Sun, Louise Y.

Health care disparities, particularly among minoritized groups, pose significant challenges within health care systems, including the field of cardiac surgery. Limited English proficiency (LEP) is an often-overlooked factor contributing to these disparities. As key members of the preoperative evaluation, intraoperative management, and postoperative care of cardiac surgery patients, anesthesiologists have both ethical and economic responsibilities to understand, recognize, and address disparities to ensure equitable care for all patients. The objective of this scoping review is to summarize the literature on how LEP impacts the utilization of health services and outcomes after cardiac surgery. More specifically, the review will map how LEP is defined in the literature, summarize the patient populations that have been studied, and describe the health care outcomes in patients with LEP after cardiac surgery. A comprehensive literature search strategy was developed in collaboration with a medical librarian and was registered before conducting the search. Studies were eligible for inclusion in our current study if (i) the patient population was composed of adults (>or = 18), (ii) the study reported health care outcomes before or after cardiac surgery, and (iii) results were stratified by a patient’s English proficiency. All randomized control trials, systematic reviews, observational studies, and cross-sectional studies published in English were included in our study. If conference abstracts met the inclusion criteria, they were included for full-text review. Opinion articles and case reports were excluded. The search produced 2401 articles with 13 articles meeting the inclusion criteria. All studies were conducted in either North America or Australia/New Zealand. The number of patients included in each study ranged from 204 to 21,789, with 4 studies having less than 1500 patients and 2 studies having greater than 10,000 patients. Through a systematic review of the literature on this topic, we identified 3 overarching themes that were inferred from the collective body of studies. First, a significant barrier to studying this topic is the absence of a universal definition of LEP. Second, the heterogeneity in several aspects of the available studies makes it difficult to draw conclusions from the results. Finally, there is a general scarcity of research done on the impact of LEP on cardiac surgery outcomes. Ultimately, our scoping review reveals an area of health disparity research that requires more attention. If disparities are found, then health care leaders may begin investigating which interventions can help mitigate these disparities.

BACKGROUND: Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndrome, predominantly affecting women. Psychological distress is common pre- and post-SCAD, yet sex-specific patterns remain understudied. This cross-sectional study aimed to examine sex differences in the psychological distress of patients with SCAD. METHODS: Adult patients diagnosed with SCAD within the past 3 years, confirmed by coronary angiography, were recruited from 6 Canadian hospitals between April 2022 and January 2025. Participants completed questionnaires assessing sociodemographics and validated measures of psychological distress: Patient Health Questionnaire-9 for depression, Generalized Anxiety Disorder-7 for generalized anxiety, Cardiac Anxiety Questionnaire for cardiac-related anxiety, and PTSD Checklist-5 for posttraumatic stress symptoms. Sex differences were analyzed using t tests for continuous variables and χ 2 tests for categorical variables. Multivariable linear regression models assessed the association between sex and psychological distress, adjusting for age, pre-SCAD mental health diagnosis, and employment status. RESULTS: Among 326 patients (92.9% women; mean age=53.3±11.1 years), women reported higher rates of preexisting mental health conditions (29.2% versus 8.7%; P =0.035). Post-SCAD women reported higher mean scores than men on the Patient-Health-Questionnaire-9, Cardiac-Anxiety-Questionnaire, and PTSD Checklist-5 (all P <0.05). Female sex was associated with greater depressive (B=2.94; P =0.010), cardiac anxiety (B=7.09; P =0.008), and posttraumatic stress symptoms (B=5.94; P =0.048) after adjustment. Clinically significant symptoms were more common in women versus men: 25.1% versus 0% (depression), 21.5% versus 4.4% (anxiety), 54.8% versus 26.1% (cardiac anxiety), and 15.5% versus 0% (posttraumatic stress). CONCLUSIONS: Both women and men experience clinically significant cardiac anxiety following SCAD, but women report a greater psychological burden, including more preexisting mental health conditions and twice the distress after SCAD. These results underscore the importance of routine psychological screening and timely intervention to support mental health and recovery outcomes, particularly among women.

