trends in Prevalence of Dementia for People Accessing Aged Care Services in Australia.

J Gerontol A Biol Sci Med Sci 2020 01;75(2):318-325

Registry of Older South Australians, Health Ageing Research Consortium, South Australian Health and Medical Research Institute, Adelaide, Australia.

Background: Studies in some high-income countries have reported a potential decline in the prevalence of dementia. Improvements in cardiovascular health may be contributing to this decline. The objective was to examine trends in prevalence of dementia and survival with dementia for people accessing aged care in Australia.

Methods: A retrospective study of older people who accessed long-term care 2008-2014 (n = 348,311) and home care 2005-2014 (n = 188,846) in Australia was developed. The age- and sex-standardized prevalence for dementia by year of access to aged care was determined using direct standardization. Generalized linear models were used to determine change in the prevalence of dementia over time and change in 1-year mortality for people who accessed long-term care.

Results: The age- and sex-standardized prevalence (95% confidence interval) of dementia declined from 50.0% (49.6, 50.5) in 2008 to 46.6% (46.0, 47.2) in 2014 for people accessing long-term care (absolute change 2008-2014: -3.8 [-4.6, -3.1]) and for people accessing home care from 25.9% (25.0, 26.5) in 2005 to 20.9% (20.2, 21.7) in 2014 (absolute change 2005-2014: -5.2 [-6.2, -4.1]). This decline in dementia occurred in concurrence with a decline in cerebrovascular disease in long-term care but despite the prevalence of hypertension, diabetes, high cholesterol, malnutrition, obesity, depression, and head injury increasing. For people accessing long-term care, 1-year mortality remained stable over time.

Conclusions: The decline in prevalence of dementia for people accessing aged care services in Australia is critical to future projection estimates and for planning of services. Further research to determine contributing factors to the decline is needed.
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http://dx.doi.org/10.1093/gerona/glz032DOI Listing
January 2020

Pain in Older Australians Seeking Aged Care Services: Findings From the Registry of Older South Australians (ROSA).

J Am Med Dir Assoc 2020 01 7;21(1):132-133. Epub 2019 Mar 7.

South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia.

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http://dx.doi.org/10.1016/j.jamda.2019.01.127DOI Listing
January 2020
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