涉及精神活性物质使用的急性心肌梗死死亡率研究中的病例确定和暴露分类

IF 2.3 3区 医学 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS
Noor-ul-Eman Haider, Syed Muhammed Rayyan, Muhammad Abbas
{"title":"涉及精神活性物质使用的急性心肌梗死死亡率研究中的病例确定和暴露分类","authors":"Noor-ul-Eman Haider,&nbsp;Syed Muhammed Rayyan,&nbsp;Muhammad Abbas","doi":"10.1002/clc.70202","DOIUrl":null,"url":null,"abstract":"<p>We welcome the recent analysis of acute myocardial infarction (AMI) death in US adults aged ≥ 65 with documented psychoactive substance abuse disorders [<span>1</span>]. Attention by the authors to an elderly population is well-timed, in light of increased co-occurrence of cardiovascular disease and substance abuse in the elderly. Two important limitations—one clinical, the other methodological—are acknowledged, however, because they affect substantially both validity and interpretability of the results.</p><p>Epidemiological studies that use death certificate data for employment are fraught with a very high potential for case ascertainment bias in this particular situation. In elderly populations, AMI is frequently listed on death certificates by clinical history or circumstantial information in place of verifying electrocardiography or cardiac biomarker tests [<span>2</span>]. Challenging presentations, cross-competing comorbidities, and silent myocardial infarction are not uncommon in this group and make both under- and overattribution of AMI as a cause of death more likely [<span>3</span>].</p><p>Equally problematic is the determination of psychoactive substance use. Toxicology is not the norm for older deaths unless there is obvious suspicion, and when it is done, it can be a restricted panel only [<span>4</span>]. This results in severe underreporting of drug use. Social stigma, clinician refusal to report, and ignorance regarding how to distinguish from prescribed versus nonprescribed use contribute to the risk of misclassification. When both outcome and exposure are tainted by classification error, cause-specific mortality rate estimates can distort changes in reporting patterns rather than capturing epidemiologic trends. Follow-up analyses using mortality registry data here need to be controlled for this dual-source bias to maintain interpretive validity.</p><p>Second, operationalization of exposure—reducing all ICD-10 F10–F19 categories into a single combined “psychoactive substance use disorder” category—is clinically restrictive. All of those codes cannot be collapsed into one usefully homogeneous category from the viewpoint of cardiovascular pathophysiology. Risk of AMI due to alcohol is secondary to chronic remodeling and arrhythmogenesis of the myocardium; cocaine and amphetamines via acute coronary vasospasm and proarrhythmic effects; opioids via hypoxia and bradyarrhythmia; sedatives via induction of hypotension and delay in conduction [<span>5</span>].</p><p>By combining these mechanistically different exposures, the study conceals substance-specific patterns of mortality and prevents investigators from being able to determine whether trends are a result of stimulant-induced acute events, alcohol-induced chronic damage, or polypharmacy effects. This limitation reduces the value of the study for cardiologists, addiction specialists, and policymakers who need substance-specific data to implement effective interventions. Further, the omission of poly-substance interaction analysis may conceal combinations at high risk—such as co-consumption of alcohol and benzodiazepines—that are synergistically fatal [<span>6</span>].</p><p>Generally speaking, these failures invalidate internal validity and clinical utility of findings. Registry-based studies of cardiovascular disease with attention to alcohol and drug use among the elderly need to use more stringent case confirmation methods—preferably via medical record abstraction or autopsy data—and substance-specific categorization to allow results to be interpreted as feasible prevention and treatment interventions [<span>7</span>]. These changes will not only enhance causal inference but also the potential for application in future work in this crucial and expanding field of cardiovascular epidemiology.</p><p>All authors contributed equally to this study.</p><p>Ethics approval is not applicable.</p><p>Informed consent is not applicable.</p><p>The authors declare no conflicts of interest.</p>","PeriodicalId":10201,"journal":{"name":"Clinical Cardiology","volume":"48 9","pages":""},"PeriodicalIF":2.3000,"publicationDate":"2025-08-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/clc.70202","citationCount":"0","resultStr":"{\"title\":\"Case Ascertainment and Exposure Classification in Acute Myocardial Infarction Mortality Studies Involving Psychoactive Substance Use\",\"authors\":\"Noor-ul-Eman Haider,&nbsp;Syed Muhammed Rayyan,&nbsp;Muhammad Abbas\",\"doi\":\"10.1002/clc.70202\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p>We welcome the recent analysis of acute myocardial infarction (AMI) death in US adults aged ≥ 65 with documented psychoactive substance abuse disorders [<span>1</span>]. Attention by the authors to an elderly population is well-timed, in light of increased co-occurrence of cardiovascular disease and substance abuse in the elderly. Two important limitations—one clinical, the other methodological—are acknowledged, however, because they affect substantially both validity and interpretability of the results.