Introduction: Language barriers represent an often-overlooked determinant of health equity. This study evaluates the impact of limited English proficiency (LEP) on major adverse cardiac events (MACE) and mortality in patients undergoing cardiovascular surgery. We hypothesized that patients with LEP have a higher incidence of adverse outcomes compared to English proficient patients. Methods: We conducted a retrospective cohort study using Cosmos, a longitudinal national electronic health record dataset. Patients were classified as having LEP if their record indicated a preferred language other than English. Adult patients aged 18-95 years who underwent coronary artery bypass grafting, valvular surgery, or thoracic aorta surgery in the United States (January 2016 - February 2025) were included. Exclusion criteria were missing language data, first in-person encounter <1 year prior to surgery, history of metastatic cancer or dialysis, and nursing home residence within 90 days of surgery. The primary outcome was MACE, a composite of stroke, revascularization, and hospitalization for myocardial infarction or heart failure. The secondary outcome was all-cause mortality. The cumulative incidence of MACE was estimated via a competing risk framework, while the cumulative incidence of mortality was estimated with the Kaplan-Meier method. Multivariate Cox proportional hazard regressions were fitted for all outcomes. Results: The cohort included 12,706 LEP patients (28.8% female) and 393,612 English-proficient patients (33.2% female). Differences in baseline characteristics included age, race, and comorbidity burden. The unadjusted cumulative incidence of MACE was higher in LEP patients, but all-cause mortality was lower (Figure 1). Over the follow-up period, the incidence rate of MACE for English proficient patients vs LEP was 185 vs 219 per 1000 patient years and 39 vs 36 per 1000 patient years for mortality. The adjusted hazard ratio for MACE was 0.97 (95% CI: 0.94 - 1.01, p = 0.19) and 0.89 (95% CI: 0.83 - 0.95, p <0.001) for mortality. Conclusions: LEP was associated with higher unadjusted cumulative incidence of MACE and lower mortality, but only the association with mortality persisted after regression analysis. Our findings highlight the need for further research into the impact of language proficiency on outcomes after cardiac surgery and the potential benefit of targeted interventions to address language-related disparities.

Background: Spontaneous Coronary Artery Dissection (SCAD) is a cause of acute coronary syndrome, particularly among women, and is associated with psychological distress, including depression, anxiety, and post-traumatic stress (PTSD) symptoms. Fibromuscular dysplasia (FMD), a vascular condition that alters the arteries, is often found in patients with SCAD, adding complexity and uncertainty with a second serious diagnosis. This study examined the differences in mental health symptoms between SCAD survivors with and without FMD to better understand their unique psychosocial needs and inform interventions to enhance patient outcomes. Methods: Patients diagnosed with SCAD within the past 3 years were recruited from 6 Canadian cardiac hospitals. Participants completed questionnaires assessing socio-demographics, comorbidities, and validated psychological measures, including Patient Health Questionnaire-9 (PHQ-9) for depression, Generalized Anxiety Disorder-7 (GAD-7) for generalized anxiety, Cardiac Anxiety Questionnaire (CAQ) for cardiac-related anxiety, and PTSD Checklist (PCL-5) for PTSD symptoms. Differences in mental health outcomes between SCAD survivors with and without FMD were analyzed using t-tests for continuous variables and chi-square tests for categorical variables. Results: The study included 326 participants (92.9% female; mean age 53.3 years), with 67 participants (20.6%) having a confirmed diagnosis of FMD at the time of questionnaire completion (39.3% FMD at study completion). Post-SCAD, patients with FMD reported significantly higher scores than patients without FMD on the GAD-7 (6.4±5.9 vs. 4.7±4.9, p = .028), CAQ (29.9±13.1 vs. 26.0±12.3, p = .023), and PCL-5 (17.2±15.4 vs. 13.3± 14.0, p = .048). The proportion of SCAD survivors with FMD scoring in the clinically diagnostic range was significantly higher than those in patients without FMD: 32.8% vs. 20.8% for depression, 31.3% vs. 17.4% for anxiety, 64.2% vs. 49.2% for cardiac anxiety, and 25.4% vs. 11.6% for PTSD (all p < .05). Conclusions: Our findings suggest that SCAD survivors with comorbid FMD experience significantly higher distress —depression, generalized anxiety, cardiac-related anxiety, and PTSD symptoms—compared to those without FMD. Longitudinal research is needed to explore the role of these mental health concerns in long-term mental health and cardiac outcomes. Enhanced psychological interventions for those with FMD may be required.

