ACCF/AHA/AMA-PCPI 2011 performance measures for adults with coronary artery disease and hypertension: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures and the American Medical Association-Physician Consortium for Performance Improvement

Does Abdominal Obesity Increase All-Cause, Cardiovascular Disease, and Cancer Mortality Risks in Older Adults? A 10-Year Follow-Up Analysis

There is insufficient evidence on the impact of abdominal obesity (AO) on mortality in older adults. Therefore, the objective to analyze the 10-year impact of AO, assessed using different diagnostic criteria, on all-cause, cardiovascular disease (CVD), and cancer mortality in older adults. In this prospective cohort study of older adults (≥60 years), sociodemographic, lifestyle, clinical history, laboratory test, and anthropometric data were analyzed. The considered were used for AO diagnostic: waist circumference (WC) of ≥88 cm for women and ≥102 cm for men; WC of ≥77.8 cm for women and ≥98.8 cm for men; and increased waist-to-hip ratio (WHR), being the highest tertile of distribution by sex. Multivariate Cox regression and Kaplan-Meier analyses were performed. A total of 418 individuals, with an average age of 70.69 ± 7.13 years, participated in the study. In the analysis adjusted for sex and age, WHR was associated with a high risk of all-cause mortality (p = 0.044). Both cutoff points used for the WC were associated with an increased CVD mortality risk. None of the AO parameters were associated with cancer mortality. An increased WHR was associated to a higher all-cause mortality risk factor, while an increased WC was a risk factor for a higher CVD mortality in older adults.

Predictors of Changes in Peak Oxygen Uptake After Outpatient Cardiac Rehabilitation: Importance of Cardiac Rehabilitation Attendance

Objective

To determine whether the number of cardiac rehabilitation (CR) sessions attended and selected clinical characteristics were predictive of patients who exhibited improvement in peak oxygen uptake (VO₂peak) after CR.

Patients and Methods

Using the Rochester Epidemiology Project records-linkage system, we identified all consecutive patients aged 18 years or older from Olmsted County, Minnesota, who underwent cardiopulmonary exercise testing before and after CR from 1999 to 2017. Regression models were created to assess the clinical predictors of VO₂peak improvement (>0% baseline) after CR.

Results

The analysis included 671 patients, of which 524 (78%) patients exhibited VO₂peak improvement after CR. The significant univariate predictors of VO₂peak improvement included younger age (odds ratio [OR], 0.98; 95% CI, 0.96-0.99), lower pre-CR VO₂peak (OR, 0.96; 95% CI, 0.94-0.99), and no history of peripheral artery disease (OR, 0.50; 95% CI, 0.31-0.81) (all, P<.005). The significant independent predictors of VO₂peak improvement from the multivariable analysis included the number of CR sessions (OR, 1.04; 95% CI, 1.02-1.05), younger age (OR, 0.96; 95% CI, 0.94-0.98), lower pre-CR VO₂peak (OR, 0.92; 95% CI, 0.89-0.95), and no history of peripheral artery disease (OR, 0.47; 95% CI, 0.28-0.78) (all, P<.005).

Conclusion

These findings highlight the importance of patient participation in CR sessions and individual clinical characteristics in influencing VO₂peak improvement after CR in patients with cardiovascular disease.

Burdensome Transitions of Care for Patients with End-Stage Liver Disease and Their Caregivers

BACKGROUND

Patients with end-stage liver disease (ESLD) experience frequent readmissions; however, studies focused on patients' and caregivers' perceptions of their transitional care experiences to identify root causes of burdensome transitions of care are lacking.

AIM

To explore the transitional care experiences of patients with ESLD and their caregivers in order to identify their supportive care needs.

METHODS

We conducted interviews with 15 patients with ESLD and 14 informal caregivers. We used semi-structured interview guides to explore their experiences since the diagnosis of ESLD including their care transitions. Two raters coded interviews independently (κ = 0.95) using template analysis.

RESULTS

Participants reported feeling unprepared to manage their informational, psychosocial, and practical care needs as they transitioned from hospital to home after the diagnosis of ESLD. Delay in the timely receipt of supportive care services addressing these care needs resulted in hospital readmissions, emotional distress, caregiver burnout, reduced work capacity, and financial hardship. Participants shared the following resources that they perceived would improve their quality of care: (1) discharge checklist, (2) online resources, (3) mental health support, (4) caregiver support and training, and (5) financial navigation.

CONCLUSION

Transitional care models that attend to the informational, psychosocial, and practical domains of care are needed to better support patients with ESLD and their caregivers at the time of diagnosis and beyond. Without attending to the multidimensional care needs of newly diagnosed patients with ESLD and their caregivers, they are at risk of burdensome transitions of care, high healthcare utilization, and poor health-related quality of life.

Transcriptome Sequencing Identifies Potential Biomarker for White Matter Lesions Diagnosis in the Hypertension Population

Hypertension is confirmed to be one of the major risk factors of leukoaraiosis (LA). However, the pathogenesis of LA is not completely understood and there is no reliable indicator for the early diagnosis of LA in the hypertensive population. This study was designed to explore the potential biomarker for LA diagnosis in patients with hypertension. And it serves as the basis for the further study of LA mechanism. In this study, This study included 110 subjects, including 50 in the LA group and 60 in the control group. First, we performed transcriptome sequencing and quantitative PCR (qPCR) in four samples from the LA group, and three from the control group (seven people) to identify relevant long non-coding RNAs (long ncRNAs or lncRNA). The 103 samples were used for qPCR validation of relevant lncRNAs and the results were consistent with the sequencing. In-depth bioinformatics analysis were performed on differentially expressed (DE) lncRNAs and mRNAs. Go-functional enrichment analysis was performed on DE mRNAs. Some DE mRNA were enriched to biological processes associated with LA, And some lncRNAs related to DE mRNAs were traceable through cis/trans analysis, suggesting that they might be regulated in some way. Additionally, potential biomarkers for LA diagnosis in the hypertension population were identified via RT-qPCR and receive operating characteristic curve (ROC) analysis of lncRNA. One lncRNA, AC020928.1, has been demonstrated to be potential biomarkers for LA diagnosis in the hypertension population. The results of the present study indicated that the lncRNA may have an important role in the pathogenesis of LA and may be a novel target for further research. As the relationship between lncRNAs and LA is just beginning to be unraveled, their specific mechanisms require further investigation.

