Statin Use and Its Facility-Level Variation in Patients With Diabetes: Insight From the Veterans Affairs National Database

We sought to determine use of any and at least moderate-intensity statin therapy in a national sample of patients with diabetes mellitus (DM), with the hypothesis that nationwide frequency and facility-level variation in statin therapy are suboptimal. We sampled patients with DM age 40 to 75 years receiving primary care between October 1, 2012, and September 30, 2013, at 130 parent facilities and associated community-based outpatient clinics in the Veterans Affairs Health Care System. We examined frequency and facility-level variation in use of any or at least moderate-intensity statin therapy (mean daily dose associated with ≥30% low-density lipoprotein cholesterol lowering). In 911 444 patients with DM, 68.3% and 58.4% were receiving any and moderate- to high-intensity statin therapy, respectively. Patients receiving statin had higher burden of cardiovascular disease, were more likely to be on nonstatin lipid-lowering therapy and to receive care at a teaching facility, and had more frequent primary-care visits. Median facility-level uses of any and at least moderate-intensity statin therapy were 68.7% (interquartile range, 65.9%-70.8%) and 58.6% (interquartile range, 55.8%-61.4%), respectively. After adjusting for several patient-related and some facility-related characteristics, the median rate ratios for any and moderate- to high-intensity statin therapy were 1.20 (95% confidence interval: 1.18-1.22) and 1.29 (95% confidence interval: 1.24-1.33) respectively, indicating 20% to 29% variation in statin use between 2 identical patients receiving care at 2 random facilities. Statin use was suboptimal in a national sample of patients with DM with modest facility-level variation, likely indicating differences in statin-prescribing patterns.

Abstract 227: Patient and Provider Generated Appropriateness Ratings for Myocardial Perfusion Imaging: Agreement With Published Criteria

Background: Appropriate use criteria (AUC) for myocardial perfusion imaging (MPI) help doctors decide which patients may benefit from MPI. The AUC development process does not include patients. Ordering providers are included, but their opinions on AUC have not been more broadly studied. We conducted an anonymous survey of patients and providers on the appropriateness of MPI in various settings. We hypothesize that both groups will overestimate the appropriateness of MPI compared to AUC.

Methods: We administered our survey to patients in primary care clinics, cardiology clinics, and nuclear medicine laboratories at our academic medical center and affiliated Veterans Affairs medical center. Participating providers were physicians, nurse practioners, and physician assistants within primary care, cardiology, and hospital medicine. The primary outcome was a comparison of patient and provider appropriateness ratings as compared to published AUC. Respondents used the same methodology as used to develop the AUC; five clinical scenarios were rated on a 1 (inappropriate) to 9 (appropriate) scale. Scenarios were based on common MPI indications and included appropriate, inappropriate, and uncertain examples (symptomatic with prior revascularization, symptomatic with low risk of heart disease, asymptomatic with low risk of heart disease, symptomatic with intermediate risk of heart disease, and asymptomatic with prior revascularization). We used subgroup analyses and logistic regression models for both groups to investigate associations between ratings and respondent characteristics.

Results: The survey was completed by 449 respondents, 338 patients and 111 providers between June and August 2014. Patient sampling was distributed between cardiology clinic (32.2%), primary care clinic (36.0%), and nuclear medicine (31.9%) laboratory. Providers were cardiology (35.1%), primary care (37.7%), hospital medicine (22.8%), and other (4.4%); 86.8% physicians. Of the five scenarios, the patient and provider ratings differed from AUC for three. In two cases, the patient generated rating was higher than the provider or published rating (5 versus 3.5 and 3, p<0.0001; 5 versus 2 and 1, p<0.0001). In the third case, the provider generated rating was lower than both the patient and published rating (2 versus 6 and 6, p<0.0001). Subgroup comparisons and logistic regression did not reveal any significant correlations between ratings and respondent characteristics.

Conclusion: In some clinical scenarios, patients and healthcare providers have differences of opinion about the appropriateness of nuclear MPI as compared to published AUC. Patients tended to overvalue MPI while healthcare providers undervalued one of the published AUC ratings. Evidence of differences in opinion raise the question as to what role patients should play in future iterations of AUC.

Abstract 232: Postgraduate Education in Quality Improvement Methods: Initial Results of the Fellows’ Applied Quality Training Curriculum

Background: Formal training in quality improvement (QI) methods is sporadic in medical educational settings. QI is a growing expectation for individual professional certifications and facility accreditations; future physicians will need to understand and apply QI methods as part of their practice. We developed a curriculum with both didactic and applied components to teach QI methods to cardiology fellows.

Methods: The Fellows Applied Quality Training (FAQT) curriculum started in July 2013 with an initial cohort of 23 postgraduate trainees in general and subspecialty cardiovascular medicine fellowships. The FAQT is a multifaceted QI curriculum consisting of online learning modules, didactic training, and the start-to-finish completion of a team-based, self-directed quality improvement project under supervision of a faculty mentor. Trainees completed selected modules from the Institute of Healthcare Improvement Open School including basic terminology and background of QI methods. Trainees were assigned to small groups and challenged to identify an area in need, design an intervention to improve quality or safety, select an appropriate metric to measure, determine how to acquire the necessary data, implement their plan, analyze data to measure their success, and formally present the results. Prior to, during, and at the completion of the FAQT, trainees completed the 13 question self-assessment from the Quality Assessment and Improvement Curriculum. This assessment asks participants to rate their confidence to perform QI activities independently. The primary outcome of our investigation was an increase in the median confidence score reported on a 4 point scale (1=not at all confident, 2=slightly confident, 3=moderately confident, 4=extremely confident) compared by Wilcoxon signed rank test.