</p><p>Epidemiological studies that use death certificate data for employment are fraught with a very high potential for case ascertainment bias in this particular situation. In elderly populations, AMI is frequently listed on death certificates by clinical history or circumstantial information in place of verifying electrocardiography or cardiac biomarker tests [<span>2</span>]. Challenging presentations, cross-competing comorbidities, and silent myocardial infarction are not uncommon in this group and make both under- and overattribution of AMI as a cause of death more likely [<span>3</span>].</p><p>Equally problematic is the determination of psychoactive substance use. Toxicology is not the norm for older deaths unless there is obvious suspicion, and when it is done, it can be a restricted panel only [<span>4</span>]. This results in severe underreporting of drug use. Social stigma, clinician refusal to report, and ignorance regarding how to distinguish from prescribed versus nonprescribed use contribute to the risk of misclassification. When both outcome and exposure are tainted by classification error, cause-specific mortality rate estimates can distort changes in reporting patterns rather than capturing epidemiologic trends. Follow-up analyses using mortality registry data here need to be controlled for this dual-source bias to maintain interpretive validity.</p><p>Second, operationalization of exposure—reducing all ICD-10 F10–F19 categories into a single combined “psychoactive substance use disorder” category—is clinically restrictive. All of those codes cannot be collapsed into one usefully homogeneous category from the viewpoint of cardiovascular pathophysiology. Risk of AMI due to alcohol is secondary to chronic remodeling and arrhythmogenesis of the myocardium; cocaine and amphetamines via acute coronary vasospasm and proarrhythmic effects; opioids via hypoxia and bradyarrhythmia; sedatives via induction of hypotension and delay in conduction [<span>5</span>].</p><p>By combining these mechanistically different exposures, the study conceals substance-specific patterns of mortality and prevents investigators from being able to determine whether trends are a result of stimulant-induced acute events, alcohol-induced chronic damage, or polypharmacy effects. This limitation reduces the value of the study for cardiologists, addiction specialists, and policymakers who need substance-specific data to implement effective interventions. Further, the omission of poly-substance interaction analysis may conceal combinations at high risk—such as co-consumption of alcohol and benzodiazepines—that are synergistically fatal [<span>6</span>].</p><p>Generally speaking, these failures invalidate internal validity and clinical utility of findings. Registry-based studies of cardiovascular disease with attention to alcohol and drug use among the elderly need to use more stringent case confirmation methods—preferably via medical record abstraction or autopsy data—and substance-specific categorization to allow results to be interpreted as feasible prevention and treatment interventions [<span>7</span>]. These changes will not only enhance causal inference but also the potential for application in future work in this crucial and expanding field of cardiovascular epidemiology.</p><p>All authors contributed equally to this study.</p><p>Ethics approval is not applicable.</p><p>Informed consent is not applicable.</p><p>The authors declare no conflicts of interest.</p>\",\"PeriodicalId\":10201,\"journal\":{\"name\":\"Clinical Cardiology\",\"volume\":\"48 9\",\"pages\":\"\"},\"PeriodicalIF\":2.3000,\"publicationDate\":\"2025-08-30\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"https://onlinelibrary.wiley.com/doi/epdf/10.1002/clc.70202\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"Clinical Cardiology\",\"FirstCategoryId\":\"3\",\"ListUrlMain\":\"https://onlinelibrary.wiley.com/doi/10.1002/clc.70202\",\"RegionNum\":3,\"RegionCategory\":\"医学\",\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"\",\"PubModel\":\"\",\"JCR\":\"Q2\",\"JCRName\":\"CARDIAC & CARDIOVASCULAR SYSTEMS\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"Clinical Cardiology","FirstCategoryId":"3","ListUrlMain":"https://onlinelibrary.wiley.com/doi/10.1002/clc.70202","RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q2","JCRName":"CARDIAC & CARDIOVASCULAR SYSTEMS","Score":null,"Total":0}
引用次数: 0