Current challenges in cardiac rehabilitation: strategies to overcome social factors and attendance barriers

INTRODUCTION

Cardiac rehabilitation (CR) significantly reduces secondary cardiovascular events and mortality and is a class 1A recommendation by the American Heart Association (AHA) and American College of Cardiology (ACC). However, it remains an underutilized intervention and many eligible patients fail to enroll or complete CR programs. The aim of this review is to identify barriers to CR attendance and discuss strategies to overcome them.

AREAS COVERED

Specific barriers to CR attendance and participation will be reviewed. This will be followed by a discussion of solutions/strategies to help overcome these barriers with a particular focus on home-based CR (HBCR).

EXPERT OPINION

HBCR alone or in combination with center-based CR (CBCR) can help overcome many barriers to traditional CBCR participation, such as schedule flexibility, time commitment, travel distance, cost, and patient preference. Using remote coaching with indirect exercise supervision, HBCR has been shown to have comparable benefits to CBCR. At this time, however, funding remains the main barrier to universal incorporation of HBCR into health systems, necessitating the need for additional cost benefit analysis and outcome studies. Ultimately, the choice for HBCR should be based on patient preference and availability of resources.

Cardiac Rehabilitation Knowledge and Attitudes of Cardiology Fellows

PURPOSE

Cardiac rehabilitation (CR) is underutilized with only 8-31% of eligible patients participating. Lack of referral and lack of physician endorsement are well-known barriers to participation. Physicians who lack insights regarding CR are less likely to refer patients and recommend it. Cardiology fellows are early career physicians who spend a significant amount of time treating patients eligible for CR. At one institution's cardiology fellowship program, we sought to assess fellow attitudes and knowledge base regarding CR and to determine their facilitators and barriers to CR endorsement and referral.

METHODS

University of Pittsburgh Department of Medicine Cardiology fellows were surveyed and interviewed to assess CR knowledge, attitudes, and perceived facilitators and barriers to CR endorsement and referral.

RESULTS

The cardiology fellows at this institution had strong belief in the benefits and cost-effectiveness of CR. Despite their support of CR, they had low CR knowledge scores. Perceived impediments to CR included complicated logistics of CR operations, limited communication between CR staff and fellows, limited time with patients, presumed patient barriers, perceived self-barriers, and poor understanding of referral processes (particularly as they varied in each hospital in which they rotated). Perceived supports to CR included greater awareness of evidence-based outcomes, awareness of patient-centered outcomes, pre-arranged order sets, and reminders for referral.

CONCLUSION

This study revealed perceptions of cardiology fellows at one institution regarding CR that have not been considered previously. Key barriers to endorsement and referral to CR were exposed as well as opportunities to overcome them. Fellowship training affords an important opportunity to improve CR education, and to potentially improve participation of eligible patients for this important aspect of care.

Association of Outpatient Practice-Level Socioeconomic Disadvantage With Quality of Care and Outcomes Among Older Adults With Coronary Artery Disease: Implications for Value-Based Payment

BACKGROUND

Medicare patients with coronary artery disease (CAD) have been a significant focus of value-based payment programs for outpatient practices. Physicians and policymakers, however, have voiced concern that value-based payment programs may penalize practices that serve vulnerable populations. This study evaluated whether outpatient practices that serve socioeconomically disadvantaged populations have worse CAD outcomes, and if this reflects the delivery of lower-quality care or rather, patient and community factors beyond the care provided by physician practices.

METHODS AND RESULTS

Retrospective cohort study of Medicare fee-for-service patients ≥65 years with CAD at outpatient practices participating in the the Practice Innovation and Clinical Excellence registry from January 1, 2010 to January 1, 2015. Outpatient practices were stratified into quintiles by the proportion of most disadvantaged patients-defined by an area deprivation score in the highest 20% nationally-served at each practice site. Prescription of guideline recommended therapies for CAD as well as clinical outcomes (emergency department presentation for chest pain, hospital admission for unstable angina or acute myocardial infarction [AMI], 30-day readmission after AMI, and 30-day mortality after AMI) were evaluated by practice-level socioeconomic disadvantage with hierarchical logistic regression models, using practices serving the fewest socioeconomically disadvantaged patients as a reference. The study included 453 783 Medicare fee-for-service patients ≥65 years of age with CAD (mean [SD] age, 75.3 [7.7] years; 39.7% female) cared for at 271 outpatient practices. At practices serving the highest proportion of socioeconomically disadvantaged patients (group 5), compared with practices serving the lowest proportion (group 1), there was no significant difference in the likelihood of prescription of antiplatelet therapy (odds ratio [OR], 0.94 [95% CI, 0.69-1.27]), β-blocker therapy if prior myocardial infarction or left ventricular ejection fraction <40% (OR, 0.97 [95% CI, 0.69-1.35]), ACE (angiotensin-converting enzyme) inhibitor or angiotensin receptor blocker if left ventricular ejection fraction <40% and/or diabetes mellitus (OR, 0.93 [95% CI, 0.74-1.19]), statin therapy (OR, 0.88 [95% CI, 0.68-1.14]), or cardiac rehabilitation (OR, 0.45 [95% CI, 0.20-1.00]). Patients cared for at the most disadvantaged-serving practices (group 5) were more likely to be admitted for unstable angina (adjusted OR, 1.46 [95% CI, 1.04-2.05]). There was no significant difference in the likelihood of emergency department presentation for chest pain or hospital admission for AMI between practices. Thirty day mortality rates after AMI were higher among patients at the most disadvantaged-serving practices (aOR, 1.31 [95% CI, 1.02-1.68]), but 30-day readmission rates did not differ. All associations were attenuated after additional adjustment for patient-level area deprivation index.