Abstract Aims The incidence of respiratory failure and use of invasive or non-invasive mechanical ventilation (MV) in the cardiac intensive care units (CICUs) is increasing. While institutional MV volumes are associated with reduced mortality in medical and surgical ICUs, this volume–mortality relationship has not been characterized in the CICU. Methods and results National population-based data were used to identify patients admitted to CICUs (2005–2015) requiring MV in Canada. CICUs were categorized into low (≤100), intermediate (101–300), and high (&gt;300) volume centres based on spline knots identified in the association between annual MV volume and mortality. Outcomes of interest included all-cause in-hospital mortality, the proportion of patients requiring prolonged MV (&gt;96 h) and CICU length of stay (LOS). Among 47 173 CICU admissions requiring MV, 89.5% (42 200) required invasive MV. The median annual CICU MV volume was 43 (inter-hospital range 1–490). Compared to low-volume centres (35.9%), in-hospital mortality was lower in intermediate [29.2%, adjusted odds ratio (aOR) 0.84, 95% confidence interval (CI) 0.72–0.97, P = 0.019] and high-volume (18.2%; aOR 0.82, 95% CI 0.66–1.02, P = 0.076) centres. Prolonged MV was higher in low-volume (29.2%) compared to high-volume (14.8%, aOR 0.70, 95% CI 0.55–0.89, P = 0.003) and intermediate-volume (23.0%, aOR 0.85, 95% CI 0.68–1.06, P = 0.14] centres. Mortality and prolonged MV were lower in percutaneous coronary intervention (PCI)-capable and academic centres, but a shorter CICU LOS was observed only in subgroup of PCI-capable intermediate- and high-volume hospitals. Conclusions In a national dataset, we observed that higher CICU MV volumes were associated with lower incidence of in-hospital mortality, prolonged MV, and CICU LOS. Our data highlight the need for minimum MV volume benchmarks for CICUs caring for patients with respiratory failure.

Abstract Funding Acknowledgements Type of funding sources: None. Background The incidence of respiratory failure and the provision of invasive and non-invasive mechanical ventilation (MV) in patients admitted to cardiac intensive care units (CICU) are increasing. While institutional MV volumes are associated with reduced mortality in medical and surgical ICUs, this relationship has not been characterized in the CICU population. Purpose By describing the relationship between institutional MV volume and outcomes in the CICUs, we hope to shed light on minimum volume benchmarks for providing MV. Methods National Canadian population-based data from 2005 to 2015 was used to identify patients admitted to CICUs requiring MV. CICUs were categorized into low (≤100), intermediate (101-300), and high (&gt;300) volume centers based on spline knots identified in the association between annual MV volume and mortality (Figure). Outcomes of interests included all-cause in-hospital mortality, the proportion of patients requiring prolonged MV (&gt;96 hours) and CICU length of stay (LOS). Results Among the 47,173 CICU admissions that required MV, 89.5% (42,200) required invasive mechanical ventilation. The median annual CICU MV volume was 127 (range 1-490). In-hospital mortality was lower in intermediate (29.2%, adjusted odds ratio [aOR] 0.84, 95% CI 0.72-0.97, p = 0.019) and high-volume (18.2%; aOR 0.82, 95% CI 0.66-1.02, p = 0.076) centers, compared to low volume centers (35.9%). The proportion of patients requiring prolonged MV was higher in low-volume (29.2%) compared to high-volume (14.8%, OR 0.70, 95% 0.55-0.89, p = 0.003) centers. Point estimates for mortality and prolonged MV were lower in PCI-capable and academic centers (Table). Significantly (p &lt;0.01) lower CICU LOS was observed only in the subgroup of PCI-capable intermediate- and high-volume hospitals. Conclusions In a national dataset, we observed that higher CICU MV hospital volumes were associated with lower in-hospital mortality, CICU LOS, and fewer episodes of prolonged MV. Pending further validation, these data suggest minimum MV volume benchmarks for CICUs caring for patients with respiratory failure. Further research is warranted to explore these associations in more detail. Unadjusted volume-outcome relationshipsOutcomesGroup 1 Annual Volume ≤100Group 2 Annual Volume 101-300Group 3 Annual Volume &gt;300Totalp-valueTotal N1770224351512047173In-hospital mortality6357 (35.0%)7122 (29.2%)933 (18.2%)14412 (30.6%)p &lt; 0.0001Median CICU LOS(hours)85796679p &lt; 0.0001Episodes of prolonged MV5161 (29.2%)5608 (23.0%)758 (14.8%)11527 (24.4%)p &lt; 0.0001Abbreviations OR (odds ratio), RD (risk difference), CI (confidence interval), PCI (percutaneous coronary intervention), LOS (length of stay)Abstract Figure. Annual CICU MV volume and mortality