Transcript Hospitalisation-leading cardiac arrhythmias in Portugal

ALBERTO,M ANDRADE,T CARDOSO,S CORREIA,C MAGALHÃES,D MEDEIROS,N NEVES,A SANTOS,J TELES,A VIEIRA,B
Background
Justification and
Aim
Cardiac arrhythmias are a large group of conditions in which there is
not a normal sinus rhythm and normal atrioventricular (AV) conduction.[1]
Some of the most common arrhythmias:[1]
•
Atrioventricular (AV) block;
•
Atrial premature beats (APB);
•
Ventricular premature beats (VPB);
•
Sinus bradycardia;
•
Atrial fibrillation (AF).
Methods
Results
Discussion
Aknowledgments
References
[1] Lévy S, et al. Arrhythmia management for the primary clinician [Internet]. UpToDate; 2010 May [cited 2011 Oct 27]. Available from:
http://www.uptodate.com/contents/arrhythmia-management-for-the-primary-care2
clinician?source=preview&anchor=H4&selectedTitle=1~150#H4
Background
AGE
Justification and
Aim
Methods
Atrial fibrillation (AF), which affects approximately 0.4% of the global
population,[2] doubles its prevalence every ten years beyond the 50
year benchmark.[3]
Results
Discussion
In the USA, roughly 70% of individuals with AF are between 65 and 85
years of age.[4]
Aknowledgments
References
The prevalence of AF in Portugal is higher than in other countries where
similar data is available, when focusing on the population aged 40 and
onwards.[5]
[2] Benjamin EJ. et al. Independent risk factors for atrial fibrillation in a population-based cohort. The Framingham Heart Study. JAMA
1994;271:840–4
[3] Kannel WB. et al. Prevalence, incidence, prognosis, and predisposing conditions for atrial fibrillation: population-based estimates. Am
J Cardiol 1998; 82(8A):2N–9N
[4] Charlemagne A. et al. Epidemiology of atrial fibrillation in France: extrapolation of international epidemiological data to France and
analysis of French hospitalisation data. Archives of Cardiovascular Diseases. 2011 Feb; 104(2):115-24
[5] Bonhorst D. et al. Prevalence of atrial fibrillation in the Portuguese population aged 40 and over: the FAMA study. Revista Portuguesa
3
de Cardiologia. 2010 Mar; 29(3):331-50
Background
Justification and
Aim
OBESITY
Methods
Fatal arrhythmias are pointed
Results
as the most frequent cause of
Discussion
death among obese patients.[6]
Aknowledgments
Fig. 1: Prevalence of obesity in
Portugal by NUT II regions, 2006[7]
References
HYPERTHYROIDISM
Associated to greater levels of cardiovascular morbidity, including
angina, myocardial infarction and arrhythmias.[8]
Hyperthyroidism  increase of cholesterol synthesis [8]
[6] Mathew B. et al. Obesity: effects on cardiovascular disease and its diagnosis. J Am Board Fam Med. 2008 Novâ Dec; 21(6): 562–568
[7] Alves C. et al. Epidemiological data on obesity in Portugal [Internet]. 10º Congresso Português de Obesidade – Porto [2006
November]. Available from: http://www.eurotrials.com/contents/files/publicacao_ficheiro_68_1.pdf
[8] Neves C. et al. Doenças da tiróide, dislipidemia, e Patologia Cardiovascular; Rev. Port Cardiol 2008; 27(10): 1211-1236
4
Background
HYPERTENSION
Justification and
Aim
Methods
Hypertension facilitates development and progression of cardiac
diseases such as left ventricular hypertrophy (LVH), coronary artery
disease (CAD), arrhythmia and heart failure.[9]
Results
Discussion
A 2007 Portuguese study (subjects aged 18 to 90 years old) pointed
North as the region with the lowest prevalence of hypertension (33,4%),
and Alentejo with the highest (49,5%).[10]
Aknowledgments
References
CHRONIC KIDNEY DISEASE (CKD)
CKD affects up to 10% of adults [11] and carries a high risk for
cardiovascular disease, including AF.[12]
[9] Ishimitsu T, et al. Hypertension complicated with heart disease. Nihon Rinsho. 2011 November; 69(11):2007-14
[10] Macedo M, et al. Prevalência, Conhecimento, Tratamento e Controlo da Hipertensão em Portugal. Estudo PAP. Revista Portuguesa
de Cardiologia. 2007; 26(1):21-39
[11] Coresh J, et al. Prevalence of chronic kidney disease in the United States. JAMA. 2007; 298: 2038-2047
[12] Soliman EZ, et al. Chronic kidney disease and prevalent atrial fibrillation: the Chronic Renal Insufficiency Cohort (CRIC). Am Heart J.
5
Background
DIABETES MELLITUS (DM)
Justification and
Aim
Methods
DM increases the incidence of cardiac arrhythmias.[13]
Individuals with DM had one third greater risk of incident AF compared
with those without diabetes after adjustment with no evidence of
interactions with race or gender.[14]
Results
Discussion
Aknowledgments
References
HYPERLIPIDEMIA
Hyperlipidemia, an important risk factor for cardiovascular disease, may
be associated with AF.[15]
[13] Aubin MC, et al. A high-fat diet increases risk of ventricular arrhythmia in female rats: enhanced arrhythmic risk in the absence of
obesity or hyperlipidemia. J Appl Physiol. 2010; 108: 933–940
[14] Huxley R, et al. Type 2 diabetes, glucose homeostasis and incident atrial fibrillation: the Atherosclerosis Risk in Communities Study.
Heart. 2012 January; 98(2): 133–138
[15] Watanabe H, et al. Association Between Lipid Profile and Risk of Atrial Fibrillation. Official Journal of the Japanese Circulation
Society.
6
Background