CONCLUSIONS

Physician outpatient practices that serve the most socioeconomically disadvantaged patients with CAD perform worse on some clinical outcomes, despite providing similar guideline-recommended care as other practices, and consequently could fare poorly under value-based payment programs. Social factors beyond care provided by outpatient practices may partly explain worse outcomes. Policymakers should consider accounting for socioeconomic disadvantage in value-based payment programs initiatives that target outpatient practices.

An experimental and theoretical study on the degradation of clonidine by hydroxyl and sulfate radicals

Emerging contaminants such as pharmaceuticals that cannot be completely removed by traditional biological treatments are ubiquitously present in water bodies with detected concentrations ranging from ng L^-1 to mg L^-1. Advanced oxidation technologies (AOTs) are promising, efficient, and environmentally friendly for the removal of these pharmaceuticals. In this study, we investigated the degradation kinetics of a model pharmaceutical, clonidine (CLD), via hydroxyl radical (OH) in UV/H₂O₂ and sulfate radical (SO₄^•-) in UV/peroxydisulfate (PS) systems for the first time. The second-order rate constants (k) of protonated cationic CLD with OH and SO₄^•- were measured to be (2.15 ± 0.07) × 10⁹ M^-1 s^-1 and (1.12 ± 0.03) × 10⁹ M^-1 s^-1, respectively. We also calculated the pK_a value of CLD and thermodynamic behaviors for reactions of CLD/HCLD⁺ with OH and SO₄^•- at M05-2X/6-311++G**//M05-2X/6-31+G** level with SMD solvation model. The pK_a value was calculated to be 8.14, confirming the literature value. H atom abstraction pathway was the most favorable pathway for both OH and SO₄^•-, while single electron transfer pathway was thermodynamically feasible only for SO₄^•- for CLD but not for HCLD⁺. In addition, the reactivities of both tautomeric forms of CLD (i.e., amino and imino CLD) with both radicals were also investigated. This study contributed to a better understanding on the degradation mechanisms of CLD and proposed the possibilities of the elimination of pharmaceuticals by applying AOTs during wastewater treatment processes.

Cardiometabolic risk factors and Framingham Risk Score in severely obese patients: Baseline data from DieTBra trial

BACKGROUND AND AIMS

Little is known about differences of cardiometabolic risk factors (CMRF) and the function of Framingham Risk Score (FRS) within severe obesity, thus we aimed to study not only CMRF and FRS, but to determine significant differences between BMI ranges within severe obesity.

METHODS AND RESULTS

In this baseline analysis of the Traditional Brazilian Diet (DieTBra) Trial, several CMRF were assessed in 150 adult patients in two BMI ranges: 35.0-44.9 kg/m² (n = 76) and ≥45 kg/m² (n = 74). Body composition was evaluated by multifrequency bioelectrical impedance analysis to measure the percent of body fat, visceral fat area and waist circumference. Pearson's Chi-squared, Fisher's Exact, Student's t-test, and Mann-Whitney's test were used in the statistical analysis with a 5% significance level. Hypertension, C-reactive protein, systolic and diastolic blood pressure and positive family history for heart diseases were more prevalent in BMI ≥45.0 kg/m² (p < 0.05). Mean values of waist circumference, body fat %, visceral fat area, and systolic blood pressure were significantly higher in patients with BMI ≥45.0 kg/m². Regarding the function of FRS, 40.0% of the patients were at high risk. No differences were found for diabetes, lifestyle, lipid parameters, and FRS within different BMI ranges, except for dyslipidemia, significantly higher among participants with BMI 35.0-44.9 kg/m².

CONCLUSION

BMI >45 kg/m² was associated with higher prevalence of hypertension, systolic and diastolic blood pressure, C-reactive protein, waist circumference, body fat % and family history of heart diseases, enhancing the risk for the occurrence of cardiovascular diseases.

Relationship Between Provider Experience and Cardiac Performance Measures in Outpatients (from the NCDR)

Compliance with cardiac performance measures for guideline-directed medical therapy remains suboptimal. There is a compelling need to identify modifiable factors that influence compliance rates, so that these factors can be addressed as targets of quality improvement. This study examines the relationship between cardiovascular provider experience and compliance with performance measures for outpatients with coronary artery disease (CAD), heart failure, and atrial fibrillation in the PINNACLE Registry. We hypothesize that providers who have been practicing longer, especially those further out from certification who may not be required to recertify, will have lower compliance rates with key cardiac performance measures. Using clinical data from January 1, 2013 to March 31, 2014 in the PINNACLE Registry, we employed a multilevel hierarchical logistic regression analysis to examine the relationship between cardiac performance measures and provider experience, defined by the number of years since initial cardiology board certification (<10 years vs 10 to 20 years vs ≥20 years). We found a significant difference in compliance in 4 out of 9 outpatient cardiac performance measures between providers with different experience levels. Providers with ≥20 years since certification were less compliant with 3 out of the 4 statistically different performance metrics; however, the absolute difference between performance measures by provider experience level was small. In conclusion, performance on several key cardiovascular quality measures demonstrate a statistically significant negative association with physician experience-level defined by years since initial cardiology certification, but the clinical significance of this finding is unclear.

Patient Perspectives on Declining to Participate in Home-Based Cardiac Rehabilitation: A MIXED-METHODS STUDY

PURPOSE

A minority of eligible patients participate in cardiac rehabilitation (CR) programs. Availability of home-based CR programs improves participation in CR, yet many continue to decline to enroll. We sought to explore among patients the rationale for declining to participate in CR even when a home-based CR program is available.

METHODS

We conducted a mixed-methods evaluation of reasons for declining to participate in CR. Between August 2015 and August 2017, a total of 630 patients were referred for CR evaluation during index hospitalization (San Francisco VA Medical Center). Three hundred three patients (48%) declined to participate in CR. Of these, 171 completed a 14-item survey and 10 patients also provided qualitative data through semistructured phone interviews.

RESULTS

The most common reason, identified by 61% of patients on the survey, was "I already know what to do for my heart." Interviews helped clarify reasons for nonparticipation and identified system barriers and personal barriers. These interviews further highlighted that declining to participate in CR was often due to competing life priorities, no memory of the initial CR consultation, and inadequate understanding of CR despite referral.