Results: Prior to the FAQT, 15 trainees reported no prior formal QI training. Of those with prior training, 4 were practical and 4 had only didactic training. At baseline, the median score given on the assessment was 3.0. After completion of online training modules, the median score did not increase (3.0, p=0.51). At the conclusion of the self-directed projects, average confidence was higher (3.27, p=0.004). The proportion of fellows reporting they were “extremely” confident about using quality assessment and improvement in your future career increased from15% to 50% while the proportion reporting “slight” confidence decreased from 30% to 5%.

Conclusion: At our institution, the majority of post-graduate medical trainees had no formal exposure to QI training. After completing a curriculum with practical application of QI methods, trainees reported an increase in their self-confidence to independently conduct QI; no increase was observed with didactic training alone.

Cardiovascular Effects of Exposure to Cigarette Smoke and Electronic Cigarettes: Clinical Perspectives From the Prevention of Cardiovascular Disease Section Leadership Council and Early Career Councils of the American College of Cardiology

Cardiovascular morbidity and mortality as a result of inhaled tobacco products continues to be a global healthcare crisis, particularly in low- and middle-income nations lacking the infrastructure to develop and implement effective public health policies limiting tobacco use. Following initiation of public awareness campaigns 50 years ago in the United States, considerable success has been achieved in reducing the prevalence of cigarette smoking and exposure to secondhand smoke. However, there has been a slowing of cessation rates in the United States during recent years, possibly caused by high residual addiction or fatigue from cessation messaging. Furthermore, tobacco products have continued to evolve faster than the scientific understanding of their biological effects. This review considers selected updates on the genetics and epigenetics of smoking behavior and associated cardiovascular risk, mechanisms of atherogenesis and thrombosis, clinical effects of smoking and benefits of cessation, and potential impact of electronic cigarettes on cardiovascular health.

Physician-level variation in the diagnosis of myocardial infarction and the use of angiography among Veterans with elevated troponin

BACKGROUND

Cardiac troponin assays have improved the ability to detect myocardial damage. However, ascertaining whether troponin elevation is due to myocardial infarction (MI) or secondary to another process can be challenging. Our aim is to evaluate provider-level variation in the diagnosis of MI and the use of invasive coronary angiography (ICA) among patients with undifferentiated elevations in cardiac troponin.

METHODS

We analyzed data from all patients with elevated troponin levels in a single Veterans Affairs (VA) Medical Center between 2006 and 2007. One of several cardiologists prospectively evaluated each patient's presentation and course of care. We compared the frequency of MI diagnosis and ICA use between physicians using univariate odds ratios (OR).

RESULTS

Among 761 patients, 34.0 % were diagnosed with MI and 25.9 % underwent ICA. The unadjusted rates of MI (23.9 to 56.7 %, P = 0.02) and ICA (17.3 to 73.3 %, P < 0.001) differed between physicians. Comparing the patient cohorts for each physician, baseline characteristics were similar except for chest pain. In multivariate regression, factors associated with the use of cardiac ICA included an abnormal electrocardiograph (ECG) (OR = 1.89, P = 0.014), level of troponin (OR = 1.71, P = 0.004), chest pain (OR = 8.60, P < 0.001), and care by non-VA physicians (OR = 4.45, P = 0.006). One physician had a lower ICA use (OR = 0.56, P = 0.017). In multivariate regression of MI, no physician-level variation was observed.

CONCLUSION

Among patients with elevated troponin, the likelihood of being diagnosed with MI and undergoing ICA is dependent on their clinical presentation. After adjustment, physician-level variation in care was observed for the use of ICA, but not for the diagnosis of MI.

Angina treatments and prevention of cardiac events: an appraisal of the evidence

Angina pectoris is the symptomatic manifestation of transient myocardial ischaemia. At the most fundamental level, angina arises when myocardial oxygen demand exceeds the ability of the coronary circulation to provide adequate oxygen delivery to maintain normal myocardial metabolic function. In vivo, the balance of oxygen demand and delivery is a complex physiological process that can be altered by a variety of interventions. Lifestyle modification is a cornerstone of cardiovascular disease management, with or without angina. Additional pharmaceutical and physical interventions are usually applied to patients with angina. Mechanisms of action for these interventions include heart rate modulation, vascular smooth muscle relaxation, metabolic manipulation, revascularization, and others. A number of these interventions have overlapping mechanisms that target angina. Additionally, some interventions may directly or indirectly prevent or delay adverse outcomes such as myocardial infarction or death. This review summarizes current evidence for many applied ischaemia treatments documented to modify angina and comments on available evidence relating to improvement in cardiovascular outcomes.

Determining the Role of Thiamine Deficiency in Systolic Heart Failure: A Meta-Analysis and Systematic Review

BACKGROUND

Approximately 5.7 million Americans carry the diagnosis of systolic heart failure (HF), a major health care burden. HF is a known manifestation of thiamine deficiency (TD). HF patients are at unique risk for developing TD, which may contribute to further altered cardiac function and symptoms.

METHODS AND RESULTS

We performed a systematic review of the literature and a meta-analysis to evaluate the prevalence of TD in HF patients, risk factors for and mechanisms of development of TD in HF population, and outcomes of thiamine supplementation in HF patients. We found 54 studies that met our selection criteria, 9 of which were suitable for meta-analysis. TD is more common in HF patients than control subjects (odds ratio 2.53, 95% confidence interval 1.65-3.87). Diuretic use, changes in dietary habits, and altered thiamine absorption and metabolism were identified as possible mechanisms of TD in HF patients. Small observational studies and randomized control trials suggest that thiamine supplementation in HF population may improve ejection fraction and reduce symptoms.

