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The magnitude of the impact of technological innovations on healthcare expenditure is unclear. This paper estimated the impact of high-technology procedures on public healthcare expenditure for patients with ischemic heart disease (IHD) in Portugal. The Blinder-Oaxaca decomposition method was applied to Portuguese NHS administrative data for IHD discharges during two periods, 2008-2015 vs. 2002-2007 (N = 434,870). We modelled per episode healthcare expenditures on the introduction of new technologies, adjusting for GDP, patient age, and comorbidities. The per episode healthcare expenditure was significantly higher in 2008-2015 compared to 2002-2007 for IHD discharges. The increase in the use of high-technology procedures contributed to 28.6% of this growth among all IHD patients, and to 18.4%, 6.8%, 11.1%, and 29.2% for acute myocardial infarction, unstable angina, stable angina, and other IHDs, respectively. Changes in the use of stents and embolic protection and/or coronary brachytherapy devices were the largest contributors to expenditure growth. High-technology procedures were confirmed as a key driver of public healthcare expenditure growth in Portugal, contributing to more than a quarter of this growth., (© 2024. The Author(s).)

Objective: The aim of this study is to evaluate the cost-effectiveness, diagnostic accuracy, clinical outcomes, and radiation exposure associated with rubidium-82 chloride perfusion PET., Methods: A comprehensive literature search up to October 2024 was conducted to identify key studies assessing the use of rubidium-82 chloride perfusion PET/CT in ischemic heart disease (IHD). These studies included economic analyses, evaluations of diagnostic accuracy, and comparisons with other imaging modalities such as single-photon emission computed tomography (SPECT), stress echocardiography, and invasive coronary angiography., Results: The reviewed studies demonstrate that rubidium-82 chloride perfusion PET/CT has high sensitivity and specificity in detecting IHD (90% and 91%, respectively) accompanied by significant coronary artery stenosis. Economic analyses show that this method is cost-effective due to a reduction in the use of downstream invasive procedures, leading to overall cost savings. Additionally, the economic impact on healthcare is enhanced by a lower level of radiation exposure compared to traditional perfusion SPECT imaging, reducing associated future radiation risks. The cost-effectiveness and minimum patient throughput required for implementing this modality In Russia were evaluated., Conclusion: The presented data confirm the cost-effectiveness of rubidium-82 chloride perfusion PET/CT by reducing costs for subsequent diagnostic and therapeutic interventions while maintaining a sufficient patient flow.

Background: This study aimed to establish availability and characteristics of cardiac rehabilitation (CR) in Latin America and the Caribbean (LAC), where cardiovascular disease is highly prevalent., Methods: In this cross-sectional sub-analysis focusing on the 35 LAC countries, local cardiovascular societies identified CR programs globally. An online survey was administered to identified programs, assessing capacity and characteristics. CR need was computed relative to ischemic heart disease (IHD) incidence from the Global Burden of Disease study., Results: ≥1 CR program was identified in 24 LAC countries (68.5% availability; median = 3 programs/country). Data were collected in 20/24 countries (83.3%); 139/255 programs responded (54.5%), and compared to responses from 1082 programs in 111 countries. LAC density was 1 CR spot per 24 IHD patients/year (vs 18 globally). Greatest need was observed in Brazil, Dominican Republic and Mexico (all with >150,000 spots needed/year). In 62.8% (vs 37.2% globally P < .001) of CR programs, patients pay out-of-pocket for some or all of CR. CR teams were comprised of a mean of 5.0 ± 2.3 staff (vs 6.0 ± 2.8 globally; P < .001); Social workers, dietitians, kinesiologists, and nurses were significantly less common on CR teams than globally. Median number of core components offered was 8 (vs 9 globally; P < .001). Median dose of CR was 36 sessions (vs 24 globally; P < .001). Only 27 (20.9%) programs offered alternative CR models (vs 31.1% globally; P < .01)., Conclusion: In LAC countries, there is very limited CR capacity in relation to need. CR dose is high, but comprehensiveness low, which could be rectified with a more multidisciplinary team., (Copyright © 2021 Elsevier Inc. All rights reserved.)

The current pandemic of SARS-COV 2 infection (Covid-19) is challenging health systems and communities worldwide. At the individual level, the main biological system involved in Covid-19 is the respiratory system. Respiratory complications range from mild flu-like illness symptoms to a fatal respiratory distress syndrome or a severe and fulminant pneumonia. Critically, the presence of a pre-existing cardiovascular disease or its risk factors, such as hypertension or type II diabetes mellitus, increases the chance of having severe complications (including death) if infected by the virus. In addition, the infection can worsen an existing cardiovascular disease or precipitate new ones. This paper presents a contemporary review of cardiovascular complications of Covid-19. It also specifically examines the impact of the disease on those already vulnerable and on the poorly resourced health systems of Africa as well as the potential broader consequences on the socio-economic health of this region., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2021 The Author(s).)

Background: One in five patients with ischaemic heart disease (IHD) develop comorbid depression or anxiety. Depression is associated with risk of non-adherence to cardiac rehabilitation (CR) and dropout, inadequate risk factor management, poor quality of life (QoL), increased healthcare costs and premature death. In 2020, IHD and depression are expected to be among the top contributors to the disease-burden worldwide. Hence, it is paramount to treat both the underlying somatic disease as well as depression and anxiety. eMindYourHeart will evaluate the efficacy and cost-effectiveness of a therapist-assisted eHealth intervention targeting depression and anxiety in patients with IHD, which may help fill this gap in clinical care., Methods: eMindYourHeart is a multi-center, two-armed, unblinded randomised controlled trial that will compare a therapist-assisted eHealth intervention to treatment as usual in 188 CR patients with IHD and comorbid depression or anxiety. The primary outcome of the trial is symptoms of depression, measured with the Hospital Anxiety and Depression Scale (HADS) at 3 months. Secondary outcomes evaluated at 3, 6, and 12 months include symptoms of depression and anxiety (HADS), perceived stress, health complaints, QoL (HeartQoL), trial dropout (number of patients dropped out in either arm at 3 months) and cost-effectiveness., Discussion: To our knowledge, this is the first trial to evaluate both the efficacy and cost-effectiveness of a therapist-assisted eHealth intervention in patients with IHD and comorbid psychological distress as part of CR. Integrating screening for and treatment of depression and anxiety into standard CR may decrease dropout and facilitate better risk factor management, as it is presented as "one package" to patients, and they can access the eMindYourHeart program in their own time and at their own convenience. The trial holds a strong potential for improving the quality of care for an increasing population of patients with IHD and comorbid depression, anxiety or both, with likely benefits to patients, families, and society at large due to potential reductions in direct and indirect costs, if proven successful. Trial registration The trial was prospectively registered on https://clinicaltrials.gov/ct2/show/NCT04172974 on November 21, 2019 with registration number [NCT04172974].

Objective: Catheter ablation is an important treatment for ventricular tachycardia (VT) that reduces the frequency of episodes of VT. We sought to evaluate the cost-effectiveness of catheter ablation versus antiarrhythmic drug (AAD) therapy., Methods: A decision-analytic Markov model was used to calculate the costs and health outcomes of catheter ablation or AAD treatment of VT for a hypothetical cohort of patients with ischaemic cardiomyopathy and an implantable cardioverter-defibrillator. The health states and input parameters of the model were informed by patient-reported health-related quality of life (HRQL) data using randomised clinical trial (RCT)-level evidence wherever possible. Costs were calculated from a 2018 UK perspective., Results: Catheter ablation versus AAD therapy had an incremental cost-effectiveness ratio (ICER) of £144 150 (€161 448) per quality-adjusted life-year gained, over a 5-year time horizon. This ICER was driven by small differences in patient-reported HRQL between AAD therapy and catheter ablation. However, only three of six RCTs had measured patient-reported HRQL, and when this was done, it was assessed infrequently. Using probabilistic sensitivity analyses, the likelihood of catheter ablation being cost-effective was only 11%, assuming a willingness-to-pay threshold of £30 000 used by the UK's National Institute for Health and Care Excellence., Conclusion: Catheter ablation of VT is unlikely to be cost-effective compared with AAD therapy based on the current randomised trial evidence. However, better designed studies incorporating detailed and more frequent quality of life assessments are needed to provide more robust and informed cost-effectiveness analyses., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Objectives: High-need (HN) Medicare beneficiaries heavily use healthcare services at a high cost. This population is heterogeneous, composed of individuals with varying degrees of medical complexity and healthcare needs. To improve healthcare delivery and decrease costs, it is critical to identify the subpopulations present within this population. We aimed to (1) identify distinct clinical phenotypes present within HN Medicare beneficiaries, and (2) examine differences in outcomes between phenotypes., Design: Latent class analysis was used to identify phenotypes within a sample of HN fee-for-service (FFS) Medicare beneficiaries aged 65 years and older using Medicare claims and post-acute assessment data., Setting: Not applicable., Participants: Two cross-sectional cohorts were used to identify phenotypes. Cohorts included FFS Medicare beneficiaries aged 65 and older who survived through 2014 (n = 415 659) and 2015 (n = 416 643)., Measurements: The following variables were used to identify phenotypes: acute and post-acute care use, functional dependency in one or more activities of daily living, presence of six or more chronic conditions, and complex chronic conditions. Mortality, hospitalizations, healthcare expenditures, and days in the community were compared between phenotypes., Results: Five phenotypes were identified: (1) comorbid ischemic heart disease with hospitalization and skilled nursing facility use (22% of the HN sample), (2) comorbid ischemic heart disease with home care use (23%), (3) home care use (12%), (4) high comorbidity with hospitalization (32%), and (5) Alzheimer's disease/related dementias with functional dependency and nursing home use (11%). Mortality was highest in phenotypes 1 and 2; hospitalizations and expenditures were highest in phenotypes 1, 3, and 4., Conclusions: Our findings represent a first step toward classifying the heterogeneity among HN Medicare beneficiaries. Further work is needed to identify modifiable utilization patterns between phenotypes to improve the value of healthcare provided to these subpopulations. J Am Geriatr Soc 68:70-77, 2019., (© 2019 The Authors. Journal of the American Geriatrics Society published by Wiley Periodicals, Inc. on behalf of The American Geriatrics Society.)