摘要

我们欢迎最近对美国≥65岁有精神活性物质滥用障碍的成人急性心肌梗死(AMI)死亡的分析。鉴于心血管疾病和药物滥用在老年人中共同发生的增加,作者对老年人口的关注是及时的。然而,两个重要的限制——一个是临床的,另一个是方法学的——是公认的,因为它们实质上影响了结果的有效性和可解释性。在这种特殊情况下,使用死亡证明数据进行就业的流行病学研究充满了非常高的病例确定偏差的可能性。在老年人群中,AMI经常通过临床病史或间接信息列在死亡证明上,以代替验证心电图或心脏生物标志物测试bb0。具有挑战性的表现、交叉竞争的合并症和无症状性心肌梗死在该组中并不罕见,这使得AMI作为死亡原因的归因更有可能被低估或过度归因。同样有问题的是精神活性物质使用的确定。毒理学不是老年人死亡的标准,除非有明显的怀疑,而且当它完成时,它只能是一个有限的小组。这导致严重漏报药物使用情况。社会污名,临床医生拒绝报告,以及对如何区分处方和非处方使用的无知,都导致了错误分类的风险。当结果和暴露都受到分类错误的影响时,针对特定原因的死亡率估计可能扭曲报告模式的变化,而不是捕捉流行病学趋势。使用死亡率登记数据的随访分析需要控制这种双源偏倚,以保持解释的有效性。其次,将ICD-10 F10-F19的所有类别简化为单一的“精神活性物质使用障碍”类别,在临床上具有限制性。从心血管病理生理学的角度来看,所有这些编码都不能归结为一个有用的同质类别。酒精引起AMI的风险继发于心肌的慢性重构和心律失常;可卡因和安非他明对急性冠状血管痉挛和心律失常的影响阿片类药物通过缺氧和慢性心律失常;镇静剂通过诱导低血压和延迟传导[5]。通过结合这些机制上不同的暴露,该研究隐藏了特定物质的死亡模式,并阻止研究人员能够确定趋势是兴奋剂引起的急性事件、酒精引起的慢性损伤还是多药作用的结果。这一限制降低了该研究对心脏病专家、成瘾专家和决策者的价值,他们需要特定物质的数据来实施有效的干预措施。此外,多物质相互作用分析的遗漏可能会隐藏高风险的组合,如酒精和苯二氮卓类药物的共同消费,这是协同致命的。一般来说,这些失败使研究结果的内部有效性和临床实用性无效。以登记为基础的心血管疾病研究,关注老年人的酒精和药物使用,需要使用更严格的病例确认方法——最好是通过医疗记录提取或尸检数据——以及物质特异性分类,以使结果被解释为可行的预防和治疗干预措施[10]。这些变化不仅会加强因果推理,而且还可能在心血管流行病学这一关键和不断扩大的领域的未来工作中应用。所有作者对这项研究的贡献相同。伦理审批不适用。知情同意不适用。作者声明无利益冲突。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Case Ascertainment and Exposure Classification in Acute Myocardial Infarction Mortality Studies Involving Psychoactive Substance Use

We welcome the recent analysis of acute myocardial infarction (AMI) death in US adults aged ≥ 65 with documented psychoactive substance abuse disorders [1]. Attention by the authors to an elderly population is well-timed, in light of increased co-occurrence of cardiovascular disease and substance abuse in the elderly. Two important limitations—one clinical, the other methodological—are acknowledged, however, because they affect substantially both validity and interpretability of the results.