CONCLUSIONS

Thiamine deficiency is more prevalent in the HF population, and its supplementation may be beneficial. The therapeutic role of thiamine in HF warrants further study.

A Cohort Study of Myocardial Perfusion Imaging in Veteran Patients Without Symptoms: Contributing Factors and Results of Testing

Myocardial perfusion imaging (MPI) is commonly used to detect ischemia. Concerns about silent ischemia may encourage orders for MPI in asymptomatic patients. Factors contributing to this practice are poorly described and the clinical utility is questionable.We conducted a single center retrospective cohort investigation on Veterans who underwent MPI between December 2010 and July 2011. We gathered data on symptoms, baseline characteristics, results of MPI, and cardiovascular events within 1 year. MPI were categorized using 2009 appropriate use criteria (AUC).Of 592 patients, 127 (21.5%) had no symptoms at the time of MPI. Comparing symptomatic and asymptomatic patients, no differences were observed in baseline characteristics except abnormal ECG, more common in asymptomatic patients (n = 86, 67.7% vs. n = 232, 49.9% for symptomatic patients, P < 0.0001). Asymptomatic MPI were more commonly inappropriate (n = 26, 21.5% vs. n = 31, 6.7% for appropriate/uncertain, P < 0.0001). Detection of ischemia between patients with and without symptoms was not different (P = 0.86); however, among asymptomatic MPI that also demonstrated ischemia, none were inappropriate (n = 10 appropriate, n = 7 uncertain). In multivariate regression, 2 factors were associated with asymptomatic status, abnormal ECG (odds ratio [OR] 2.29, 95% confidence interval [CI] 1.5-3.49) and age over the median (OR 0.63, 95% CI: 0.41-0.95).A substantial portion of MPI tests are ordered for patients without symptoms. When compared to symptomatic patients, MPI for asymptomatic patient were more commonly inappropriate; however, the prevalence of ischemia was similar. MPI may be clinically relevant in some asymptomatic patients and decisions to test should be based on the AUC.

Stress Testing After Percutaneous Coronary Intervention in the Veterans Affairs HealthCare System: Insights from the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program

BACKGROUND

Stress testing after percutaneous coronary intervention (PCI) in fee-for-service settings is common and rates vary by hospital. Rates of stress testing after PCI within integrated healthcare systems, such as the Veterans Affairs (VA) are unknown.

METHODS AND RESULTS

We evaluated all VA patients who underwent PCI from October 2007 through June 2010. To avoid the influence of Medicare eligibility on rates of stress testing use in the VA, we excluded Medicare eligible patients during the follow-up period. Hospital-level variation in risk-standardized rates of stress testing and the association with 1-year mortality and myocardial infarction was determined from Markov chain Monte Carlo methods. Among 10 293 patients undergoing PCI at 55 VA hospitals, 2239 (21.8%) had a stress test performed within 1 year of PCI and 3902 (37.9%) within 2 years. Most stress tests after PCI were performed with nuclear imaging (79.8%). The hospital-level risk-standardized rate of stress testing differed significantly from the average at 14 hospitals, with 8 (14.5%) hospitals significantly below and 6 (10.9%) hospitals significantly above the average stress testing rate. Hospital-level risk-standardized stress testing rates were not significantly correlated with risk-standardized mortality (Spearman ρ=-0.24; P=0.08) or myocardial infarction rates (Spearman ρ=0.20; P=0.14).

CONCLUSIONS

In the VA, nearly 40% of patients underwent stress testing in the 2 years after PCI, which is a third less than published studies from other healthcare systems. However, stress testing rates varied across VA hospitals, suggesting opportunities to optimize the use of stress testing are still present in integrated healthcare systems.

Diagnostic yield of routine noninvasive cardiovascular testing in low-risk acute chest pain patients

Contemporary professional society recommendations for patients presenting to the emergency department with acute chest pain and low clinical risk encourage noninvasive testing for coronary artery disease (CAD) before, or shortly after, discharge from the emergency department. Recent reports indicate that a strategy of universal testing has a low diagnostic yield and may not be necessary. We examined data from a prospective cohort of patients who underwent evaluation of acute chest pain in our chest pain evaluation center (CPEC). Patients presenting with normal initial electrocardiogram and cardiac injury markers were eligible for observation and noninvasive testing for CAD in our CPEC. All patients were asked to participate in the prospective registry. The 213 subjects who consented were young, obese, and predominantly women (mean age 43.8 ± 12.5, mean body mass index of 30.8 ± 7, 64.8% women). Prevalence of diabetes was 10.3% (hypertension 37.1%, hyperlipidemia 17.8%, and current tobacco use 23.5%) Exercise treadmill testing was the primary method of evaluation (n = 104, 49%) followed by computed tomography coronary angiography (n = 58, 27%) and myocardial perfusion imaging (n = 20, 9%). Of 203 patients who underwent testing, 11 had abnormal test results, 4 of whom had obstructive CAD based on invasive coronary angiography. The positive predictive value for obstructive CAD after an abnormal test was 45.5%, and the overall diagnostic yield for obstructive CAD was 2.5%. In conclusion, in patients with acute chest pain evaluated in a CPEC, the yield of routine use of noninvasive testing for CAD was minimal and the positive predictive value of an abnormal test was low.

Metrics of quality care in veterans: correlation between primary-care performance measures and inappropriate myocardial perfusion imaging

BACKGROUND

Approximately 10% to 20% of myocardial perfusion imaging (MPI) tests are inappropriate based on professional-society recommendations. The correlation between inappropriate MPI and quality care metrics is not known.