Current challenge: swiftly manage growing numbers of patients with
cardiac arrhythmias.
Main goal: to find out whether there is or not an
asymmetrical distribution in hospitalisations due to
cardiac arrhythmias in Portugal, and to provide a
possible explanation for those findings.
Justification and
Aim
Methods
Results
Discussion
Aknowledgments
References
Analyse Portuguese arrhythmia-caused hospitalisations from 2000
to 2008, dividing it by NUT II regions and age groups;
Resort to population age, Hypertension, Diabetes Mellitus,
Hyperthyroidism,
Obesity,
Chronic
Kidney
Disease
and
Hyperlipidemia to try and explain our findings;
Study the evolution of the arrhythmias and associated factors.
7
Background
Justification and
Aim
Methods
Patients resident in
mainland Portugal
Mainland Portuguese
public acute care
hospitals with
discharges
Patient’s age ranged from
0 to 108 years.
Number of episodes
113 631
Hospitalisations
Between 2000 and
2008
Principal diagnosis
codified in ICD-9-CM
as “426 Conduction
disorders” or “427
Cardiac
dysrhythmias”
Results
Discussion
Aknowledgments
References
48,2 %
51,8 %
Male (58 839)
Female (54 792)
8
Background
Mainland Portugal is currently divided into five NUT II regions:
Justification and
Aim
Methods
North
Results
Discussion
Centre
Aknowledgments
References
Lisbon
Alentejo
Algarve
Fig. 2: Portugal map by
NUT II regions [16]
[16] INE – Instituto Nacional de Estatística. Available from: http://www.ine.pt/xportal/xmain?xpid=INE&xpgid=ine_princindic
9
Background
Justification and
Aim

This study is both descriptive and
relational.[17]
Methods
Results

Covers a nine-year period (2000-2008).
Discussion
Aknowledgments

Each episode was analysed only once: cross-sectional study.[17]


Readmissions were considered independent (new) episodes.
References
Should be regarded as an epidemiologic study.
[17] Trochim W. Time in research [Internet]. Research Methods Knowledge Base; 2006 November [cited 2011 Dec 2]. Available from:
http://www.socialresearchmethods.net/kb/timedim.php
10
Background
Database was provided by Department of Health Information and
Justification and
Aim
Decision Sciences, Faculty of Medicine, University of Porto.
Methods
Papers about cardiac arrhythmias:
Results

to relate them with age, gender, demographic or geographic data,
Discussion
hyperthyroidism, obesity, hypertension, chronic kidney disease,
Aknowledgments
diabetes mellitus and hyperlipidemia .
References
ICD-9-CM arrhythmia diagnosis codes based on Quan H. et al. [18]
• 426 Conduction disorders
• 427 Cardiac dysrhythmias
Main data collection method: on-line research on Pubmed.
[18] Quan H. et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Medical Care. 2005 Nov;
43(11):1130-9
11
Background
Principal diagnosis
Secondary diagnosis
Justification and
Aim
Methods
426 and 427 ICD-9-CM codes
Chosen based on frequency
Results
Congestive heart failure, Syncope and Collapse, Atrial
Fibrillation and Chronic Isquemic Heart Disease
•Heart related diseases: Excluded from the analysis
Discussion
Aknowledgments
References
Obesity, Hyperlipidemia, Chronic Kidney disease
and Diabetes Mellitus
Hypertension
•Appeared twice: Frequencies were merged
12
Background
Justification and
Aim
Demographic variables:
Methods
Gender
Results
Discussion
Patient’s age group
Aknowledgments
Patient’s residence
by NUT II regions
Portuguese
population data
References
Obtained from INE[16]
Ageing Index
[16] INE – Instituto Nacional de Estatística. Available from: http://www.ine.pt/xportal/xmain?xpid=INE&xpgid=ine_princindic
13
Background
IBM SPSS Statistics v20® and Microsoft Office Excel 2010®
Justification and
Aim
Methods
Results
Discussion
Aknowledgments