CONCLUSION

We identified that most patients declining to participate in a home-based CR program did not understand the benefits and rationale for CR. This could be related to the timing of the consultation or presentation method. Many patients also indicated that competing life priorities prevented their participation. Modifications in the consultation process and efforts to accommodate personal barriers may improve participation.

Cardiac rehabilitation in older adults: New options

Cardiac rehabilitation (CR) is an important component in the continuum of care for patients with cardiovascular diseases, including the older population. Benefits of CR which include mortality benefit, decreased hospitalizations, increased functional capacity all extend to an older population. In Medicare beneficiaries which represent an older population, utilization of CR continues to remain low despite evidence that suggests lower hospitalization rates, Medicare costs, and improved symptoms. Given poor referral rates, enrollment rates, and completion rates, a call for new strategies has been made by all major societies. However, several barriers exist. Newer models of CR constructed to overcome these barriers are reviewed below. Some of these new strategies include alternative site CR or home‐based CR and the utilization of technology.

Home-Based Cardiac Rehabilitation: A Scientific Statement From the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology

Cardiac rehabilitation (CR) is an evidence-based intervention that uses patient education, health behavior modification, and exercise training to improve secondary prevention outcomes in patients with cardiovascular disease. CR programs reduce morbidity and mortality rates in adults with ischemic heart disease, heart failure, or cardiac surgery but are significantly underused, with only a minority of eligible patients participating in CR in the United States. New delivery strategies are urgently needed to improve participation. One potential strategy is home-based CR (HBCR). In contrast to center-based CR services, which are provided in a medically supervised facility, HBCR relies on remote coaching with indirect exercise supervision and is provided mostly or entirely outside of the traditional center-based setting. Although HBCR has been successfully deployed in the United Kingdom, Canada, and other countries, most US healthcare organizations have little to no experience with such programs. The purpose of this scientific statement is to identify the core components, efficacy, strengths, limitations, evidence gaps, and research necessary to guide the future delivery of HBCR in the United States. Previous randomized trials have generated low- to moderate-strength evidence that HBCR and center-based CR can achieve similar improvements in 3- to 12-month clinical outcomes. Although HBCR appears to hold promise in expanding the use of CR to eligible patients, additional research and demonstration projects are needed to clarify, strengthen, and extend the HBCR evidence base for key subgroups, including older adults, women, underrepresented minority groups, and other higher-risk and understudied groups. In the interim, we conclude that HBCR may be a reasonable option for selected clinically stable low- to moderate-risk patients who are eligible for CR but cannot attend a traditional center-based CR program.

Predictors of Patient Participation and Completion of Home-Based Cardiac Rehabilitation in the Veterans Health Administration for Patients With Coronary Heart Disease

Traditional, facility-based cardiac rehabilitation (CR) is vastly underutilized in the United States. The Veterans Health Administration (VA) has developed new home-based cardiac rehabilitation (HBCR) programs to address this issue. However, the characteristics of patients who choose HBCR are unknown. We sought to determine predictors of participation and completion of HBCR at the San Francisco VA (SFVA). We evaluated patients hospitalized for ischemic heart disease between 2013 and 2016 at SFVA. Logistic regression models were used to identify predictors of participation and completion of HBCR. In 724 patients with ischemic heart disease who were eligible for CR between 2013 and 2016, 314 (43%) enrolled in HBCR. Older age was associated with lower odds of participation in HBCR (odds ratio [OR] 0.84; p <0.01). Additionally, patients with coronary artery bypass grafting (CABG) were twice as likely as those with percutaneous coronary intervention to participate in HBCR (OR 2.03; 95% confidence interval 1.40, 2.97). In HBCR participants, 48% (150/314) completed ≥9 sessions. Patients with CABG were twice as likely as those with percutaneous coronary intervention to complete the HBCR program (OR 2.02; 95% confidence interval 1.18, 3.44). There were no differences in participation or completion rates by gender, race, ethnicity, or rurality. Our study showed that the SFVAMC HCBR program achieved a 43% participation rate, well above the VA average of 13%. There were no disparities by gender, race, or rurality in terms of participation and adherence. CABG as the indication for CR was the most significant predictor of participation and completion of HBCR.

Number of Board-Certified Cardiologists and Acute Myocardial Infarction-Related Mortality in Japan - JROAD and JROAD-DPC Registry Analysis

BACKGROUND

The appropriate number of board-certified cardiologists (BCC) for the treatment of acute myocardial infarction (AMI) has not been thoroughly examined in Japan. This study investigated whether the number of BCC/50 cardiovascular beds affects acute outcome in AMI treatment. Methods and Results: Data on 751 board-certified teaching hospitals and 63,603 patients with AMI were obtained from the Japanese Registry Of All cardiac and vascular Diseases (JROAD) and JROAD Diagnosis Procedure Combination (JROAD-DPC) databases between 1 April 2012 and 31 March 2014. The hospitals were categorized into 3 groups based on the median number of BCC/50 cardiovascular beds: first tertile, 5.0 (IQR, 4.0-5.7); second, 8.3 (IQR, 7.4-9.8); third, 15.3 (IQR, 12.5-22.7), and the patients with AMI admitted to the categorized hospitals were compared (first tertile, 12,002 patients; second, 23,930; third, 27,671). On hierarchical logistic modeling, the adjusted OR for 30-day mortality were 0.86 (95% CI: 0.74-1.00) for the second tertile and 0.75 (95% CI: 0.65-0.88) for the third tertile.

CONCLUSIONS

Patients with AMI admitted to hospitals with a large number of BCC/50 cardiovascular beds had a lower 30-day mortality rate. This tendency was independent of patient and hospital characteristics. This is the first study to provide new information on the association between the number of BCC and in-hospital AMI-related mortality in Japan.