Epidemiological studies that use death certificate data for employment are fraught with a very high potential for case ascertainment bias in this particular situation. In elderly populations, AMI is frequently listed on death certificates by clinical history or circumstantial information in place of verifying electrocardiography or cardiac biomarker tests [2]. Challenging presentations, cross-competing comorbidities, and silent myocardial infarction are not uncommon in this group and make both under- and overattribution of AMI as a cause of death more likely [3].

Equally problematic is the determination of psychoactive substance use. Toxicology is not the norm for older deaths unless there is obvious suspicion, and when it is done, it can be a restricted panel only [4]. This results in severe underreporting of drug use. Social stigma, clinician refusal to report, and ignorance regarding how to distinguish from prescribed versus nonprescribed use contribute to the risk of misclassification. When both outcome and exposure are tainted by classification error, cause-specific mortality rate estimates can distort changes in reporting patterns rather than capturing epidemiologic trends. Follow-up analyses using mortality registry data here need to be controlled for this dual-source bias to maintain interpretive validity.

Second, operationalization of exposure—reducing all ICD-10 F10–F19 categories into a single combined “psychoactive substance use disorder” category—is clinically restrictive. All of those codes cannot be collapsed into one usefully homogeneous category from the viewpoint of cardiovascular pathophysiology. Risk of AMI due to alcohol is secondary to chronic remodeling and arrhythmogenesis of the myocardium; cocaine and amphetamines via acute coronary vasospasm and proarrhythmic effects; opioids via hypoxia and bradyarrhythmia; sedatives via induction of hypotension and delay in conduction [5].

By combining these mechanistically different exposures, the study conceals substance-specific patterns of mortality and prevents investigators from being able to determine whether trends are a result of stimulant-induced acute events, alcohol-induced chronic damage, or polypharmacy effects. This limitation reduces the value of the study for cardiologists, addiction specialists, and policymakers who need substance-specific data to implement effective interventions. Further, the omission of poly-substance interaction analysis may conceal combinations at high risk—such as co-consumption of alcohol and benzodiazepines—that are synergistically fatal [6].

Generally speaking, these failures invalidate internal validity and clinical utility of findings. Registry-based studies of cardiovascular disease with attention to alcohol and drug use among the elderly need to use more stringent case confirmation methods—preferably via medical record abstraction or autopsy data—and substance-specific categorization to allow results to be interpreted as feasible prevention and treatment interventions [7]. These changes will not only enhance causal inference but also the potential for application in future work in this crucial and expanding field of cardiovascular epidemiology.

All authors contributed equally to this study.

Ethics approval is not applicable.

Informed consent is not applicable.

The authors declare no conflicts of interest.

求助全文
通过发布文献求助,成功后即可免费获取论文全文。 去求助
来源期刊
Clinical Cardiology
Clinical Cardiology 医学-心血管系统
CiteScore
5.10
自引率
3.70%
发文量
189
审稿时长
4-8 weeks
期刊介绍: Clinical Cardiology provides a fully Gold Open Access forum for the publication of original clinical research, as well as brief reviews of diagnostic and therapeutic issues in cardiovascular medicine and cardiovascular surgery. The journal includes Clinical Investigations, Reviews, free standing editorials and commentaries, and bonus online-only content. The journal also publishes supplements, Expert Panel Discussions, sponsored clinical Reviews, Trial Designs, and Quality and Outcomes.
×
引用
GB/T 7714-2015
复制
MLA
复制
APA
复制
导出至
BibTeX EndNote RefMan NoteFirst NoteExpress
×
提示
您的信息不完整,为了账户安全,请先补充。
现在去补充
×
提示
您因"违规操作"
具体请查看互助需知
我知道了
×
提示
确定
请完成安全验证×
copy
已复制链接
快去分享给好友吧!
我知道了
右上角分享
点击右上角分享
0
联系我们:info@booksci.cn Book学术提供免费学术资源搜索服务,方便国内外学者检索中英文文献。致力于提供最便捷和优质的服务体验。 Copyright © 2023 布克学术 All rights reserved.
京ICP备2023020795号-1
ghs 京公网安备 11010802042870号
Book学术文献互助
Book学术文献互助群
群 号:604180095
Book学术官方微信