Unpaired, two-tail t-tests and Welch tests

95% CI (confidence intervals)

Frequencies

Logistic regression
References
14
Background
Justification and
Aim
Methods
Results
Discussion
Aknowledgments
Table 1 – Characteristics of the patients hospitalised due to cardiac arrhythmias, from
2000 to 2008, in mainland Portugal.
References
Note: Readmissions were considered independent episodes.
 Gender and age distribution were very similar across all NUT II regions, as
expected.
 In particular, all five regions registered their greatest number of
hospitalisations in patients within the 75-79 years old range.
15
Background
Justification and
Aim
Methods
Results
Discussion
Aknowledgments
References
Table 2 – Number of Hospitalisations (NOH) per a hundred thousand inhabitants, by year
and NUT II region.
Note: Results were obtained by dividing the NOH of each region for its total population, times a
hundred thousand.
16
Background
Justification and
Aim
Methods
Results
Discussion
Aknowledgments
References
Chart 1 – Number of Hospitalisations (NOH) per a hundred thousand inhabitants, by
year and NUT II region.
Note: Results were obtained by dividing the NOH of each region for its total population, times a
hundred thousand.
17
Background
Justification and
Aim
Methods
Results
Discussion
Aknowledgments
Table 3 – p-values* for comparisons between the values of the NUT II regions.
References
Note: *Obtained through t-tests.
 There was a general trend of increasing hospitalisations per year. Lisbon is
the sole exception, showing an inversion to negative evolution between
2005 and 2006.
 Regarding NOH per a hundred thousand inhabitants, North stands clearly
apart from all other regions.
18
Background
Justification and
Aim
Methods
Results
Discussion
Aknowledgments
References
Table 4 – Ageing Index (AgIdx) by NUT II regions, from 2000 to 2008.
Notes: Ageing Index: quotient between the number of people of 65 years-old or more and the
number of those of 14 or less years-old. It is expressed in number of elders by 100 youngsters;
*Obtained through Welch test.
 The Ageing Index rose steadily in North and Centre, while it hovered
around the same values in the remaining regions.
 North is, concerning general population, by far the youngest region, in
contrast with Alentejo.
19
Background
Justification and
Aim
Methods
Results
Discussion
Aknowledgments
References
Chart 2 – Number of Hospitalisations (NOH) per a hundred thousand inhabitants, by age
group and NUT II region.
Notes: Results were obtained by dividing the NOH of each region for its total population by age group,
times a hundred thousand. A nine year average was used for values of NOH and population by age
group.
20
Background
Justification and
Aim
Obesity
Chronic ischemic heart disease
Methods
Atrial fibrillation
Results
Chronic kidney disease
Syncope and colapse
Discussion
Congestive heart failure
Hyperlipidemia
Aknowledgments
Diabetes mellitus
Hypertension
References
0
5
10
15
20
25
30
35
Percentage (%)
Chart 3 – Most frequent secondary diagnoses registered on patients at time of
admission.
 Hypertension was the most registered disease, having being diagnosed
to 29,1% of patients.
 Hyperthyroidism, despite not appearing in this chart, is a well-known
arrhythmia-potentiating factor, so was included for analysis.
21
Background
Justification and
Aim
Methods
Results
Discussion
Table 5 – Number of hospitalisations with Hypertension, Obesity, Hyperlipidemia,
Chronic Kidney Disease (CKD), Hyperthyroidism or Diabetes Mellitus (DM) as
secondary diagnoses, per a hundred thousand hospitalisations due to cardiac
arrhythmias and per NUT II region.
Aknowledgments
References
22
Background
Justification and
Aim
Methods
Results
Discussion
Aknowledgments
References
Table 6 – Odds ratio for secondary diagnoses and demographic variables on the
hospitalisations motivated by cardiac arrhythmias.
Notes: All hospitalisations in mainland Portugal from 2000 to 2008 were included in this logistic regression.
The dependent variable was the principal diagnosis leading to the hospitalisation: 1 – cardiac
arrhythmia; 0 – other.
* For secondary diagnoses: number of hospitalisations featuring that disease as secondary diagnosis.
† For demographic variables: number of hospitalisations in that region.
** Base category for odds ratio determination.
23
Background
 Age is a risk factor in the emergence of cardiac arrhythmias (AOR =
1,04).
 All co-morbidities (secondary diagnoses excluding heart-related diseases ),
bar CKD and DM, obtained significant adjusted odds ratio values
above 1 for hospitalisations due to arrhythmias.
Justification and
Aim
Methods
Results
Discussion
Aknowledgments
 DM apparently turned out being a protective factor, in contrast with
what is described.
References
 Hyperthyroidism deserves a special attention, since it is the most
important factor for the appearance of cardiac arrhythmias:
individuals with hyperthyroidism are 3,45 times likelier to develop
arrhythmias than those without this condition.
24
Background
 There is no significant difference between Centre, Alentejo and
Algarve regarding NOH per a 100 000 inhabitants, nor when
eliminating the factor age.
Justification and
Aim
Methods
Results
 This proved to be strange, because Centre features a lower NOH with
any co-morbidities than Alentejo or Algarve and a lower AOR.
Discussion
Aknowledgments
References