Errors in Electronic Health Record-Based Data Query of Statin Prescriptions in Patients With Coronary Artery Disease in a Large, Academic, Multispecialty Clinic Practice

BACKGROUND

With the recent implementation of the Medicare Quality Payment Program, providers face increasing accountability for delivering high-quality care. Such pay-for-performance programs aim to leverage systematic data captured by electronic health record (EHR) systems to measure performance; however, the fidelity of EHR query for assessing performance has not been validated compared with manual chart review. We sought to determine whether our institution's methodology of EHR query could accurately identify cases in which providers failed to prescribe statins for eligible patients with coronary artery disease.

METHODS AND RESULTS

A total of 9459 patients with coronary artery disease were seen at least twice at the Emory Clinic between July 2014 and June 2015, of whom 1338 (14.1%, 95% confidence interval 13.5-14.9%) had no statin prescription or exemption per EHR query. A total of 120 patient cases were randomly selected and reviewed by 2 physicians for further adjudication. Of the 120 cases initially classified as statin prescription failures, only 21 (17.5%; 95% confidence interval, 11.7-25.3%) represented true failure following physician review.

CONCLUSIONS

Sole reliance on EHR data query to measure quality metrics may lead to significant errors in assessing provider performance. Institutions should be cognizant of these potential sources of error, provide support to medical providers, and form collaborative data management teams to promote and improve meaningful use of EHRs. We propose actionable steps to improve the accuracy of EHR data query that require hypothesis testing and prospective validation in future studies.

Factors Associated With Utilization of Cardiac Rehabilitation Among Patients With Ischemic Heart Disease in the Veterans Health Administration: A QUALITATIVE STUDY

BACKGROUND

Cardiac rehabilitation (CR) programs reduce morbidity and mortality in patients with ischemic heart disease but are vastly underutilized in the United States, including the Veterans Health Administration (VA) Healthcare System. Numerous barriers affecting utilization have been identified in other health care systems, but the specific factors affecting Veterans are unknown. We sought to identify barriers and facilitators associated with utilization of CR in VA facilities.

METHODS

We performed a qualitative study of 56 VA patients, providers, and CR program managers at 30 VA facilities across the United States. We conducted semistructured interviews with key informants to explore their attitudes and knowledge toward CR. Interviews were conducted until thematic saturation occurred. Analyses using grounded theory to identify key themes were conducted using the qualitative data analysis package ATLAS.ti.

RESULTS

We identified 6 themes as barriers and 5 as facilitators. The most common barriers to participation in CR were patient transportation issues (68%), lack of patient willingness to participate (41%), and no access to a nearby VA hospital with a CR program (30%). The most common facilitators were involvement of a dedicated provider or "clinical champion" (50%), provider knowledge of or experience with CR (48%), and patient desire for additional medical support (32%).

CONCLUSIONS

Our findings suggest that addressing access issues and educating and activating providers on CR may increase utilization of CR programs. Targeting these specific factors may improve utilization of CR programs.

Quality of Care of the Initial Patient Cohort of the Diabetes Collaborative Registry®

BACKGROUND

Although guidelines and performance measures exist for patients with diabetes mellitus, achievement of these metrics is not well known. The Diabetes Collaborative Registry^® (DCR) was formed to understand the quality of diabetes mellitus care across the primary and specialty care continuum in the United States.

METHODS AND RESULTS

We assessed the frequency of achievement of 7 diabetes mellitus-related quality metrics and variability across the Diabetes Collaborative Registry^® sites. Among 574 972 patients with diabetes mellitus from 259 US practices, median (interquartile range) achievement of the quality metrics across the practices was the following: (1) glycemic control: 19% (5-47); (2) blood pressure control: 80% (67-88); (3) angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers in patients with coronary artery disease: 62% (51-69); (4) nephropathy screening: 62% (53-71); (5) eye examination: 0.7% (0.0-79); (6) foot examination: 0.0% (0.0-2.3); and (7) tobacco screening/cessation counseling: 86% (80-94). In hierarchical, modified Poisson regression models, there was substantial variability in meeting these metrics across sites, particularly with documentation of glycemic control and eye and foot examinations. There was also notable variation across specialties, with endocrinology practices performing better on glycemic control and diabetes mellitus foot examinations and cardiology practices succeeding more in blood pressure control and use of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers.

CONCLUSIONS

The Diabetes Collaborative Registry^® was established to document and improve the quality of outpatient diabetes mellitus care. While target achievement of some metrics of cardiovascular risk modification was high, achievement of others was suboptimal and highly variable. This may be attributable to fragmentation of care, lack of ownership among various specialists concerning certain domains of care, incomplete documentation, true gaps in care, or a combination of these factors.

Antianginal medications and long-term outcomes after elective catheterization in patients with coronary artery disease

BACKGROUND

Antianginal medications are a class I recommendation by the American College of Cardiology/American Heart Association guidelines for stable ischemic heart disease. We sought to better understand guidance in drug selection and real-life outcomes of antianginal medication use.

HYPOTHESIS

In patients with stable ischemic heart disease, antianginal medications lower mortality.

METHODS

We evaluated 5608 patients with obstructive coronary artery disease (CAD) on elective cardiac catheterization with follow-up through self-administered questionnaires. Patients were classified as being prescribed a particular medication if they received that medication at index catheterization, or within 3 months postcatheterization. The association between antianginal medication use and outcomes was evaluated using Cox proportional hazards models.

RESULTS

Compared with the 11% not prescribed any antianginal medication, patients prescribed antianginal medication were more likely to be older and female; have a history of hypertension, diabetes mellitus, peripheral vascular disease, or 3-vessel CAD; have lower adjusted mortality (hazard ratio [HR]: 0.75, 95% confidence interval [CI]: 0.63-0.89); and experience mortality or myocardial infarction (HR: 0.83, 95% CI: 0.71-0.98). Compared with patients not taking β-blockers (17%), those taking β-blockers had a lower risk of mortality (HR: 0.76, 95% CI: 0.66-0.88). Patients prescribed calcium channel blockers or long-acting nitrates had a higher risk of mortality compared with nonusers (HR: 1.16, 95% CI: 1.04-1.29; HR: 1.20, 95% CI: 1.08-1.34; respectively).

CONCLUSIONS

Antianginal medications are not universally prescribed among obstructive CAD patients; nonuse was associated with higher mortality. For CAD patients with or without prior myocardial infarction, β-blockers were associated with improved long-term survival.