Objectives: To estimate the burden of disease attributable to obesity and overweight conditions using disability-adjusted life-years (DALYs) in Colombia., Methods: The burden of disease was estimated following an adapted methodology published by the World Health Organization. A selection of diseases was performed in which overweight and obesity are risk factors. DALYs were calculated by obtaining the proportion of cases and deaths of every disease that can be attributable to obesity and overweight conditions. The economic impact of obesity was calculated by multiplying the cost of care per patient for each comorbidity by the number of cases attributable exclusively to obesity., Results: A total of 997 371 DALYs were estimated, 45% of which corresponded to men; 81% of DALYs corresponded to years lived with disability. Conditions with greater attributable DALYs are, in order, hypertension (31.6% of the total DALYs), type 2 diabetes mellitus (28.0%), cardiac ischemic disease (14.6%), and lower back pain (11.2%). An estimation of 20.5 DALYs per 1000 inhabitants was made. The economic impact of care for comorbidities associated with obesity could amount to $2158 million., Conclusions: Obesity and overweight conditions are related to higher mortality and disability than previously estimated; effective interventions aimed at prevention and treatment will have a high impact on quality of life., (Copyright © 2019 ISPOR--The professional society for health economics and outcomes research. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to assess temporal trends in the incidence of ischemic stroke among patients undergoing percutaneous coronary intervention (PCI), predictors of post-PCI ischemic stroke, and the impact of post-PCI ischemic stroke on in-hospital morbidity, mortality, length of stay, and cost., Background: Data on the incidence and outcomes of ischemic stroke in patients undergoing PCI in the contemporary era are limited., Methods: The National Inpatient Sample was used to identify patients who underwent PCI between January 1, 2003, and December 31, 2016. The incidence of post-PCI ischemic stroke was calculated, and its predictors were assessed. In-hospital outcomes of patients with and those without post-PCI stroke were also compared., Results: The adjusted incidence of post-PCI ischemic stroke increased during the study period from 0.6% to 0.96% following PCI for ST-segment elevation myocardial infarction, from 0.5% to 0.6% following PCI for non-ST-segment elevation myocardial infarction, and from 0.3% to 0.72% following PCI for unstable angina or stable ischemic disease (p trend  <0.001). Carotid disease, cardiogenic shock, atrial fibrillation, and older age were the strongest predictors of post-PCI ischemic stroke. Post-PCI stroke rates were lower at high-volume versus low- to intermediate-volume centers. Thrombolytics, cerebral angiography, and mechanical thrombectomy use increased over time but remained infrequent. After propensity score matching, in-hospital mortality was higher among patients with post-PCI stroke (23.5% vs. 11.0%, 9.5% vs. 2.8%, and 11.5% vs. 2.4% in the ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, and unstable angina or stable ischemic heart disease cohorts, respectively; p < 0.001). Post-PCI stroke was associated with a >2-fold increase in length of stay, a >3-fold increase in nonhome discharges, and a >60% increase in cost., Conclusions: The incidence of post-PCI ischemic stroke increased significantly over the past decade, partially because of the increasing complexity of patients undergoing PCI over time. Further studies are needed to systematically assess contributors to this worrisome trend and to identify effective strategies for its mitigation., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Most studies measure the impact of ischemic heart disease (IHD) on individuals using quality of life metrics such as disability-adjusted life-years (DALYs); however, IHD also has an enormous impact on productive life years (PLYs). The objective of this study was to project the indirect costs of IHD resulting from lost PLYs to older Australian workers (45-64 years), government, and society 2015-2030., Methods: Nationally representative data from the Surveys of Disability, Ageing and Carers (2003, 2009) were used to develop the base population in the microsimulation model (Health&WealthMOD2030), which integrated data from established microsimulation models (STINMOD, APPSIM), Treasury's population and workforce projections, and chronic conditions trends., Results: We projected that 6700 people aged 45-64 were out of the labour force due to IHD in 2015, increasing to 8100 in 2030 (21 increase). National costs consisted of a loss of AU$273 (US$263) million in income for people with IHD in 2015, increasing to AU$443 ($US426) million (62% increase). For the government, extra welfare payments increased from AU$106 (US$102) million in 2015 to AU$143 (US$138) million in 2030 (35% increase); and lost income tax revenue increased from AU$74 (US$71) million in 2015 to AU$117 (US$113) million in 2030 (58% increase). A loss of AU$785 (US$755) million in GDP was projected for 2015, increasing to AU$1125 (US$1082) million in 2030., Conclusions: Significant costs of IHD through lost productivity are incurred by individuals, the government, and society. The benefits of IHD interventions include not only improved health but also potentially economic benefits as workforce capacity.

To assess the frequency and costs of revascularization procedures in patients with stable ischemic heart disease (SIHD) initiating ranolazine versus traditional antianginals. Adults (≥18 years) with a diagnosis of SIHD who initiated ranolazine or a traditional antianginal (beta-blocker [BB], calcium channel blocker [CCB], or long-acting nitrate [LAN]) as second or third line therapy between 2008 and 2016, were selected from the IBM MarketScan Databases. Inverse probability weighting based on propensity score was employed to balance the ranolazine and traditional antianginals cohorts on patient clinical characteristics. Outcomes assessed were frequency and total cost of revascularization procedures over a 12-month follow-up. A total of 108,741 patients with SIHD were included. Of these, 18% initiated treatment with ranolazine, 21% received BBs, 24% received CCBs, and 37% were treated with LANs. Revascularization rates were significantly lower in ranolazine patients (11%) than in BB (16%) and LAN (14%) patients (both p <0.001), and more comparable to CCB patients (10%; p = 0.007). Compared with BB and LAN, those in the ranolazine cohort were less likely to have a revascularization procedure during hospitalization and had a shorter length of stay if hospitalized (all p <0.001). The mean healthcare costs associated with revascularization were lower in ranolazine patients ($2,933) than in BB ($4,465) and LAN ($3,609) patients (p <0.001), but similar to CCB patients ($2,753; p = 0.29). In conclusion, ranolazine treatment in patients with SIHD was associated with fewer revascularization procedures and lower associated healthcare costs compared with patients initiating BB or LAN, and comparable to patients initiating CCBs., (Copyright © 2019 Elsevier Inc. All rights reserved.)

PET-based cardiac nuclear imaging plays a large role in the management of ischemic heart disease. Compared with conventional single-photon emission CT myocardial perfusion imaging, PET provides superior accuracy in diagnosis of coronary artery disease and, with the incorporation of myocardial blood flow and coronary flow reserve, adds value in assessing prognosis for established coronary and microvascular disease. This review describes these and other uses of PET in ischemic heart disease, including assessing myocardial viability in ischemic cardiomyopathy. Developments in novel PET flow tracers and molecular imaging tools to assess atherosclerotic plaque vulnerability, vascular calcification, and vascular remodeling also are described., (Published by Elsevier Inc.)