HYPOTHESIS

Inappropriate MPI will be associated with low achievement of quality care metrics.

METHODS

We conducted a retrospective cross-sectional investigation at a single Veterans Affairs medical center. Myocardial perfusion imaging tests ordered by primary-care clinicians between December 2010 and July 2011 were assessed for appropriateness (by 2009 criteria). Using documentation of the clinical encounter where MPI was ordered, we determined how often quality care metrics were achieved.

RESULTS

Among 516 MPI patients, 52 (10.1%) were inappropriate and 464 (89.9%) were not inappropriate (either appropriate or uncertain). Hypertension (82.2%), diabetes mellitus (41.3%), and coronary artery disease (41.1%) were common. Glycated hemoglobin levels were lower in the inappropriate MPI cohort (6.6% vs 7.5%; P = 0.04). No difference was observed in the proportion with goal hemoglobin (62.5% vs 46.3% for appropriate/uncertain; P = 0.258). Systolic blood pressure was not different (132 mm Hg vs 135 mm Hg; P = 0.34). Achievement of several other categorical quality metrics was low in both cohorts and no differences were observed. More than 90% of clinicians documented a plan to achieve most metrics.

CONCLUSIONS

Inappropriate MPI is not associated with performance on metrics of quality care. If an association exists, it may be between inappropriate MPI and overly aggressive care. Most clinicians document a plan of care to address failure of quality metrics, suggesting awareness of the problem.

Prevalence and implications of severe anxiety in a prospective cohort of acute chest pain patients

Anxiety is a common condition which can manifest with symptoms of chest discomfort. Chest discomfort is one of the most common reasons to seek emergency medical care. We hypothesize that anxiety is highly prevalent, poorly diagnosed, and poorly treated in an acute care environment. We analyzed data from a prospective registry of chest pain patients with low to intermediate likelihood of acute coronary syndrome and coronary artery disease. Scores from the General Anxiety Disorder-7 questionnaire determined the prevalence of anxiety. Differences in presentation, evaluation, and 30-day outcomes were compared for subjects with and without severe anxiety. Of the 151 included subjects, severe anxiety was observed in 15%, moderate 14%, mild 30%, and 41% had no anxiety symptoms. Subjects with severe anxiety had similar baseline characteristics, cardiac risk factors, and symptoms to those without severe anxiety, except for the current use of tobacco (50.0% vs. 18.6%; P = 0.001). Anxiety was self-reported by 54.5% of subjects with severe anxiety and 27.3% were on antianxiety medications. Hospital admission (P = 0.888) and repeated emergency department visits within 30 days (P = 0.554) were not different between the 2 groups. Anxiety is common among patients seeking emergency evaluation of chest pain. Half of patients with severe anxiety were diagnosed and roughly one quarter were medically treated. Cardiac risk factors and symptoms are not different for patients with severe anxiety; these patients warrant a similar evaluation for heart disease as those patients without anxiety.

Clinical utility of inappropriate positron emission tomography myocardial perfusion imaging: test results and cardiovascular events

BACKGROUND

Appropriate use criteria for myocardial perfusion imaging (MPI) were developed to categorize scenarios where MPI might be beneficial (appropriate) or not (inappropriate). Few investigations have evaluated the clinical utility of this categorization strategy, particularly with positron emission tomography (PET) MPI.

METHODS AND RESULTS

We conducted this retrospective cohort investigation in a Veterans Affairs (VA) medical center, on predominantly male subjects who underwent PET-MPI. We correlated appropriateness to test result and cardiovascular events. Of 521 subjects, 414 (79.5%) were appropriate, 54 (10.4%) were uncertain, and 53 (10.2%) were inappropriate. PET-MPI was abnormal more often when appropriate or uncertain (28% and 34.6%, respectively, vs 7.7% for inappropriate, P = .003). Among abnormal inappropriate tests, none detected occult ischemia. By Cox regression, summed difference score ≥5 (HR 5.06, 95% CI 2.72-9.44) and an abnormal test result (HR 4.48, 95% CI 2.19-9.14) were associated with higher likelihood of catheterization. Log-rank analysis demonstrated similar likelihood of catheterization when comparing abnormal vs normal test result (P < .0001) and between appropriate, uncertain, and inappropriate tests (P = .024).

CONCLUSIONS

Inappropriate PET-MPI was rarely abnormal, associated with low catheterization rates, and failed to detect occult ischemia for any subjects. The clinical utility of inappropriate PET-MPI is negligible.

A training program in cardiovascular cell-based therapy: from the NHLBI Cardiovascular Cell Therapy Research Network

Stem/progenitor cell-based therapies offer novel treatment for many prevalent diseases. However, most physicians are not trained or introduced to cell therapy. We describe a model of a training program aimed at empowering physician-scientists with the knowledge and skills necessary for advancing the field of cardiovascular cell therapy. To date, five full-time scholars have completed this training program, obtained a full-time academic appointment in Cardiovascular Disease, and continue to actively contribute to the advancement of cell therapy applications. Another has returned to his parent institution to complete his PhD and several part-time scholars have continued in scholarly activities in other academic programs.