Prevalence of unrecognized diabetes, prediabetes and metabolic syndrome in patients undergoing elective percutaneous coronary intervention

BACKGROUND

Diabetes mellitus (DM) and metabolic syndrome are important targets for secondary prevention in cardiovascular disease. However, the prevalence in patients undergoing elective percutaneous coronary intervention is not well defined. We aimed to analyse the prevalence and characteristics of patients undergoing percutaneous coronary intervention with previously unrecognized prediabetes, diabetes and metabolic syndrome.

METHODS

Data were collected from 740 patients undergoing elective percutaneous coronary intervention between November 2010 and March 2013 at a tertiary referral center. Prevalence of DM and prediabetes was evaluated using Haemoglobin A1c (A1c ≥ 6.5% for DM, A1c 5.7-6.4% for prediabetes). A modified definition was used for metabolic syndrome [three or more of the following criteria: body mass index ≥30 kg/m2; triglycerides ≥ 150 mg/dL; high density lipoprotein <40 mg/dL in men and <50 mg/dL in women; systolic blood pressure ≥ 130 mmHg and/or diastolic ≥ 85 mmHg; and A1c ≥ 5.7% or on therapy].

RESULTS

Mean age was 67 years, median body mass index was 28.2 kg/m(2) and 39% had known DM. Of those without known DM, 8.3% and 58.5% met A1c criteria for DM and for prediabetes at time of percutaneous coronary intervention. Overall, 54.9% met criteria for metabolic syndrome (69.2% of patients with DM and 45.8% of patients without DM).

CONCLUSION

Among patients undergoing elective percutaneous coronary intervention, a substantial number were identified with a new DM, prediabetes, and/or metabolic syndrome. Routine screening for an abnormal glucometabolic state at the time of revascularization may be useful for identifying patients who may benefit from additional targeting of modifiable risk factors.

Quality Markers in Cardiology. Main Markers to Measure Quality of Results (Outcomes) and Quality Measures Related to Better Results in Clinical Practice (Performance Metrics). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del Área del Corazón): A SEC/SECTCV Consensus Position Paper

Cardiology practice requires complex organization that impacts overall outcomes and may differ substantially among hospitals and communities. The aim of this consensus document is to define quality markers in cardiology, including markers to measure the quality of results (outcomes metrics) and quality measures related to better results in clinical practice (performance metrics). The document is mainly intended for the Spanish health care system and may serve as a basis for similar documents in other countries.

Variation in performance measure criteria significantly affects cardiology practice rankings: Insights from the National Cardiovascular Data Registry's Practice Innovation and Clinical Excellence Registry

BACKGROUND

Million Hearts is a national initiative to prevent 1 million heart attacks and strokes over 5 years by improving cardiovascular prevention. An important tool in the success of programs like Million Hearts is public ranking on the quality of practices, yet different measures may provide different rankings, so the true quality of practices is difficult to discern. We evaluated the quality of ambulatory cardiology care using performance measure metrics.

METHODS

We compared rankings of practices participating in the National Cardiovascular Data Registry's Practice Innovation and Clinical Excellence Registry using measures from (1) the physician quality reporting system and (2) the American College of Cardiology/American Heart Association/Physician Consortium for Performance Improvement. We compared achievement rates for measures between the 2 frameworks and determined correlations in rankings using Spearman correlation coefficients.

RESULTS

From January 1, 2008 to December 31, 2012, there were 1,711,326 patients enrolled from 111 US practices. Among eligible patients, the physician quality reporting system and American College of Cardiology/American Heart Association/Physician Consortium for Performance Improvement measures were achieved in 76.1% versus 77.4% for antiplatelet prescription (P < .001), 68.3% versus 90.8% for blood pressure control (P < .001), 26.9% versus 43.4% for cholesterol control (P < .001), and 37.4% versus 40.6% for smoking cessation (P = .383). Practice rankings were strongly correlated for antiplatelet prescription (correlation coefficient 0.98) and cholesterol control (0.92) but poorly correlated for blood pressure control (0.39) and smoking cessation (0.22).

CONCLUSIONS

Evaluation of preventive care and individual practice rankings vary significantly depending on how measures are defined. Publicly reported measures need to be validly associated with outcomes to avoid incorrectly evaluating practice performance and failing to achieve public health goals.

Hospital-level variation in angina and mortality at 1 year after myocardial infarction: insights from the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH) Registry

BACKGROUND

Despite calls to expand measurement of acute myocardial infarction (AMI) outcomes to include symptom burden, little has been done to describe hospital-level variation in this patient-centered outcome, or its association with mortality. Understanding the relationship between symptoms and longer-term mortality could inform the importance of these outcomes for monitoring quality of care.

METHODS AND RESULTS

Among 4316 patients with AMI treated at 24 hospitals participating in the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH) study, we assessed risk-standardized 1-year symptom burden as measured by the Seattle Angina Questionnaire Angina Frequency Score and mortality attributed to the hospital that provided AMI care. Median odds ratios were used to assess outcome variation and reflect the relative odds of an outcome for 2 patients with identical covariates at different, randomly selected, hospitals. We then evaluated the correlation between hospital-level mortality and angina. Finally, we determined the extent to which variation in mortality and angina was explained by achievement of AMI performance measures. We observed hospital variation in risk-adjusted 1-year mortality (range, 4.9%-8.6%; median odds ratio, 1.30; P=0.01) and angina (range, 17.7%-29.4%; median odds ratio, 1.34; P<0.001). At the hospital level, mortality and angina at 1 year were weakly correlated (r=0.40; 95% confidence interval, 0.00-0.68; P=0.05). Accounting for the quality of AMI care did not attenuate variation in risk-adjusted 1-year mortality or angina.

CONCLUSIONS

Symptom burden and mortality vary at the hospital level after AMI and are only weakly correlated. These findings suggest that symptom burden should be considered a separate quality domain that is not well captured by current quality metrics.