Background: Coronary ischemia requiring early percutaneous coronary intervention (PCI) is a rare but serious complication of isolated valve surgery. We sought of assess the incidence, predictors and outcomes of early PCI after isolated valve surgery using the national inpatient sample., Methods: Patients who underwent isolated aortic valve replacement (AVR), isolated mitral valve repair (MVr) or replacement (MVR) between 2003 and 2014 were identified. Patients who had early postoperative PCI were compared with patients who did not require PCI. Primary end point was in-hospital mortality. Secondary endpoints were complications, length-of-stay and cost., Results: Among the 135,611 included patients, 1,074 (0.8%) underwent PCI prior to discharge. Unadjusted in-hospital mortality was higher in patients requiring early PCI following AVR (11.2 vs. 3.1%), MVR (24.1 vs. 5.5%), and MVr (22.4 vs. 2.5%) (P < 0.001) compared with patients not requiring PCI. Postoperative PCI remained independently associated with higher mortality after adjusting for demographics, comorbidities and hospital characteristics (adjusted OR [aOR] = 3.74, 95%CI 2.70-5.17 for AVR, aOR = 6.10, 95%CI 4.53-8.23 for MVR, and aOR = 9.90, 95%CI 7.22-13.58 for MVr). Patients undergoing PCI had higher incidences of stroke, acute kidney injury, infectious complications, higher hospital charges, and longer hospitalizations. Age, robotic-assisted surgery, and chronic renal failure were independent predictors of needing early postoperative PCI., Conclusions: Early PCI after isolated aortic or mitral valve surgery is rare but is associated with substantial in-hospital morbidity, mortality, and cost. Further studies are needed to identify preventable causes, and optimal management strategies of this serious complication., (© 2018 Wiley Periodicals, Inc.)

Background: Balancing ischemic and bleeding risk is an evolving framework., Methods and Results: Our objectives were to simulate changes in risks for adverse events and event-driven costs with use of ticagrelor or prasugrel versus clopidogrel according to varying levels of ischemic and bleeding risk. Using the validated PARIS risk functions, we estimated 1-year ischemic (myocardial infarction or stent thrombosis) and bleeding (Bleeding Academic Research Consortium types 3 or 5) event rates among PARIS study participants who underwent percutaneous coronary intervention with drug-eluting stent implantation for an acute coronary syndrome and were discharged with aspirin and clopidogrel (n=1497). Simulated changes in adverse events with ticagrelor or prasugrel were calculated by applying treatment effects from randomized trials for a 1-year time horizon. Event costs were estimated using National Inpatient Sample data. Net costs were calculated between antiplatelet therapy groups according to level of ischemic and bleeding risk. After weighting events for quality-of-life impact, we calculated event rates and costs for risk-tailored treatment versus clopidogrel under multiple drug pricing assumptions. One-year rates (per 1000 person-years) for ischemic events were 12.6, 24.1, and 66.1, respectively, among those at low (n=630), intermediate (n=536), and high (n=331) ischemic risk. Analogous bleeding rates were 11.0, 23.9, and 66.2, respectively, among low (n=728), intermediate (n=634), and high (n=135) bleeding risk patients. Mean per event costs were $22 174 (ischemic) and $12 203 (bleeding). When risks for ischemia matched or exceeded bleeding, simulated utility-weighted event rates favored ticagrelor/prasugrel, whereas clopidogrel reduced utility-weighted events when bleeding exceeded ischemic risk. One-year costs were sensitive to drug pricing assumptions, and risk-tailored treatment with either agent progressed from cost incurring to cost saving with increasing generic market share., Conclusions: Tailoring antiplatelet therapy intensity to patient risk may improve health utility and could produce cost savings in the first year after percutaneous coronary intervention., Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT00998127.

Background: The American College of Cardiology/American Heart Association (ACC/AHA) recently published a rigorous framework to guide integration of economic data into clinical guidelines. We assessed the quality of economic evaluations in a major ACC/AHA clinical guidance report., Methods: We systematically identified cost-effectiveness analyses (CEAs) of RCTs cited in the ACC/AHA 2012 Guideline for the Diagnosis and Management of Patients with Stable Ischemic Heart Disease. We extracted: (1) study identifiers; (2) parent RCT information; (3) economic analysis characteristics; and (4) study quality using the Quality of Health Economic Studies instrument (QHES)., Results: Quality scores were categorized as high (≥75 points) or low (<75 points). Of 1,266 citations in the guideline, 219 were RCTs associated with 77 CEAs. Mean quality score was 81 (out of 100) and improved over time, though 29.9% of studies were low-quality. Cost-per-QALY was the most commonly reported primary outcome (39.0%). Low-quality studies were less likely to report study perspective, use appropriate time horizons, or address statistical and clinical uncertainty. Funding was overwhelmingly private (83%). A detailed methodological assessment of high-quality studies revealed domains of additional methodological issues not identified by the QHES., Conclusions: Economic evaluations of RCTs in the 2012 ACC/AHA ischemic heart disease guideline largely had high QHES scores but methodological issues existed among "high-quality" studies. Because the ACC/AHA has generally been more systematic in its integration of scientific evidence compared to other professional societies, it is likely that most societies will need to proceed more cautiously in their integration of economic evidence., (Copyright © 2018 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Because specialty care accounts for half of Medicare expenditures, improving its value is critical to the success of Medicare accountable care organizations (ACOs) in curbing spending growth. However, whether ACOs have reduced low-value specialty care without compromising use of high-value services remains unknown., Methods and Results: Using national Medicare data, we identified 2 cohorts: beneficiaries for whom the value of coronary revascularization is lower (those with ischemic heart disease without angina, congestive heart failure, or recent admission for acute myocardial infarction) and beneficiaries for whom its value is higher (those with recent acute myocardial infarction admission). We then determined the provider groups who cared for the cohorts, distinguishing between those participating (n=298) and those not participating in a Medicare ACO (1329). After measuring the provider groups' use of coronary artery bypass grafting and percutaneous coronary intervention among the 2 cohorts, we fit multivariable models to test the statistical significance of rates of change in low- and high-value revascularization after ACO participation. During the pre-ACO period, participating and nonparticipating provider groups had similar rates of low- and high-value revascularization. Our multivariable model results show that rates of change for low- and high-value coronary revascularization were not altered by a provider group's participation in a Medicare ACO (lower value: difference, -0.04 per year; 95% confidence interval, -0.11 to 0.03; higher value: difference, 0.96 per year; 95% confidence interval, -0.46 to 2.4)., Conclusions: We found no association between provider group participation in a Medicare ACO and use of low- or high-value coronary revascularization., (© 2018 American Heart Association, Inc.)

Background: Myocardial injury after noncardiac surgery (MINS) is a mostly asymptomatic condition that is strongly associated with 30-day mortality; however, it remains mostly undetected without systematic troponin T monitoring. We evaluated the cost and consequences of postoperative troponin T monitoring to detect MINS., Methods: We conducted a model-based cost-consequence analysis to compare the impact of routine troponin T monitoring versus standard care (troponin T measurement triggered by ischemic symptoms) on the incidence of MINS detection. Model inputs were based on Canadian patients enrolled in the Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) study, which enrolled patients aged 45 years or older undergoing inpatient noncardiac surgery. We conducted probability analyses with 10 000 iterations and extensive sensitivity analyses., Results: The data were based on 6021 patients (48% men, mean age 65 [standard deviation 12] yr). The 30-day mortality rate for MINS was 9.6%. We determined the incremental cost to avoid missing a MINS event as $1632 (2015 Canadian dollars). The cost-effectiveness of troponin monitoring was higher in patient subgroups at higher risk for MINS, e.g., those aged 65 years or more, or with a history of atherosclerosis or diabetes ($1309)., Conclusion: The costs associated with a troponin T monitoring program to detect MINS were moderate. Based on the estimated incremental cost per health gain, implementation of postoperative troponin T monitoring seems appealing, particularly in patients at high risk for MINS.

Background: As job stress is associated with various diseases and psychiatric conditions, we aimed to estimate the job stress-attributable burden of disease in Korea based on the concept of disability-adjusted life years (DALY)., Methods: We selected ischemic heart disease (IHD), stroke, major depressive disorder (MDD), and suicide as health outcomes from job stress, because of the ease of access to data estimating burdens and of important meaning of them in Korean occupational background., Results: Our findings demonstrated that approximately 21% of Korean workers were exposed to high job strain, which was attributable for approximately 6.7% of IHDs, 6.9% of strokes, 13.6% of MDDs, and 4% of suicides. In terms of job stress-attributable DALY, the burdens of disease per 100,000 people were 38 for IHD, 72 for stroke, 168 for MDDs, and 44 for suicides., Conclusion: The present findings suggested that one-fifth of Korean workers were suffering from high job strain. Although the figures may not be accurate due to several assumptions, job stress is an important risk factor for health in working environment in Korea., Competing Interests: Disclosure: The authors have no potential conflicts of interest to disclose.

Background: Ischemic heart disease (IHD/ICD10: I20-I25) is the second leading cause of deaths in Japan and accounts for 40% of deaths due to heart diseases. This study aimed to calculate the economic burden of IHD using the cost of illness (COI) method and to identify key factors that drive the change of the economic burden of IHD., Methods: We calculated the cost of illness (COI) every 3 years from 1996 to 2014 using governmental statistics. We then predicted the COI for every 3 years starting from 2017 up to 2029 using the fixed and variable model estimations. Only the estimated future population was used as a variable in the fixed model estimation. By contrast, variable model estimation considered the time trend of health-related indicators over the past 18 years. We derived the COI from the sum of direct and indirect costs (morbidity and mortality)., Results: The past estimation of COI slightly increased from 1493.8 billion yen in 1996 to 1708.3 billion yen in 2014. Future forecasts indicated that it would decrease from 1619.0 billion yen in 2017 to 1220.5 billion yen in 2029., Conclusion: The past estimation showed that the COI of IHD increased; in the mixed model, the COI was predicted to decrease with the continuing trend of health-related indicators. The COI of IHD in the future projection showed that, although the average age of death increased by social aging, the influence of the number of deaths and mortality cost decreased.