Usefulness of Beta blockade in contemporary management of patients with stable coronary heart disease

Considerable progress has been made over the last few decades in the management of clinically stable coronary heart disease (SCHD), including improvements in interventions (e.g., percutaneous revascularization), pharmacological management, and risk factor control (e.g., smoking, diet, activity level, hypercholesterolemia, hypertension). Although β blockers have long been used for the treatment of SCHD, their efficacy was established in the era before widespread use of reperfusion interventions, modern medical therapy (e.g., angiotensin-converting enzyme inhibitors, angiotensin receptor blockers), or preventive treatments (e.g., aspirin, statins). On the basis of these older data, β blockers are assumed beneficial, and their use has been extrapolated beyond patients with heart failure and previous myocardial infarction, which provided the best evidence for efficacy. However, there are no randomized clinical trials demonstrating that β blockers decrease clinical events in patients with SCHD in the modern era. Furthermore, these agents are associated with weight gain, problems with glycemic control, fatigue, and bronchospasm, underscoring the fact that their use is not without risk. In conclusion, data are currently lacking to support the widespread use of β blockers for all SCHD patients, but contemporary data suggest that they be reserved for a well-defined high-risk group of patients with evidence of ongoing ischemia, left ventricular dysfunction, heart failure, and perhaps some arrhythmias.

Abstract 349: Elevated Troponin: How Well Does it Predict a Diagnosis of Acute Coronary Syndrome?

Background: Cardiac troponins are highly sensitive for detection of myocardial necrosis and considered the reference standard for diagnosing acute coronary syndromes (ACS). Due to high sensitivity and widespread use in patients with low likelihood of ACS, the positive predictive value (PPV) of elevated troponin for determining ACS may be limited.

Methods: From 2006-2007, all patients with elevated troponin ( > 0.03 ng/dL) at our facility were evaluated by an attending cardiologist within 24 hours of a positive troponin in order to determine the presence or absence of ACS. Patients were tracked during their hospitalization with data gathered prospectively in a database maintained for quality purposes. We conducted a cross sectional investigation of patients in this database to ascertain the PPV of elevated troponin for diagnosing ACS. Baseline characteristics and symptoms for patients with and without ACS were compared. Multivariate logistic regression was performed to determine correlations between the diagnosis of ACS and patient characteristics, symptoms and other objective findings.

Results: 1018 patients were included. Mean initial troponin value was higher for patients with ACS (0.42 versus 0.13, p < 0.0001). Overall, the PPV of elevated troponin for diagnosing ACS was only 29.8%. The PPV varied widely depending on the initial symptom reported (highest, chest pain 48.8%; lowest, low energy 2.3%). In multivariate logistic regression, few patient characteristics were correlated with ACS, including smoking (odds ratio [OR] 4.36, 95% confidence interval [CI] 2.45-7.76, p < 0.0001) and hyperlipidemia (OR 1.62, 95% CI 1.16-2.27, p=0.005). New electrocardiogram changes (OR 5.43, 95% CI 3.49-8.46, p<0.0001) and troponin value greater than 10 fold above upper limit of normal (OR 2.79, 95% CI 1.12-6.96, p=0.028) were correlated with ACS. The only symptom correlated with ACS was chest pain (OR 5.00, 95% CI 3.51-7.13).

Conclusion: Elevated troponin alone has weak PPV for diagnosing ACS when adjudicated by an attending cardiologist. Troponin elevations were observed with various presenting symptoms, and the PPV was dependent on chief complaint. New electrocardiogram changes, level of troponin elevation, chest pain, and smoking were strongly correlated with the diagnosis of ACS.

Abstract 153: Stress Testing Following PCI in the VA Health Care System: Insights from the VA CART Program

Background: Use of stress testing following percutaneous coronary intervention (PCI) is common in community practice with 60% of patients undergoing stress testing within 24 months of PCI. Rates of stress testing following PCI within integrated and salaried healthcare systems like the VA are unknown.

Methods: Using national data from the VA Clinical Assessment Reporting and Tracking (CART) Program, we evaluated all VA patients who had PCI from October 2007-September 2011. We assessed the proportion of patients undergoing stress testing, stress test type, and timing of stress testing in the 2 years following PCI. To be consistent with prior studies, we excluded stress tests performed within 60 days of PCI as these may reflect assessment of residual ischemia in anticipation of staged procedures. Timing of follow-up stress testing was determined from 30-day incremental windows of follow-up.

Results: Overall, 7,145 of 21,635 patients (33.0%) had a stress test performed within 2 years of PCI. The vast majority of stress tests following PCI were performed with nuclear imaging (80.8%). Treadmill stress ECG without imaging represented 15.2% of stress tests and stress echo 3.9%. Patients undergoing stress testing in follow-up were younger (63.4 vs 65.7 years, P<.001) and less likely to have comorbid congestive heart failure (21.8% vs 25.1%, P<.001) or chronic obstructive pulmonary disease (23.2% vs 25.5%, P<.001). In 30-day incremental windows of follow-up, first stress tests were most commonly performed in the 60-90 days following PCI (Figure).

Conclusions: About 1 in 3 patients had a stress test performed in the 2 years following PCI in the VA. This rate is nearly half that reported from prior studies of community practice. Further study is needed to understand if this represents underuse of stress testing in VA or overuse in fee-for-service care.

Clinician-dependent variations in inappropriate use of myocardial perfusion imaging: training, specialty, and location

BACKGROUND

Inappropriate use of myocardial perfusion imaging (MPI) may vary depending on the training, specialty, or practice location of the clinician.

METHODS

We conducted a cross-sectional investigation of consecutive patients who underwent MPI at our Veterans Affairs medical center between December 2010 and July 2011. Characteristics of the MPI ordering clinicians were extracted to investigate any associations with inappropriate use.

RESULTS

582 patients were included, 9.8% were inappropriate. No difference in inappropriate use was observed between cardiology and non-cardiology clinicians (n = 21, 9.5% vs n = 36, 10.0%, P = .83); no difference was noted between nurse practitioners/physician assistants, attending physicians, and housestaff (7.5% vs 11.2% vs 1.8%, P = .06). Comparing inpatient, emergency department and outpatient clinician groups, the difference was null (8.6% vs 6.3% vs 10.1%, P = .75). For most clinician groups, the most common inappropriate indication was an asymptomatic scenario; however, some groups were different: definite acute coronary syndrome for inpatient clinicians and low risk syncope for emergency medicine clinicians.