Achievement of optimal medical therapy goals for U.S. adults with coronary artery disease: results from the REGARDS Study (REasons for Geographic And Racial Differences in Stroke)

OBJECTIVES

In a nonclinical trial setting, we sought to determine the proportion of individuals with coronary artery disease (CAD) with optimal risk factor levels based on the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive DruG Evaluation) trial.

BACKGROUND

In the COURAGE trial, the addition of percutaneous coronary intervention (PCI) to optimal medical therapy did not reduce the risk of death or myocardial infarction in stable CAD patients but resulted in more revascularization procedures.

METHODS

The REGARDS (REasons for Geographic And Racial Differences in Stroke) study is a national prospective cohort study of 30,239 African-American and white community-dwelling individuals older than 45 years of age who enrolled in 2003 through 2007. We calculated the proportion of 3,167 participants with self-reported CAD meeting 7 risk factor goals based on the COURAGE trial: 1) aspirin use; 2) systolic blood pressure <130 mm Hg and diastolic blood pressure <85 mm Hg (<80 mm Hg if diabetic); 3) low-density lipoprotein cholesterol <85 mg/dl, high-density lipoprotein cholesterol >40 mg/dl, and triglycerides <150 mg/dl; 4) fasting glucose <126 mg/dl; 5) nonsmoking status; 6) body mass index <25 kg/m(2); and 7) exercise ≥4 days per week.

RESULTS

The mean age of participants was 69 ± 9 years; 33% were African American and 35% were female. Overall, the median number of goals met was 4. Less than one-fourth met ≥5 of the 7 goals, and 16% met all 3 goals for aspirin, blood pressure, and low-density lipoprotein cholesterol. Older age, white race, higher income, more education, and higher physical functioning were independently associated with meeting more goals.

CONCLUSIONS

There is substantial room for improvement in risk factor reduction among U.S. individuals with CAD.

CHRNA5 variant predicts smoking cessation in patients with acute myocardial infarction

INTRODUCTION

While smoking is a major modifiable risk factor for secondary prevention of myocardial infarction (MI), active smoking is common among patients hospitalized with acute MI. Recent studies suggest that nicotinic receptor variants, and specifically the high-risk CHRNA5 rs16969968 A allele, are associated with cessation failure among noncardiac patients. This study investigates the association between CHRNA5 rs16969968 and smoking cessation in patients hospitalized with acute MI.

METHODS

Using data from the TRIUMPH study, we ascertained smoking status at the time of index hospitalization for acute MI and 1 year after hospitalization. After adjusting for age and sex, we used logistic regression to model the association between smoking cessation and CHRNA5 rs16969968.

RESULTS

At index admission, 752 Caucasian subjects were active smokers and 699 were former smokers. Among these ever-smokers, the A allele was associated with significantly decreased abstinence (45.0% abstinence for A allele carriers vs. 51.7% for GG homozygotes; odds ratio [OR] = 0.70, 95% confidence interval [CI] = 0.56-0.88, p = .0027). The A allele was also significantly associated with decreased abstinence at 1 year (69.1% abstinence for A allele carriers vs. 76.0% for GG homozygotes; OR = 0.70, 95% CI = 0.53-0.94, p = .0185).

CONCLUSIONS

Among patients who have smoked and who are hospitalized with acute MI, the high-risk CHRNA5 allele was associated with lower likelihood of quitting before hospitalization and significantly less abstinence 1 year after hospitalization with MI. The CHRNA5 rs16969968 genotype may therefore identify patients who would benefit from aggressive, personalized smoking cessation intervention.

Therapeutic interventions to reduce the risk of progression from prediabetes to type 2 diabetes mellitus

Clinical trials have demonstrated that it is possible to prevent diabetes through lifestyle modification, pharmacological intervention, and surgery. This review aims to summarize the effectiveness of these various therapeutic interventions in reducing the risk of progression of prediabetes to diabetes, and address the challenges to implement a diabetes prevention program at a community level. Strategies focusing on intensive lifestyle changes are not only efficient but cost-effective and/or cost-saving. Indeed, lifestyle intervention in people at high risk for type 2 diabetes mellitus (T2DM) has been successful in achieving sustained behavioral changes and a reduction in diabetes incidence even after the counseling is stopped. Although prediabetes is associated with health and economic burdens, it has not been adequately addressed by interventions or regulatory agencies in terms of prevention or disease management. Lifestyle intervention strategies to prevent T2DM should be distinct for different populations around the globe and should emphasize sex, age, ethnicity, and cultural and geographical considerations to be feasible and to promote better compliance. The translation of diabetes prevention research at a population level, especially finding the most effective methods of preventing T2DM in various societies and cultural settings remains challenging, but must be accomplished to stop this worldwide epidemic.

Variations in coronary artery disease secondary prevention prescriptions among outpatient cardiology practices: insights from the NCDR (National Cardiovascular Data Registry)

OBJECTIVES

This study assessed practice variations in secondary prevention medication prescriptions among coronary artery disease (CAD) patients treated in outpatient practices participating in the National Cardiovascular Data Registry (NCDR) Practice Innovation and Clinical Excellence (PINNACLE) registry.

BACKGROUND

Among patients with CAD, secondary prevention with a combination of beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and statins reduces cardiac mortality and myocardial infarction (MI). Accordingly, every CAD patient should receive the combination of these medications for which they are eligible. However, little is known about current prescription patterns of these medications and the variation in use among outpatient cardiology clinics.

METHODS

Using data from NCDR PINNACLE registry, a national outpatient cardiology practice registry, we assessed medication prescription patterns among eligible CAD patients, between July 2008 and December 2010. Overall rates of prescription and variation by practice were calculated, adjusting for patient characteristics.

RESULTS

Among 156,145 CAD patients in 58 practices, 103,830 (66.5%) patients were prescribed the optimal combination of medications for which they were eligible. The median rate of optimal combined prescription by practice was 73.5% and varied from 28.8% to 100%. After adjustment for patient factors, the practice median rate ratio for prescription was 1.25 (95% confidence interval: 1.20 to 1.32), indicating a 25% likelihood that 2 random practices would differ in treating identical CAD patients.