Objectives: This study aimed to examine the 30-day unplanned readmissions rate, predictors of readmission, causes of readmissions, and clinical impact of readmissions after percutaneous coronary intervention (PCI)., Background: Unplanned rehospitalizations following PCI carry significant burden to both patients and the local health care economy and are increasingly considered as an indicator of quality of care., Methods: Patients undergoing PCI between 2013 and 2014 in the U.S. Nationwide Readmission Database were included. Incidence, predictors, causes, and cost of 30-day unplanned readmissions were determined., Results: A total of 833,344 patients with PCI were included, of whom 77,982 (9.3%) had an unplanned readmission within 30 days. Length of stay for the index PCI was greater (4.7 vs. 3.9 days) and mean total hospital cost ($23,211 vs. $37,524) was higher for patients who were readmitted compared with those not readmitted. The factors strongly independently associated with readmissions were index hospitalization discharge against medical advice (odds ratio [OR]: 1.91; 95% confidence interval [CI]: 1.65 to 2.22), transfer to short-term hospital for inpatient care (OR: 1.62; 95% CI: 1.38 to 1.90), discharge to care home (OR: 1.57; 95% CI: 1.51 to 1.64), and chronic kidney disease (OR: 1.50; 95% CI: 1.44 to 1.55). Charlson Comorbidity Index score (OR: 1.28; 95% CI: 1.27 to 1.29) and number of comorbidities (OR: 1.18; 95% CI: 1.17 to 1.18) were independently associated with unplanned readmission. The majority of readmissions were due to noncardiac causes (56.1%)., Conclusions: Thirty-day readmissions after PCI are relatively common and relate to baseline comorbidities and place of discharge. More than one-half of the readmissions were due to noncardiac causes., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Ischemic heart disease (IHD) is a frequent accompaniment of chronic obstructive pulmonary disease (COPD). Co-occurrence of these two diseases is associated with many risk factors, difficulties in implementing appropriate therapies, numerous complications, and high spending for treatment. All these elements significantly reduce the quality of life of patients. The aim of this study was to estimate the expenditure for medications involved with IHD pharmacotherapy in the course of COPD. This retrospective study was based on the review of medical files of 57 patients, 27 women and 30 men, diagnosed with IHD, according to the severity classification, in the course of COPD which was staged according to the GOLD criteria. We found a considerable increase in per capita per year retail spending for drugs. The spending increased with the severity class of IHD; from 27.41 EUR in Class I to 142.30 EUR in Class IV. This spending did not include the treatment cost for the basic disease, i.e., COPD. A high individual cost burden was decreased by a discounting intervention of the National Health Fund. Despite a relatively high drug expenditure, we consider the treatment being cost-effective since we noticed a reduction in the classical risk factors for IHD, related to metabolic disturbances and lifestyle features, as soon as 2 months after treatment initiation. This study confirms that heart disease accompanying COPD is a frequent occurrence, generating high costs of treatment, which relates to the severity of this comorbidity.

Background: Cardiac rehabilitation (CR) is a cornerstone of secondary prevention of ischemic heart disease. It is critically important in low- and middle-income countries (LMIC), where the burden of ischemic heart disease is substantial and growing. However, the availability and utilization of CR in LMIC is not systematically known., Objectives: This study sought to characterize the availability, use, and barriers to the use of CR., Methods: Electronic databases (Cochrane Library, EMBASE, PubMed, Web of Science) were searched from January 1, 1980 to May 31, 2013 for articles on CR in LMIC. Citations on availability, use, and/or barriers to CR were screened for inclusion by title, abstract, and full text. Data were summarized by region or country to determine the characteristics of CR in LMIC and gaps in the peer-reviewed biomedical publications., Results: Our search yielded a total of 5,805 citations, of which 34 satisfied full inclusion and exclusion criteria. The total number of CR programs available ranged from 1 in Algeria and Paraguay to 51 in Serbia. Referral rates for CR ranged from 5.0% in Mexico to 90.3% in Lithuania. Attendance rates ranged from 31.7% in Bulgaria to 95.6% in Lithuania, and CR attendance was correlated with higher educational background. The most commonly cited barrier to CR in LMIC was lack of physician referral., Conclusions: Our results illustrate that the published reports reflects heterogeneity of CR availability and use in LMIC. Overall, CR is insufficiently available and underutilized. Further characterization of CR in LMIC, especially in Asia and Africa, is necessary to develop targeted strategies to improve availability and utilization. Patient, physician, and systems factors must be addressed to overcome barriers to participation in CR in LMIC., (Copyright © 2016 World Heart Federation (Geneva). Published by Elsevier B.V. All rights reserved.)

Background: Ischemic heart disease (IHD) has emerged as a major cause of morbidity and mortality in patients with autoimmune conditions such as systemic lupus erythematosus and rheumatoid arthritis, but the risk of IHD in Sjögren's syndrome (SjS) is unknown. To fill this knowledge gap, we estimated the prevalence and risk of IHD with SjS compared to controls from the general population using the Healthcare Cost and Utilization Project National Inpatient Sample 2011 database., Materials and Methods: The Healthcare Cost and Utilization Project administrative longitudinal database contains encounter-level information on inpatient stays, emergency department visits and ambulatory surgery in all U.S. hospitals. We conducted a cross-sectional study among the inpatient population diagnosed with SjS and matched 1:4 with controls for age, sex and hospital region. Odds ratio for IHD was calculated as cases compared to controls. The contribution of various risk factors to IHD was also evaluated by logistic regression., Results: Analysis demonstrated that 7,154 of 13,086 cases (54.7%) of SjS had IHD compared to 27,367 of 52,448 controls (52.2%). The adjusted odds ratio for IHD in those with SjS was 0.898 (95% CI: 0.844-0.955). Patients with SjS were significantly more likely to have hypertension, diabetes, apnea and lipid disorders., Conclusions: To our knowledge, this is the largest population-based study investigating the risk of IHD in patients with SjS. We found a modest, though statistically significant, decrease in the risk of IHD in SjS compared to controls., (Copyright © 2017 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.)

Background: Coronary artery disease is the most prevalent cardiovascular disease. In the United States, 7% of adults over 20 years of age are estimated to have coronary artery disease. In Brazil, a prevalence of 5 to 8% has been estimated in adults over 40 years of age, with an increased number of hospitalizations associated with both stable and acute clinical manifestations; and health care costs have quadrupled in the last decade. To estimate the direct costs of managing ischemic heart disease patient care in a teaching hospital in Brazil from the perspective of the service payer, the Brazilian Unified Health System., Methods: This study was a retrospective cohort study for the identification and valuation of resources used at both the outpatient and in-hospital levels in a sample of 330 patients selected from the hospital's ischemic heart disease clinic. Data were collected from computerized hospital records and patients' hospital bills from January 2000 to October 2015. A bivariate analysis and binary logistic regression were performed with p < 0.05 considered statistically significant., Results: The study population consisted of 330 patients with a mean age 61 ± 10 years and a follow-up period of 107 ± 2.6 months; of the patients, 55% were male, 89% had hypertension, 48% had diabetes, and 65% had acute myocardial infarction. The mean annual cost of outpatient management was US $1,521 per patient. The mean cost per hospitalization was US $1,976, and the expenses were higher in the first and last years of follow-up. Unstable angina, revascularization procedures, diabetes, hypertension and obesity were predictors of higher hospitalization costs (p <0.05)., Conclusion: The cost estimates in this study indicate a high proportion of drug treatment costs in the treatment of ischemic heart disease. Treatment costs are higher in the first year and at the end of treatment, and some clinical factors are associated with greater hospital care costs. These results may serve as a basis for the evaluation of existing public policies and inputs for cost-effectiveness studies in coronary artery disease., Trial Registration: CEP HCPA 11-0460 . Ethics Committee of Hospital de Clínicas de Porto Alegre.

In 2011, for the first time in the history of humankind, non-communicable diseases became the leading cause of death worldwide. This change in trend is obviously multifactorial and very complex, as it is the paradoxical result of social, economic and health system growth worldwide. Vaccination and infectious diseases control, changing dietary habits worldwide, sedentary behaviour, globalisation, industrialisation (resulting in a shift from manual to sedentary labour), tobacco and sugary beverage surges in low- and middle-income countries and rapid urbanisation have all played a role in this epidemic transition. At the same time, the increase in cardiovascular risk factors, together with a decline in mortality in high-income countries in the past two decades, has led to a significant upsurge in the prevalence of secondary prevention of ischaemic heart disease. With this, the effect that non-adherence to cardioprotective drugs is having has become progressively clear, both in terms of clinical outcomes and as a driver of increased healthcare expenditure. The cardiovascular polypill, which was originally proposed as a strategy to improve accessibility to cardioprotective drugs worldwide, has proven to be a mainstay therapeutic approach for improving medication adherence in cardiovascular disease. In the current paper, we aim to review the need for a polypill strategy in the present scenario of cardiovascular disease, the available data that support such a strategy and the various clinical trials that are in progress that will help further shape future indications for the cardiovascular polypill.