CONCLUSIONS

Clinician groups appear to order inappropriate MPI at similar rates, regardless of their training, specialty, or practice location. Differences in the most common type of inappropriate testing suggest that interventions to reduce inappropriate use should be tailored to specific clinician types.

Left ventricular mass in a patient with peripheral eosinophilia

: A 63-year-old man presented with dyspnea and night sweats. Blood work revealed an elevated white count of 23.7 × 10 cells/l with 33% eosinophils and bone marrow biopsy made a diagnosis of myeloproliferative eosinophilia. Transthoracic echocardiography found a large left ventricular mass filling the distal third of the cavity. Transesophageal echocardiograpm confirmed the findings. Herein, we discuss this unique case of hypereosinophilic syndromes with pathognomonic imaging of its cardiovascular sequelae.

Comparing two strategies for emergency department chest pain patients: immediate computed tomography coronary angiography versus delayed outpatient treadmill testing

Chest pain (CP) is a common emergency department (ED) complaint and return visits (recidivism) are common. Recidivism may be related to incomplete evaluation of a patient's complaint. Computed tomography coronary angiography (CTCA) is accurate for diagnosing coronary artery disease (CAD) in patients with CP. We will compare a strategy of immediate CTCA with a strategy of delayed outpatient stress testing and hypothesize that CTCA will reduce recidivism in patients with CP. We conducted a retrospective cohort study comparing strategies for ED patients with CP: immediate CTCA (CT cohort) versus delayed outpatient stress testing (control cohort). Two hundred eighty subjects were included, 140 in each of the strategies. Recidivism within 6 months of the index ED evaluation occurred in 12 subjects from the CT cohort and 18 subjects from the control cohort (9% vs. 13%, P = 0.41). Duration of stay was increased in the CT cohort (456 vs. 417 min, P = 0.031). Immediate CTCA was associated with improved detection of obstructive CAD (8% vs. 1%, P = 0.005). In conclusion, immediate CTCA, when compared with delayed outpatient stress testing, did not reduce ED recidivism for CP. Length of stay was increased in the immediate CTCA cohort. The use of CTCA improved detection of obstructive CAD.

A quality improvement project for reducing cardiac computed tomography radiation dose in a community-based, multihospital setting

Radiation associated with computed tomography coronary angiography (CTCA) is a persistent concern. Strategies for reducing radiation exposure have been described, primarily in academic settings. We developed a standard protocol for CTCA acquisition focused on radiation reduction strategies in a community-based, multihospital setting and hypothesized that the protocol would be effective at reducing radiation in this setting. The protocol included the use of body mass index based tube voltage adjustment and routine use of prospective electrocardiographic gating with either dose modulation or step-and-shoot acquisition. Data on radiation exposure were collected retrospectively and compared by nonparametric testing. Some hospitals failed to routinely record radiation exposure data; only 2 facilities had data available from both before and after the intervention for direct comparison. Data were acquired from 124 subjects, 41 from the standard of care group and 83 scanned under the new protocol. In hospital A, radiation was significantly reduced by 61% from 20.5 ± 4.6 millisieverts (mSv) to 7.9 ± 4.8 mSv (P < 0.001). Within the new protocol group for hospital A, radiation was lower with step-and-shoot (4.0 ± 1.5 mSv) as compared to dose modulation (10.2 ± 4.2 mSv, P < 0.001). In hospital B, which already employed step-and-shoot acquisition, radiation dose was reduced 16% from 9.3 ± 3.0 mSv to 7.9 ± 2.2 mSv (P < 0.017) by applying body mass index-based tube voltage adjustment alone. In conclusion, a minimal investment in institutional resources can result in a reduction in radiation exposure from CTCA, even in a community-based, multihospital setting. Some facilities do not routinely record radiation exposure data.

Mortality implications of angina and blood pressure in hypertensive patients with coronary artery disease: New data from extended follow-up of the International Verapamil/Trandolapril Study (INVEST)

BACKGROUND

Angina and hypertension are common in patients with coronary artery disease (CAD); however, the effect on mortality is unclear. We conducted this prespecified analysis of the International Verapamil/Trandolapril Study (INVEST) to assess relationships between angina, blood pressure (BP), and mortality among elderly, hypertensive CAD patients.

HYPOTHESIS

Angina and elevated BP will be associated with higher mortality.

METHODS

Extended follow-up was performed using the National Death Index for INVEST patients in the United States (n = 16 951). Based on angina history at enrollment and during follow-up visits, patients were divided into groups: persistent angina (n = 7184), new-onset angina (n = 899), resolved angina (n = 4070), and never angina (n = 4798). Blood pressure was evaluated at baseline, during drug titration, and during follow-up on-treatment. On-treatment systolic BP was classified as tightly controlled (<130 mm Hg), controlled (130-139 mm Hg), or uncontrolled (≥140 mm Hg). A Cox proportional hazards model was created adjusting for age, heart failure, diabetes, renal impairment, myocardial infarction, stroke, and smoking. The angina groups and BP control groups were compared using the never-angina group as the reference.

RESULTS

Only in the persistent-angina group was a significant association with mortality observed, with an apparent protective effect (hazard ratio: 0.82, 95% confidence interval: 0.75-0.89, P < 0.0001). Uncontrolled BP was associated with increased mortality risk (hazard ratio: 1.29, 95% confidence interval: 1.20-1.40, P < 0.0001), as were several other known cardiovascular risk factors.