A counterbalance between age influence and co-morbidities could
explain chart 1, but age was shown to be irrelevant for comparing
these three regions (chart 2).
25
Background
 Chart 1 brings all attention to North, which registered the lowest NOH
per a 100 000 inhabitants.
 Lisbon does not stand apart from Centre, Alentejo and Algarve.
 However, when the age groups are included, age’s influence is
eliminated and significant differences are found for both North and
Lisbon in comparison with the other three regions and between
themselves (chart 2), but while North still has the lowest ratios, Lisbon
holds the worst scenario.
 Since North and Lisbon are the youngest regions, some conclusions
can be withdrawn:
 regarding North, a young population means more protection
(other factors also contribute to a low NOH/100 000 inhabitants);
 concerning Lisbon, age influence is offsetting co-morbidities,
resulting in an outcome on the level of Centre, Alentejo and
Algarve. Without age’s protective effect, hospitalisations in Lisbon
rose sharply.
 In fact, when accounting all the factors, Lisbon has a AOR of 1,56 in
comparison with North.
Justification and
Aim
Methods
Results
Discussion
Aknowledgments
References
26
Background
 North presents higher values of NOH with Obesity, Hyperlipidemia, CKD
and DM per a 100 000 hospitalisations due to arrhythmias than Lisbon.
 Obesity and Hyperlipidemia increase the odds of being hospitalised
due to arrhythmias (Adjusted Odds Ratio (AOR) = 1,17 and AOR=1,14)
and are higher in North, which seems to be a contradiction.
Justification and
Aim
Methods
Results
Discussion
Aknowledgments
 However, Hypertension (AOR = 1,30) and Hyperthyroidism (AOR = 3,45)
are both more frequent in Lisbon and are more relevant (higher AOR)
than Obesity and Hyperlipidemia.
References
 As such, we suppose that hypertension and hyperthyroidism are at the
root of the differences found in chart 2.
 Nonetheless, we believe they are not the unique reasons for such
glaring disparities.
27
Background
Justification and
Aim
Methods
Age distribution is a major contibutor in assessing the
susceptibility of a population to hospitalisation-leading
cardiac arrhythmias.
Results
Discussion
Aknowledgments
References
With this factor eliminated, hypertension’s and
hyperthyroidism’s prevalence are the most relevant
influencers in the number of hospitalisations.
28
Background
Justification and
Aim
Methods
North population has a lower risk of being hospitalised than
Lisbon population.
This may be due to the North’ relative youth and to a
greater prevalence of hyperthyroidism and hypertension in
Lisbon. Nonetheless, we suspect there are other underlying
reasons contributing to these results.
Results
Discussion
Aknowledgments
References
Centre, Algarve and Alentejo were similar in terms of
number of hospitalisations. However, this was an
unpredictable result, revealing the high degree of
complexity on the epidemiology of cardiac arrhythmias.
Therefore, further studies on this issue are encouraged.
29
Background
Justification and
Aim
Methods
Some important information is not
routinely collected, for example
information related to secondary
diagnoses.
Results
Discussion
Aknowledgments
The high prevalence of cardiac
arrhythmias as principal diagnosis
might be explained by the
increase
in
repeated
hospitalisations, (readmissions were
considered
as
independent
events).
References
This could also introduce some bias on the results.
30
Background
Justification and
Aim
We would like to express thanks to:
•
Professor Doutor Alberto Freitas, for his continuous commitment,
guidance and advice;
Methods
Results