Objective: To estimate the cost of smoking in Singapore in 2014 from the societal perspective., Methods: A prevalence-based, disease-specific approach was undertaken to estimate the smoking-attributable costs. These include direct and indirect costs of inpatient treatment, premature mortality, loss of productivity due to medical leaves and smoking breaks., Results: In 2014, the social cost of smoking in Singapore was conservatively estimated to be at least US$479.8 million, ∼0.2% of the 2014 gross domestic product. Most of this cost was attributable to productivity losses (US$464.9 million) and largely concentrated in the male population (US$434.9 million). Direct healthcare costs amounted to US$14.9 million where ischaemic heart disease and lung cancer had the highest cost burden., Conclusions: The social cost of smoking is smaller in Singapore than in other Asian countries. However, there is still cause for concern. A recently observed increase in smoking prevalence, particularly among adolescent men, is likely to result in rising total cost. Most significantly, our results suggest that a large share of the overall cost burden lies outside the healthcare system or may not be highly salient to the relevant decision makers. This is partly because of the nature of such costs (indirect or intangible costs such as productivity losses are often not salient) or data limitations (a potentially significant fraction of direct healthcare expenditure may be in private primary care where costs are not systematically captured and reported). The case of Singapore thus illustrates that even in countries perceived as success stories, strong multisectoral anti-tobacco strategies and a supporting research agenda continue to be needed., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Cardiac magnetic resonance (CMR) has emerged as a reliable and accurate diagnostic tool for the evaluation of patients with cardiac disease in several clinical settings and with proven additional diagnostic and prognostic value compared with other imaging modalities. This document has been developed by the working group on the 'application of CMR' of the Italian Society of Cardiology to provide a perspective on the current state of technical advances and clinical applications of CMR and to inform cardiologists on how to implement their clinical and diagnostic pathways with the inclusion of this technique in clinical practice. The writing committee consisted of members of the working group of the Italian Society of Cardiology and two external peer reviewers with acknowledged experience in the field of CMR.

Aim: We aimed to summarize the pooled effect of early discharge compared with ordinary discharge after percutaneous coronary intervention (PCI) on the composite endpoint of re-infarction, revascularization, stroke, death, and incidence of rehospitalization. We also aimed to compare costs for the two strategies., Methods: The study was a systematic review and a meta-analysis of 12 randomized controlled trials including 2962 patients, followed by trial sequential analysis. An estimation of cost was considered. Follow-up time was 30 days., Results: For early discharge, pooled effect for the composite endpoint was relative risk of efficacy (RRe)=0.65, 95% confidence interval (CI) (0.52-0.81). Rehospitalization had a pooled effect of RRe=1.10, 95% CI (0.88-1.38). Early discharge had an increasing risk of rehospitalization with increasing frequency of hypertension for all populations, except those with stable angina, where a decreasing risk was noted. Advancing age gave increased risk of revascularization. Early discharge had a cost reduction of 655 Euros per patient compared with ordinary discharge., Conclusion: The pooled effect supports the safe use of early discharge after PCI in the treatment of a heterogeneous population of patients with coronary artery disease. There was an increased risk of rehospitalization for all subpopulations, except patients with stable angina. Clinical trials with homogeneous populations of acute coronary syndrome are needed to be conclusive on this issue., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

The evaluation of patients with suspected stable ischemic heart disease is among the most common diagnostic evaluations with nearly 20 million imaging and exercise stress tests performed annually in the United States. Over the past decade, there has been an evolution in imaging research with an ever-increasing focus on larger registries and randomized trials comparing the effectiveness of varying diagnostic algorithms. The current review highlights recent randomized trial evidence with a particular focus comparing the effectiveness of cardiac imaging procedures within the stable ischemic heart disease evaluation for coronary artery disease detection, angina, and other quality of life measures, and major clinical outcomes. Also highlighted are secondary analyses from these trials on the economic findings related to comparative cost differences across diagnostic testing strategies., (Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: To summarise all available evidence on the differences in burden of ischaemic heart disease (IHD) between metropolitan and rural communities of Australia., Methods: Systematic review of peer-reviewed literature published between 1990 and 2014. Search terms were derived from the four major topics: (1) rural; (2) ischaemic heart disease; (3) Australia; and (4) burden of disease. Terms were adapted for six databases and two independent researchers screened results. Studies were included if they compared outcomes related to IHD in adults aged 18 years and over, between (at least) two areas of differing remoteness, at the same point in time., Results: Twenty studies were included and presented data collected between 1969 and 2010. Seventeen studies showed a clear disparity in IHD outcomes between major cities and regional and remote areas, with a consistently higher burden observed outside major cities. Among Aboriginal and Torres Strait Islander populations, fewer differences were observed and some IHD outcomes were not associated with remoteness., Conclusions: Populations outside of major cities in Australia bear a disproportionately high burden of ill health due to IHD, yet the majority of the rural populations are yet to be investigated in terms of burden of disease outcomes from IHD., Implications: Remoteness is a key determinant of IHD burden in Australia. The reasons for increased IHD burden in rural compared to metropolitan communities of Australia are poorly understood, which has implications for the design of targeted interventions to reduce geographical inequalities., (Copyright © 2016 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: The prevalence of ischemic heart disease is high. Few recent studies have investigated the periods of sick leave of these patients. Our aim is to determine the length of sick leave after an acute coronary syndrome, its costs, associated factors and to assess the use of antidepressants and/or anxiolytics., Methods: An observational study of a retrospective cohort of patients on sick leave due to ischemic heart disease in a health region between 2008-2011, with follow-up until the first return to work, death, or end of the study (31/12/2012)., Measurements: length of sick leave, sociodemographic variables and medical prescriptions., Results: Four hundred and ninety-seven patients (mean age 53 years, 90.7% male), diagnosed with acute myocardial infarction (60%), angina pectoris (20.7%) or chronic form of ischemic heart disease (19.1%). Thirty-seven per cent of patients took anxiolytics the year after diagnosis and 15% took antidepressants. The average duration of sick leave was 177 days (95% CI: 163-191 days). Patients diagnosed with acute myocardial infarction returned to work after a mean of 192 days, compared to 128 days in cases with angina pectoris. Patients who took antidepressants during the year after diagnosis returned to work after a mean of 240 days. The mean work productivity loss was estimated to be 9,673 euros/person., Conclusions: The mean duration of sick leave due to ischemic heart disease was almost six months. Consumption of psychotropic medication doubled after the event. Older age, suffering an acute myocardial infarction and taking antidepressants were associated with a longer sick leave period.

Background: Malaysia is an upper-middle income country with a tax-based health financing system. Health care is relatively affordable, and safety nets are provided for the needy. The objectives of this study were to determine the out-of-pocket health spending, proportion of catastrophic health spending (out-of-pocket spending >40% of non-food expenditure), economic hardship and financial coping strategies among patients with ischaemic heart disease (IHD) in Malaysia under the present health financing system., Methods: A cross-sectional study was conducted at the National Heart Institute of Malaysia involving 503 patients who were hospitalized during the year prior to the survey., Results: The mean annual out-of-pocket health spending for IHD was MYR3045 (at the time US$761). Almost 16% (79/503) suffered from catastrophic health spending (out-of-pocket health spending ≥40% of household non-food expenditures), 29.2% (147/503) were unable to pay for medical bills, 25.0% (126/503) withdrew savings to help meet living expenses, 16.5% (83/503) reduced their monthly food consumption, 12.5% (63/503) were unable to pay utility bills and 9.0% (45/503) borrowed money to help meet living expenses., Conclusions: Overall, the economic impact of IHD on patients in Malaysia was considerable and the prospect of economic hardship likely to persist over the years due to the long-standing nature of IHD. The findings highlight the need to evaluate the present health financing system in Malaysia and to expand its safety net coverage for vulnerable patients., (© The Author 2016. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