CONCLUSIONS

In hypertensive CAD patients, persistent angina was associated with lower mortality. The observed effect was small compared with other cardiovascular risk factors, such as BP, which were associated with increased mortality.

Abstract 356: Comparison Of Inappropriate Myocardial Perfusion Imaging By Specialty Training And Encounter Location

Objective: To investigate the association between inappropriate use of myocardial perfusion imaging (MPI), specialty training of the ordering provider, and location of the clinical encounter.

Methods: We conducted a retrospective analysis of MPI performed in a single Veterans Affairs (VA) medical center from August 2010 through November 2011. We classified the indication for each MPI test using the 2009 Appropriate Use Criteria (AUC). We investigated for associations between MPI ordered for inappropriate indications, the subspecialty training of the ordering provider (cardiology vs. other), and the location of the clinical encounter (emergency department [ED], inpatient, or outpatient).

Results: We analyzed 598 subjects, 95% of whom were male. Diabetes (41.2%), hypertension (82.3%), and hyperlipidemia (76.0%) were common, as were prior myocardial infarction (40.5%) and prior revascularization (34.6%). Overall, 78.4% of MPI were appropriate, 9.5% uncertain, and 10.5% were inappropriate. An indication could not be determined for 3.2% of patients. Distribution of appropriateness by provider type and location of encounter are demonstrated in the Figure. The most common inappropriate indication did differ between groups. For Cardiology providers the most common inappropriate MPI was for asymptomatic patients within 2 years of percutaneous coronary intervention (AUC indication #59) while for noncardiology providers, the most common was asymptomatic patients with intermediate coronary heart disease (CHD) risk and a normal electrocardiogram (AUC indication #13). For inpatient MPI, definite acute coronary syndrome (AUC indication #10) was the most common inappropriate test, while for outpatient MPI, asymptomatic patients with low CHD risk was the most common (AUC indication #12), and for ED MPI syncope with low CHD risk was the most common (AUC indication #20).

Conclusions: The proportion of MPI ordering for inappropriate indications was similar when comparing the specialty training of the ordering provider and the location of the ordering encounter. The most common inappropriate indications ordered by each group, however, were different. Our findings suggest that initiatives to reduce inappropriate use should be aimed at all providers, but targeted to specific inappropriate indications.

Design and implementation of a stand-alone chest pain evaluation center within an academic emergency department

Chest pain is a common presenting symptom for emergency department (ED) patients; however, a thorough cardiac evaluation can be difficult to complete within the ED setting. Implementation of a stand-alone unit for the evaluation of chest pain may improve care for patients with chest pain. We designed a protocol for identifying patients without an acute coronary syndrome and with low-to-intermediate likelihood of obstructive coronary artery disease (CAD). These patients were monitored in a stand-alone chest pain evaluation center (CPEC) staffed with a small group of providers and tested for CAD, if necessary. In the first 6 weeks of operation, 181 patients were evaluated in the CPEC. The prevalence of CAD risk factors was low. Of the 181 patients, 159 (88%) were discharged home and 22 (12%) required admission to the hospital for further care. We compared the number of chest pain evaluations and admissions for first 6 weeks of operation to the same 6-week period from the 2 previous years. Whereas ED chest pain evaluations increased 66% over the 2-year time frame, the proportion admitted to the hospital decreased from 53% to 42% (P < 0.0001). In conclusion, evidence-based evaluation of chest pain in patients without acute coronary syndrome and with low-to-intermediate likelihood of obstructive CAD can result in the significant majority of patients being discharged from the ED. Creation of a stand-alone CPEC in an academic hospital was associated with a significant reduction in hospital admissions.

Membranous ventricular septal aneurysm diagnosed by means of cardiac computed tomography

WEBSITE FEATURE

Efficacy and safety of unfractionated heparin plus glycoprotein IIb/IIIa inhibitors during revascularization for an acute coronary syndrome: a meta-analysis of randomized trials performed with stents and thienopyridines

BACKGROUND

Early studies of glycoprotein IIb/IIIa inhibitors (GPIs) demonstrated benefit during percutaneous coronary intervention for acute coronary syndromes (ACS). Since their introduction, the magnitude of benefit of GPIs has become unclear.

HYPOTHESIS

We hypothesized that adding a GPI to unfractionated heparin in ACS patients treated with stents and thienopyridines is beneficial.

METHODS

We searched the MEDLINE, Cochrane, and clinicaltrials.gov databases for randomized clinical trials that studied the use of GPIs during ACS. We required that patients be randomly assigned to unfractionated heparin plus a GPI versus unfractionated heparin plus placebo (or control). Additional inclusion criteria included the use of coronary stents and periprocedural thienopyridines. Outcomes were assessed at 30 days. Random effects DerSimonian-Laird summary risk ratios (RR) and 95% confidence intervals (CIs) were constructed.

RESULTS

Sixteen studies with 7611 patients were included. Myocardial infarction was 3.1% with GPI versus 4.4% with control (RR = 0.74; 95% CI, 0.59-0.94, P = 0.014); revascularization, 1.7% versus 2.7% (RR = 0.64; 95% CI, 0.46-0.89, P = 0.008); major bleeding, 2.5% versus 2.1% (RR = 1.21; 95% CI, 0.89-1.63, P = 0.22); minor bleeding, 5.5% versus 4.1% (RR = 1.37; 95% CI, 1.06-1.78, P = 0.016); and mortality, 2.2% versus 2.9% (RR = 0.79; 95% CI, 0.59-1.06, P = 0.12), respectively.