Discussion
•
Professor Doutor Altamiro da Costa Pereira, for his constructive
criticisms and sharp suggestions to improve our work;
Aknowledgments
References
•
Professor Fernando Lopes, for decisive orientation on a critical step of
our work.
Special thanks go to supervisor Vasco Santos, whose knowledge and
assistance was essential for the successful completion of this study.
31
Background
[1] Lévy S. et al. Arrhythmia management for the primary clinician [Internet]. UpToDate;
2010 May [cited 2011 Oct 27]. Available from: http://www.uptodate.com/contents/arrhythmiamanagement-for-the-primary-careclinician?source=preview&anchor=H4&selectedTitle=1~150#H4
[2] Benjamin EJ. et al. Independent risk factors for atrial fibrillation in a population-based
cohort. The Framingham Heart Study. JAMA 1994;271:840–4
[3] Kannel WB. et al. Prevalence, incidence, prognosis, and predisposing conditions for
atrial fibrillation: population-based estimates. Am J Cardiol 1998; 82(8A):2N–9N
[4] Charlemagne A. et al. Epidemiology of atrial fibrillation in France: extrapolation of
international epidemiological data to France and analysis of French hospitalisation data.
Archives of Cardiovascular Diseases. 2011 Feb; 104(2):115-24
Justification and
Aim
Methods
Results
Discussion
Aknowledgments
References
[5] Bonhorst D. et al. Prevalence of atrial fibrillation in the Portuguese population aged 40
and over: the FAMA study. Revista Portuguesa de Cardiologia. 2010 Mar; 29(3):331-50
[6] Mathew B. et al. Obesity: effects on cardiovascular disease and its diagnosis. J Am
Board Fam Med. 2008 Novâ Dec; 21(6): 562–568
[7] Alves C. et al. Epidemiological data on obesity in Portugal [Internet]. 10º Congresso
Português
de
Obesidade
–
Porto
[2006
November].
Available
from:
http://www.eurotrials.com/contents/files/publicacao_ficheiro_68_1.pdf
32
Background
[8] Neves C. et al. Doenças da tiróide, dislipidemia, e Patologia Cardiovascular; Rev. Port
Cardiol 2008; 27(10): 1211-1236
[9] Ishimitsu T, et al. Hypertension complicated with heart disease. Nihon Rinsho. 2011
November; 69(11): 2007-14
[10] Macedo M, et al. Prevalência, Conhecimento, Tratamento e Controlo da Hipertensão
em Portugal. Estudo PAP. Revista Portuguesa de Cardiologia. 2007; 26(1): 21-39
[11] Coresh J, et al. Prevalence of chronic kidney disease in the United States. JAMA.
2007; 298: 2038-2047
Justification and
Aim
Methods
Results
Discussion
Aknowledgments
References
[12] Soliman EZ, et al. Chronic kidney disease and prevalent atrial fibrillation: the Chronic
Renal Insufficiency Cohort (CRIC). Am Heart J. 2010; 159: 1102-1107
[13] Aubin MC, et al. A high-fat diet increases risk of ventricular arrhythmia in female rats:
enhanced arrhythmic risk in the absence of obesity or hyperlipidemia. J Appl Physiol. 2010;
108: 933–940
[14] Huxley R, et al. Type 2 diabetes, glucose homeostasis and incident atrial fibrillation: the
Atherosclerosis Risk in Communities Study. Heart. 2012 January; 98(2): 133–138
[15] Watanabe H, et al. Association Between Lipid Profile and Risk of Atrial Fibrillation.
Official Journal of the Japanese Circulation Society
33
Background
Justification and
Aim
[16]
INE
–
Instituto
Nacional
de
Estatística.
http://www.ine.pt/xportal/xmain?xpid=INE&xpgid=ine_princindic
Available
from:
[17] Trochim W. Time in research [Internet]. Research Methods Knowledge Base; 2006
November
[cited
2011
Dec
2].
Available
from:
http://www.socialresearchmethods.net/kb/timedim.php
[18] Quan H. et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10
administrative data. Medical Care. 2005 Nov; 43(11): 1130-9
Methods
Results
Discussion
Aknowledgments
References
34