As the major engine of economic growth in China, the Pearl River Delta (PRD) region is one of the most urbanized regions in the world. Rapid development has brought great wealth to its citizens; however, at the same time, increasing emissions of ambient pollutants from vehicles and industrial combustions have caused considerable air pollution and negative health effects for the region's residents. In this study, the concentration response function method was applied together with satellite-retrieved particulate matter (PM 10 and PM 2.5 ) concentration data to estimate the health burden caused by this pollutant from 2004 to 2013. The value of statistical life was used to calculate the economic loss due to the negative health effects of particulate matter pollution. Our results show that in the whole PRD region, the estimated number of deaths from the four diseases attributable to PM 2.5 was the highest in 2012, at 45,000 (19,000-61,000); the number of all-cause hospital admissions due to PM 10 was the highest in 2013, reaching up to 91,000 (0-270,000) (excluding Hong Kong). Among the 10 cities, the capital city Guangzhou suffered the most from ambient particulate matter pollution and had the highest mortality and morbidity over the 10years. The cost of mortality in this region was the highest in 2012, at 46,000 million USD, or around 6.1% of local total gross domestic product (GDP). The positive spatial relationship between the degree of urbanization and the particulate matter concentration proves that the urbanization process does worsen air quality and hence increases the health risks of local urban citizens. It is recommended that local governments further enhance their control policies to better guarantee the health and wealth benefits of local residents., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Aims: To obtain a reliable estimation of the health impact of air pollution, we explored the effects of air pollutants on years of life lost from ischaemic heart disease in Tianjin, China., Methods and Results: We conducted a retrospective ecological analysis using daily time series set in six urban districts in Tianjin. Our data included 28,365 ischaemic heart disease deaths registered in 2002-2006. The main outcome measures were years of life lost and deaths from ischaemic heart disease. We found mean concentrations of daily particulate matter with an aerodynamic diameter of less than 10 µm in size (PM 10 ), sulfur dioxide and nitrogen dioxide of 125.6 µg/m 3 , 78.7 µg/m 3 , 55.1 µg/m 3 , respectively. Interquartile range increases of PM 10 , sulfur dioxide and nitrogen dioxide were associated with increases in years of life lost from ischaemic heart disease of 13.8, 4.8 and 22.7 years in single pollutant models, respectively. The effects associated with an interquartile range increase in PM 10 were greater in women than men. During the 5 years, there were 27,485 years and 1252 deaths advanced by PM 10 pollution over expected rates when daily levels did exceed the World Health Organization air quality guidelines. That is to say, on average, 63.12 hours per person were lost by air pollution in the 5-year period in Tianjin., Conclusions: Short-term exposure to air pollution has a significant impact on ischaemic heart disease years of life lost and mortality in Tianjin, particularly among women. Air quality improvement has become necessary to protect public health., (© The European Society of Cardiology 2016.)

Objectives: Chronic Obstructive Pulmonary Disease (COPD) has a substantial impact on health care systems worldwide. Particularly, cardiovascular diseases such as ischemic heart disease (IHD) are frequent in individuals with COPD, but the economic consequences of combined COPD and IHD are by large unknown. Therefore, our study has the objective to investigate excess costs of IHD in COPD patients., Methods: Out of German Statutory Health Insurance claims data we identified 26,318 COPD patients with and 10,287 COPD patients without IHD based on ICD-10 codes (COPD J44; IHD I2[0,1,2,5]) of the year 2011 and matched 9986 of them in a 1:1 ratio based on age and gender. Then, we investigated health care service expenditures in 2012 via Generalized Linear Models. Moreover, we evaluated a potential non-linear association between health care expenditures and age in a gender-stratified Generalized Additive Model., Results: The prevalence of IHD in individuals with COPD increases with rising age up to a share of 50%. COPD patients with IHD cause adjusted mean annual per capita health care service expenditures of ca. €7400 compared with ca. €5800 in COPD patients without IHD. Moreover, excess costs of IHD have an inverse u-shape, peaking in the early (men) respectively late seventies (women)., Conclusions: IHD in COPD patients is associated with excess costs of ca. € 1,500, with the exact amount varying age- and gender-dependently. Subgroups with high excess costs indicate medical need that calls for efficient care strategies, considering COPD and IHD together particularly between 70 and 80 years of age., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Purpose: to analyze clinical and economical effectiveness of meldonium as component of integrated program of cardio-rehabilitation in patients with ischemic heart disease (IHD) in the early period after percutaneous coronary intervention (PCI) with incomplete revascularization., Material and Methods: A program of controlled physical training (CPT) was carried out in patients with stable IHD and positive post PCI exercise test (n=48, age less or equal 65 years) starting 8-10 days after PCI. CRT program consisted of 2 phases - inhospital (exercise on treadmill with max heart rate [HR] 80% of that achieved in initial test, 10 times during 2 weeks) and home (exercise on treadmill with max HR 60% of HR achieved in initial test, 3 times a week for 2 months). Before initiation of CRT patients were distributed into 2 groups: CRT without (n=23; 56.7+/-7.1 years) and with (n=25; 54.6+/-6.8 years) administration of meldonium (1000 mg/day intravenously). Control group (n=24; 50+/-8.4 years) consisted of patients who were under outpatient observation, received similar drug therapy, but were not subjected to CRT. After completion of CRT (in 2.5 months) all patients underwent clinical-instrumental examination with determination of exercise tolerance., Results: Exercise duration and metabolic equivalent (MET) increased by 43.9, 36.6, 4.1% and 42.1, 34.8, 3.4% in CRT+ meldonium, CRT only, and control groups, respectively., Conclusion: In patients with documented ischemia after PCI inclusion of meldonium in the scheme of rehabilitation was associated with improved physical performance and optimal cost-effectiviness.

Objectives: Ischemic heart disease (IHD) is a large public health problem and is associated with a number of modifiable risk factors. The aim of this study was to estimate the IHD burden and attributable to risk factors in Fujian, China during 1990 to 2013., Methods: IHD deaths, disability-adjusted life years (DALYs) and attributable to risk factors were estimated as part of the Global Burden of Disease (GBD) 2013 Study. Statistical models were employed to produce comprehensive results of IHD deaths, DALYs and attributable to risk. Means and 95% uncertainty intervals (UIs) were calculated for mortality and DALYs. The median of the percent change and 95% UI were determined for the period between 1990 and 2013., Results: The age-standardized IHD deaths rate increased by 15.3% from 1990 [74.7 (95% UI 62.9-99.1) per 100,000] to 2013 [82.7 (56.5-95.5) per 100,000]. The age-standardized IHD DALYs has slightly decreased 8.8% from 1990 to 2013[from 1356.2 (1134.3-1732.1) to 1202.7 (879.6-1404.6) per 100,000]. All risks combined account for 94.7% (92.9%- 96.0%) of IHD DALYs for all ages in 2013. The five leading risk factors for all ages IHD DALYs were high systolic blood pressure, high total cholesterol, smoking, diet high in sodium, and high fasting plasma glucose., Conclusion: Despite decreased age-standardized IHD deaths and DALY rate since 1990, population growth and aging led to a higher global burden of IHD in 2013. Behavioral, environmental, and metabolic risks can explain most of the IHD DALYs providing many opportunities for prevention., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Africa is a continent characterized by marked ethnic, sociodemographic, and economic diversity, with profound changes in many regions over the past 2 decades. This diversity has an impact on cardiovascular disease presentation and outcomes. Within Africa and within the individual countries, one can find regions having predominantly communicable diseases such as rheumatic heart disease, tuberculous pericarditis, or cardiomyopathy and others having a marked increase in noncommunicable disease such as hypertension and hypertensive heart disease. Ischemic heart disease remains rare in most countries. Difficulties in the planning and implementation of effective health care in most African countries are compounded by a paucity of studies and a low rate of investment in research and data acquisition. The fiduciary responsibilities of companies working in Africa should include the effective and efficient use of natural resources to promote the overall health of populations., (© 2016 American Heart Association, Inc.)

Assessment of cost of management of patients during 1 year after stenting of coronary arteries has shown that priority should be given to active introduction into practical health care of technologies increasing duration of life and lowering probability of invalidization. We stress the need for evaluation of indirect expenditures on patients care because of their substantial share in the total cost. We also consider essential to elaborate measures of state regulation of medication supply irrespective of type of treatment for shifting expenditures from hospital to ambulatory sector and improvement of effectiveness of pharmacotherapy.

Background: The value of drug-eluting stents in preventing cardiovascular events has not been investigated in Mexico., Objective: To conduct a cost-effectiveness analysis of early and new-generation drug-eluting stents from the perspective of a healthcare provider., Methods: We conducted a cost-effectiveness analysis of early and new-generation drug-eluting stents in patients with ischemic cardiomyopathy attending a Cardiology Hospital of the Mexican Social Security Institute. The health endpoint used was major acute cardiovascular events prevented. The effectiveness by stent type was obtained from the literature. A retrospective chart review study was conducted to collect cost data on cardiovascular events including seven cost categories. Average and incremental cost-effectiveness ratios were estimated. Deterministic and probabilistic sensitivity analyses were performed to test the robustness of estimates., Results: Incremental cost-effectiveness ratios in base-case were 28,910 and US$ 35,590 for early and new-generation stents, respectively. In an optimal scenario, incremental-cost effectiveness ratio was 24,776 and US$ 25,262 for early and new stents, respectively. Probabilistic sensitivity analysis suggested that 90% of cases were cost-effective when willingness-to-pay was 58,000 and US$ 66,000 for early and new-generation stents, respectively., Conclusions: The cost-effectiveness ratios of early and new-generation stents were significantly higher than corresponding bare-metal stents.