CONCLUSIONS

Among ACS patients treated with stents and thienopyridines, GPIs were associated with reduced myocardial infarction and revascularization. Minor, but not major bleeding was increased with GPIs. Mortality was similar between the groups. © 2011 Wiley Periodicals, Inc. Supporting information may be found in the online version of this article This work was supported by an unrestricted grant from the Florida Heart Research Institute, which had no role in the study design, data collection, analysis, or interpretation, manuscript writing, or decision to proceed with publication. Anthony A Bavry has received research support from Novartis Pharmaceuticals and serves as a contractor for American College of Cardiology Cardiosource. The other authors have no funding, financial relationships, or conflicts of interest to disclose.

Evidence of pre-procedural statin therapy a meta-analysis of randomized trials

OBJECTIVES

The purpose of this study was to summarize the evidence of pre-procedural statin therapy to reduce periprocedure cardiovascular events.

BACKGROUND

Invasive procedures can result in adverse cardiovascular events, such as myocardial infarction (MI) and death. We hypothesized that statins might improve clinical outcomes when used before invasive procedures.

METHODS

We searched the MEDLINE, Cochrane, and clinicaltrials.gov databases from inception to February 2010 for randomized, controlled trials that examined statin therapy before invasive procedures. Invasive procedures were defined as percutaneous coronary intervention, coronary artery bypass grafting (CABG), and noncardiac surgery. We required that studies initiated statins before the procedure and reported clinical outcomes. A DerSimonian-Laird model was used to construct random-effects summary risk ratios.

RESULTS

Eight percent of the screened trials (21 of 270) met our selection criteria, which included 4,805 patients. The use of pre-procedural statins significantly reduced post-procedural MI (risk ratio [RR]: 0.57, 95% confidence interval [CI]: 0.46 to 0.70, p < 0.0001). This benefit was seen after both percutaneous coronary intervention (p < 0.0001) and noncardiac surgical procedures (p = 0.004), but not CABG (p = 0.40). All-cause mortality was nonsignificantly reduced by statin therapy (RR: 0.66, 95% CI: 0.37 to 1.17, p = 0.15). Pre-procedural statins also reduced post-CABG atrial fibrillation (RR: 0.54, 95% CI: 0.43 to 0.68, p < 0.0001).

CONCLUSIONS

Statins administered before invasive procedures significantly reduce the hazard of post-procedural MI. Additionally, statins reduce the risk of atrial fibrillation after CABG. The routine use of statins before invasive procedures should be considered.

Acute myocardial infarction during infusion of liposomal doxorubicin for recurrent breast cancer

Doxorubicin and anthracycline antineoplastic agents are well known for their myocardial toxicity. This effect, however, is thought to be a direct one on the myocardium as a result of free radical formation and oxidative stress. We present the case of a patient who suffered an acute myocardial infarction during her first infusion of a liposomal formulation of doxorubicin as part of chemotherapy for recurrent breast cancer. To our knowledge, this is the first report of an angiographically proven infarction temporally related to exposure to this chemotherapeutic agent.

Responsible use of computed tomography in the evaluation of coronary artery disease and chest pain

Many options are available to clinicians for the noninvasive evaluation of the cardiovascular system and patient concerns about chest discomfort. Cardiac computed tomography (CT) is a rapidly advancing field of noninvasive imaging. Computed tomography incorporates coronary artery calcium scoring, coronary angiography, ventricular functional analysis, and information about noncardiac thoracic anatomy. We searched the PubMed database and Google from inception to September 2009 for resources on the accuracy, risk, and predictive capacity of coronary artery calcium scoring and CT coronary angiography and have reviewed them herein. Cardiac CT provides diagnostic information comparable to echocardiography, nuclear myocardial perfusion imaging, positron emission tomography, and magnetic resonance imaging. A cardiac CT study can be completed in minutes. In patients with a nondiagnostic stress test result, cardiac CT can preclude the need for invasive angiography. Prognostic information portends excellent outcomes in patients with normal study results. Use of cardiac CT can reduce health care costs and length of emergency department stays for patients with chest pain. Cardiac CT examination provides clinically relevant information at a radiation dose similar to well-established technologies, such as nuclear myocardial perfusion imaging. Advances in technique can reduce radiation dose by 90%. With appropriate patient selection, cardiac CT can accurately diagnose heart disease, markedly decrease health care costs, and reliably predict clinical outcomes.

Concurrence of angiographic coronary artery disease in patients with apical ballooning syndrome (tako-tsubo cardiomyopathy)

OBJECTIVE

To determine the coexistence of coronary artery disease (CAD) in an unselected cohort of patients with apical ballooning syndrome (ABS).

BACKGROUND

ABS is a clinical condition of unknown etiology with symptoms that mimic an acute coronary syndrome and is characterized by the presence of transient left ventricular dysfunction primarily affecting the apex of the heart.

METHODS

We conducted a retrospective case series in a single tertiary care hospital. Patients were identified by searching for several inclusive discharge diagnoses in all hospitalized patients. Suspected cases were analyzed using prespecified diagnostic criteria. Demographic, clinical, and imaging data were collected. Coronary lesions were assessed by quantitative angiography.

RESULTS

Thirty-one cases of ABS were identified. The majority of the cases were female, and ischemia was documented in all patients by electrocardiographic or cardiac biomarker criteria. Nineteen patients (61.3%) had angiographic evidence of CAD, with multivessel involvement in seven (23%). Nine patients (29%) had luminal stenosis severity greater than 50% in at least one epicardial vessel.

CONCLUSIONS

In an unselected cohort of patients with ABS, coronary atherosclerosis is commonly present. Whether CAD simply coexists or is related to the pathophysiology of ABS is unclear.