Aim: To determine the effectiveness and cost-effectiveness of a mobile phone intervention to improve exercise capacity and physical activity behaviour in people with ischaemic heart disease (IHD)., Methods and Results: In this single-blind, parallel, two-arm, randomized controlled trial adults (n = 171) with IHD were randomized to receive a mobile phone delivered intervention (HEART; n = 85) plus usual care, or usual care alone (n = 86). Adult participants aged 18 years or more, with a diagnosis of IHD, were clinically stable as outpatients, able to perform exercise, able to understand and write English, and had access to the Internet. The HEART (Heart Exercise And Remote Technologies) intervention involved a personalized, automated package of text messages and a secure website with video messages aimed at increasing exercise behaviour, delivered over 24 weeks. All participants were able to access usual community-based cardiac rehabilitation, which involves encouragement of physical activity and an offer to join a local cardiac support club. All outcomes were assessed at baseline and 24 weeks and included peak oxygen uptake (PVO2; primary outcome), self-reported physical activity, health-related quality of life, self-efficacy and motivation (secondary outcomes). Results showed no differences in PVO2 between the two groups (difference -0.21 ml kg(-1)min(-1), 95% CI: -1.1, 0.7; p = 0.65) at 24 weeks. However significant treatment effects were observed for selected secondary outcomes, including leisure time physical activity (difference 110.2 min/week, 95% CI: -0.8, 221.3; p = 0.05) and walking (difference 151.4 min/week, 95% CI: 27.6, 275.2; p = 0.02). There were also significant improvements in self-efficacy to be active (difference 6.2%, 95% CI: 0.2, 12.2; p = 0.04) and the general health domain of the SF36 (difference 2.1, 95% CI: 0.1, 4.1; p = 0.03) at 24 weeks. The HEART programme was considered likely to be cost-effective for leisure time activity and walking., Conclusions: A mobile phone intervention was not effective at increasing exercise capacity over and above usual care. The intervention was effective and probably cost-effective for increasing physical activity and may have the potential to augment existing cardiac rehabilitation services., (© The European Society of Cardiology 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

The increasing prominence of the private sector in health care provision has generated considerable interest in understanding its implications on quality and cost. This paper investigates the phenomenon of cream skimming in a mixed public-private hospital setting using the novel approach of analysing hospital transfers. We analyse hospital administrative data of patients with ischemic heart disease from the state of Victoria, Australia. The data set contains approximately 1.77 million admission episodes in 309 hospitals, of which 132 are public hospitals, and 177 private hospitals. We ask if patients transferred between public and private hospitals differ systematically in the severity and complexity of their medical conditions; and if so, whether utilisation also differs. We find that patients with higher disease severity are more likely to be transferred from private to public hospitals whereas the opposite is true for patients transferred to private hospitals. We also find that patients transferred from private to public hospitals stayed longer and cost more than private-to-private transfer patients, after controlling for patients' observed health conditions and personal characteristics. Overall, the evidence is suggestive of the presence of cream skimming in the Victorian hospital system, although we cannot conclusively rule out other mechanisms that might influence hospital transfers., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Few studies in China have focused on direct expenditures for cardiovascular diseases (CVDs), making cost trends for CVDs uncertain. Epidemic modeling and forecasting may be essential for health workers and policy makers to reduce the cost burden of CVDs.To develop a time series model using Box-Jenkins methodology for a 15-year forecasting of CVD hospitalization costs in Shanghai.Daily visits and medical expenditures for CVD hospitalizations between January 1, 2008 and December 31, 2012 were analyzed. Data from 2012 were used for further analyses, including yearly total health expenditures and expenditures per visit for each disease, as well as per-visit-per-year medical costs of each service for CVD hospitalizations. Time series analyses were performed to determine the long-time trend of total direct medical expenditures for CVDs and specific expenditures for each disease, which were used to forecast expenditures until December 31, 2030.From 2008 to 2012, there were increased yearly trends for both hospitalizations (from 250,354 to 322,676) and total costs (from US $ 388.52 to 721.58 million per year in 2014 currency) in Shanghai. Cost per CVD hospitalization in 2012 averaged US $ 2236.29, with the highest being for chronic rheumatic heart diseases (US $ 4710.78). Most direct medical costs were spent on medication. By the end of 2030, the average cost per visit per month for all CVDs was estimated to be US $ 4042.68 (95% CI: US $ 3795.04-4290.31) for all CVDs, and the total health expenditure for CVDs would reach over US $1.12 billion (95% CI: US $ 1.05-1.19 billion) without additional government interventions.Total health expenditures for CVDs in Shanghai are estimated to be higher in the future. These results should be a valuable future resource for both researchers on the economic effects of CVDs and for policy makers.

Objective: Healthcare and mortality costs of secondhand smoke (SHS) exposure at home among non-smokers in California were estimated for the year 2009., Methods: Costs were estimated with an epidemiological model using California SHS home exposure rates and published relative risks. Healthcare costs included nine conditions, and mortality was estimated for four perinatal and three adult conditions. Three mortality-related measures were estimated: deaths, years of potential life lost (YPLL) and the value of lost productivity., Results: SHS-attributable healthcare costs totalled over $241 million. The most costly conditions for children and adolescents were attention deficit hyperactivity disorder ($7.8 million) and middle ear disease ($5.6 million). For adults, the most costly conditions were ischaemic heart disease (IHD) ($130.0 million) and asthma ($67.4 million). Deaths of 821 Californians were attributable to SHS exposure in the home, including 27 infants whose mothers smoked while pregnant and 700 adults who died from IHD. These deaths represented a loss of over 13 000 YPLL and $119 million in lost productivity., Conclusions: The economic impact of SHS exposure in the home totalled $360 million in California in 2009. Policies that reduce exposure to SHS at home have great potential for reducing healthcare and mortality costs., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: ASCERT (American College of Cardiology Foundation and the Society of Thoracic Surgeons Collaboration on the Comparative Effectiveness of Revascularization Strategies) was a large observational study designed to compare the long-term effectiveness of coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) to treat coronary artery disease (CAD) over 4 to 5 years., Objectives: This study examined the cost-effectiveness of CABG versus PCI for stable ischemic heart disease., Methods: The Society of Thoracic Surgeons and American College of Cardiology Foundation databases were linked to the Centers for Medicare and Medicaid Services claims data. Costs for the index and observation period (2004 to 2008) hospitalizations were assessed by diagnosis-related group Medicare reimbursement rates; costs beyond the observation period were estimated from average Medicare participant per capita expenditure. Effectiveness was measured via mortality and life-expectancy data. Cost and effectiveness comparisons were adjusted using propensity score matching with the incremental cost-effectiveness ratio expressed as cost per quality-adjusted life-year gained., Results: CABG patients (n = 86,244) and PCI patients (n = 103,549) were at least 65 years old with 2- or 3-vessel coronary artery disease. Adjusted costs were higher for CABG for the index hospitalization, study period, and lifetime by $10,670, $8,145, and $11,575, respectively. Patients undergoing CABG gained an adjusted average of 0.2525 and 0.3801 life-years relative to PCI over the observation period and lifetime, respectively. The life-time incremental cost-effectiveness ratio of CABG compared to PCI was $30,454/QALY gained., Conclusions: Over a period of 4 years or longer, patients undergoing CABG had better outcomes but at higher costs than those undergoing PCI., (Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Mononuclear stem cells have been studied for their potential in myocardial ischemia. In our previous published article, ReACT(®) phase I/II clinical trial, our results suggest that a certain cell population, promonocytes, directly correlated with the perceived angiogenesis in refractory angina patients. This study is ReACT's clinical update, assessing long-term sustained efficacy. The ReACT phase IIA/B noncontrolled, open-label, clinical trial enrolled 14 patients with refractory angina and viable ischemic myocardium, without ventricular dysfunction, who were not suitable for myocardial revascularization. The procedure consisted of direct myocardial injection of a specific mononuclear cell formulation, with a certain percentage of promonocytes, in a single series of multiple injections (24-90; 0.2 ml each) into specific areas of the left ventricle. Primary endpoints were Canadian Cardiovascular Society Angina Classification (CCSAC) improvement at the 12-month follow-up and ischemic area reduction (scintigraphic analysis) at the 12-month follow-up, in correlation with ReACT's formulation. A recovery index (for patients with more than 1 year follow-up) was created to evaluate CCSAC over time, until April 2011. Almost all patients presented progressive improvement in CCSAC beginning 3 months (p=0.002) postprocedure, which was sustained at the 12-month follow-up (p=0.002), as well as objective myocardium ischemic area reduction at 6 months (decrease of 15%, p<0.024) and 12 months (decrease of 100%, p<0.004) The recovery index (n=10) showed that the patients were graded less than CCSAC 4 for 73.9 ± 24.2% over a median follow-up time of 46.8 months. After characterization, ReACT's promonocyte concentration suggested a positive correlation with CCSAC improvement (r=-0.575, p=0.082). Quality of life (SF-36 questionnaire) improved significantly in almost all domains. Cost-effectiveness analysis showed decrease in angina-related direct costs. Refractory angina patients presented a sustained long-term improvement in CCSAC and myocardium ischemic areas after the procedure. The long-term follow-up and strong improvement in quality of life reinforce effectiveness. Promonocytes may play a key role in myocardial neoangiogenesis. ReACT dramatically decreased direct costs.

This paper investigates the effects of global budgets on the amount of resources devoted to cardio-cerebrovascular disease patients by hospitals of different ownership types and these patients' outcomes. Theoretical models predict that hospitals have financial incentives to increase the quantity of treatments applied to patients. This is especially true for for-profit hospitals. If that's the case, it is important to examine whether the increase in treatment quantity is translated into better treatment outcomes. Our analyses take advantage of the National Health Insurance of Taiwan's implementation of global budgets for hospitals in 2002. Our data come from the National Health Insurance's claim records, covering the universe of hospitalized patients suffering acute myocardial infarction, ischemic heart disease, hemorrhagic stroke, and ischemic stroke. Regression analyses are carried out separately for government, private not-for-profit and for-profit hospitals. We find that for-profit hospitals and private not-for-profit hospitals did increase their treatment intensity for cardio-cerebrovascular disease patients after the 2002 implementation of global budgets. However, this was not accompanied by an improvement in these patients' mortality rates. This reveals a waste of medical resources and implies that aggregate expenditure caps should be supplemented by other designs to prevent resources misallocation.

Introduction: Coronary artery bypass grafting (CABG) and percutaneous coronary interventions (PCI) are procedures commonly performed on patients with significant obstructive coronary artery disease to relieve symptoms of ischaemia, improve survival or both. Although the efficacy of both procedures at the individual level has been established, the impact of advances in coronary artery revascularisation procedures (CARP) on long-term outcomes and cost-effectiveness at the population level are yet to be assessed. Our aim is to evaluate a minimum of 6-year outcomes and costs for the total population of patients who had CARP in Western Australia (WA) in 2000-2005., Methods and Analysis: This retrospective population cohort study will link clinical and administrative health data for a previously defined cohort including all patients in WA who had a CARP in the period 2000-2005. The cohort consists of 19,014 patients who had 21,175 procedures (15,429 PCI and 5746 CABG). We are now collecting a minimum of 6 years follow-up of morbidity and mortality data for the cohort using the WA Data Linkage System, clinical registries and hospital records, with 12 years follow-up for cases in the year 2000. Comparison of long-term outcomes for different CARP will be reported (PCI vs CABG; bare metal stents vs drug-eluting stents vs CABG). Cost-effectiveness analysis of CARP from the perspective of the healthcare sector will be performed using individual level cost data and average costs from Australian Refined Diagnosis Related Groups., Ethics and Dissemination: This study has received ethics approval from the University of Western Australia, the Western Australian Department of Health and all participating hospitals. Being a large population cohort study, approval included a waiver of informed consent. All findings will be presented at local, national and international healthcare/academic conferences and published in peer-reviewed journals., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Cardiac magnetic resonance imaging (CMR) is increasingly used to assess patients for myocardial viability prior to revascularisation. This is important to ensure that only those likely to benefit are subjected to the risk of revascularisation., Objectives: To assess current evidence on the accuracy and cost-effectiveness of CMR to test patients prior to revascularisation in ischaemic cardiomyopathy; to develop an economic model to assess cost-effectiveness for different imaging strategies; and to identify areas for further primary research., Data Sources: Databases searched were: MEDLINE including MEDLINE In-Process & Other Non-Indexed Citations Initial searches were conducted in March 2011 in the following databases with dates: MEDLINE including MEDLINE In-Process & Other Non-Indexed Citations via Ovid (1946 to March 2011); Bioscience Information Service (BIOSIS) Previews via Web of Science (1969 to March 2011); EMBASE via Ovid (1974 to March 2011); Cochrane Database of Systematic Reviews via The Cochrane Library (1996 to March 2011); Cochrane Central Register of Controlled Trials via The Cochrane Library 1998 to March 2011; Database of Abstracts of Reviews of Effects via The Cochrane Library (1994 to March 2011); NHS Economic Evaluation Database via The Cochrane Library (1968 to March 2011); Health Technology Assessment Database via The Cochrane Library (1989 to March 2011); and the Science Citation Index via Web of Science (1900 to March 2011). Additional searches were conducted from October to November 2011 in the following databases with dates: MEDLINE including MEDLINE In-Process & Other Non-Indexed Citations via Ovid (1946 to November 2011); BIOSIS Previews via Web of Science (1969 to October 2011); EMBASE via Ovid (1974 to November 2011); Cochrane Database of Systematic Reviews via The Cochrane Library (1996 to November 2011); Cochrane Central Register of Controlled Trials via The Cochrane Library (1998 to November 2011); Database of Abstracts of Reviews of Effects via The Cochrane Library (1994 to November 2011); NHS Economic Evaluation Database via The Cochrane Library (1968 to November 2011); Health Technology Assessment Database via The Cochrane Library (1989 to November 2011); and the Science Citation Index via Web of Science (1900 to October 2011). Electronic databases were searched March-November 2011., Review Methods: The systematic review selected studies that assessed the clinical effectiveness and cost-effectiveness of CMR to establish the role of CMR in viability assessment compared with other imaging techniques: stress echocardiography, single-photon emission computed tomography (SPECT) and positron emission tomography (PET). Studies had to have an appropriate reference standard and contain accuracy data or sufficient details so that accuracy data could be calculated. Data were extracted by two reviewers and discrepancies resolved by discussion. Quality of studies was assessed using the QUADAS II tool (University of Bristol, Bristol, UK). A rigorous diagnostic accuracy systematic review assessed clinical and cost-effectiveness of CMR in viability assessment. A health economic model estimated costs and quality-adjusted life-years (QALYs) accrued by diagnostic pathways for identifying patients with viable myocardium in ischaemic cardiomyopathy with a view to revascularisation. The pathways involved CMR, stress echocardiography, SPECT, PET alone or in combination. Strategies of no testing and revascularisation were included to determine the most cost-effective strategy., Results: Twenty-four studies met the inclusion criteria. All were prospective. Participant numbers ranged from 8 to 52. The mean left ventricular ejection fraction in studies reporting this outcome was 24-62%. CMR approaches included stress CMR and late gadolinium-enhanced cardiovascular magnetic resonance imaging (CE CMR). Recovery following revascularisation was the reference standard. Twelve studies assessed diagnostic accuracy of stress CMR and 14 studies assessed CE CMR. A bivariate regression model was used to calculate the sensitivity and specificity of CMR. Summary sensitivity and specificity for stress CMR was 82.2% [95% confidence interval (CI) 73.2% to 88.7%] and 87.1% (95% CI 80.4% to 91.7%) and for CE CMR was 95.5% (95% CI 94.1% to 96.7%) and 53% (95% CI 40.4% to 65.2%) respectively. The sensitivity and specificity of PET, SPECT and stress echocardiography were calculated using data from 10 studies and systematic reviews. The sensitivity of PET was 94.7% (95% CI 90.3% to 97.2%), of SPECT was 85.1% (95% CI 78.1% to 90.2%) and of stress echocardiography was 77.6% (95% CI 70.7% to 83.3%). The specificity of PET was 68.8% (95% CI 50% to 82.9%), of SPECT was 62.1% (95% CI 52.7% to 70.7%) and of stress echocardiography was 69.6% (95% CI 62.4% to 75.9%). All currently used diagnostic strategies were cost-effective compared with no testing at current National Institute for Health and Care Excellence thresholds. If the annual mortality rates for non-viable patients were assumed to be higher for revascularised patients, then testing with CE CMR was most cost-effective at a threshold of £20,000/QALY. The proportion of model runs in which each strategy was most cost-effective, at a threshold of £20,000/QALY, was 40% for CE CMR, 42% for PET and 16.5% for revascularising everyone. The expected value of perfect information at £20,000/QALY was £620 per patient. If all patients (viable or not) gained benefit from revascularisation, then it was most cost-effective to revascularise all patients., Limitations: Definitions and techniques assessing viability were highly variable, making data extraction and comparisons difficult. Lack of evidence meant assumptions were made in the model leading to uncertainty; differing scenarios were generated around key assumptions., Conclusions: All the diagnostic pathways are a cost-effective use of NHS resources. Given the uncertainty in the mortality rates, the cost-effectiveness analysis was performed using a set of scenarios. The cost-effectiveness analyses suggest that CE CMR and revascularising everyone were the optimal strategies. Future research should look at implementation costs for this type of imaging service, provide guidance on consistent reporting of diagnostic testing data for viability assessment, and focus on the impact of revascularisation or best medical therapy in this group of high-risk patients., Funding: The National Institute of Health Technology Assessment programme.