CONCLUSIONS

Among a national registry of CAD patients treated in outpatient cardiology practices, over one-third of patients failed to receive their optimal combination of secondary prevention medications. Significant variation was observed across practices, even after adjusting for patient characteristics, suggesting that quality improvement efforts may be needed to support more uniform practice.

Residual dyslipidemia among United States adults treated with lipid modifying therapy (data from National Health and Nutrition Examination Survey 2009-2010)

Despite available medications for dyslipidemia, many treated patients still have suboptimal lipid levels. The aim of this study was to examine the extent of residual dyslipidemia in United States adults. Of 2509 United States adults aged ≥18 years from the National Health and Nutrition Examination Survey (NHANES) 2009-2010, 1,129 (41.8% weighted) had hyperlipidemia on the basis of modified treatment guidelines for low-density lipoprotein (LDL) cholesterol according to risk category or pharmacologic treatment. Of these, 484 (42.4%) were treated with lipid-modifying therapy, and the proportions of subjects who still had LDL cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides, or non-HDL cholesterol not at recommended levels were examined. In this cohort treated for hyperlipidemia, the mean age was 60.1 ± 14.9 years, and 52% were men. Only 36.5% of subjects receiving treatment for hyperlipidemia were at goal or normal levels for all 3 lipids (LDL cholesterol, HDL cholesterol, and triglycerides). LDL cholesterol remained higher than goal for 37.5% of subjects, 28.9% had low HDL cholesterol, and 36.3% had elevated triglycerides. One, 2, and 3 lipid parameters were at abnormal levels in 32.4%, 23.0%, and 8.2% of subjects, respectively; 36.5% had no lipid disorder. In addition, 38.6% of treated subjects were above non-HDL cholesterol goal, and even in those at LDL cholesterol goal, 12.9% were not at non-HDL cholesterol goal. Those with cardiovascular disease conditions had poorer goal attainment of LDL cholesterol, HDL cholesterol, and composite all lipids than those without cardiovascular disease. In conclusion, despite widely available treatments for dyslipidemia, many patients remain at suboptimal lipid levels, indicating need for greater adherence to lifestyle and medical therapies to address these gaps in the management of dyslipidemia.

A novel risk classification paradigm for patients with impaired glucose tolerance and high cardiovascular risk

We used baseline data from the NAVIGATOR trial to (1) identify risk factors for diabetes progression in those with impaired glucose tolerance and high cardiovascular risk, (2) create models predicting 5-year incident diabetes, and (3) provide risk classification tools to guide clinical interventions. Multivariate Cox proportional hazards models estimated 5-year incident diabetes risk and simplified models examined the relative importance of measures of glycemia in assessing diabetes risk. The C-statistic was used to compare models; reclassification analyses compare the models' ability to identify risk groups defined by potential therapies (routine or intensive lifestyle advice or pharmacologic therapy). Diabetes developed in 3,254 (35%) participants over 5 years median follow-up. The full prediction model included fasting and 2-hour glucose and hemoglobin A1c (HbA1c) values but demonstrated only moderate discrimination for diabetes (C = 0.70). Simplified models with only fasting glucose (C = 0.67) or oral glucose tolerance test values (C = 0.68) had higher C statistics than models with HbA1c alone (C = 0.63). The models were unlikely to inappropriately reclassify participants to risk groups that might receive pharmacologic therapy. Our results confirm that in a population with dysglycemia and high cardiovascular risk, traditional risk factors are appropriate predictors and glucose values are better predictors than HbA1c, but discrimination is moderate at best, illustrating the challenges of predicting diabetes in a high-risk population. In conclusion, our novel risk classification paradigm based on potential treatment could be used to guide clinical practice based on cost and availability of screening tests.

Real incidence of diabetes mellitus in a coronary disease population

The high prevalence of unknown diabetes mellitus (DM) in patients with coronary disease and that the oral glucose tolerance test (OGTT) is the best diagnostic method in this context are well known. However, data about the incidence of DM in this population have not been well described. In the present study, we sought to determine the actual incidence of new-onset DM in patients with coronary disease using the OGTT. Our secondary objective was to validate a predictive model. We studied a series of 338 patients with coronary disease without known DM using the OGTT. After the OGTT, the patients were reclassified as normoglycemic, prediabetic, and unknown DM, according to the American Diabetes Association 2010 criteria. After 3 years of follow-up, the patients without DM were again reassessed using the OGTT. We then built a predictive model using the multivariate logistic regression method and validated it using the leave-one-out method. The final sample was 191 patients. The mean follow-up was 3.13 years. The overall incidence of DM was 43.6 cases/1,000 person-years (95% confidence interval [CI] 26.8 to 60.4). The incidence was significantly different between the initially normoglycemic patients (11.5%, 95% CI 2.3% to 31.8%) and the prediabetic patients (70.5%, 95% CI 42.7% to 98.3%; p <0.001). A risk model that included the glucose level 2 hours after challenge, glycosylated hemoglobin and triglyceride levels, and presence of noncoronary vascular disease showed good predictive capacity for incident DM (area under the curve 0.882, 95% CI 0.819 to 0.946; p <0.0001). In conclusion, the real incidence of new DM is very high in the coronary population, especially in those with prediabetes. It is necessary to use the OGTT for diagnosis, but we can optimize its indication using a risk model.

Assessing appropriateness of lipid management among patients with diabetes mellitus: moving from target to treatment

BACKGROUND

Performance measures that emphasize only a treat-to-target approach may motivate overtreatment with high-dose statins, potentially leading to adverse events and unnecessary costs. We developed a clinical action performance measure for lipid management in patients with diabetes mellitus that is designed to encourage appropriate treatment with moderate-dose statins while minimizing overtreatment.

METHODS AND RESULTS

We examined data from July 2010 to June 2011 for 964 818 active Veterans Affairs primary care patients ≥18 years of age with diabetes mellitus. We defined 3 conditions as successfully meeting the clinical action measure for patients 50 to 75 years old: (1) having a low-density lipoprotein (LDL) <100 mg/dL, (2) taking a moderate-dose statin regardless of LDL level or measurement, or (3) receiving appropriate clinical action (starting, switching, or intensifying statin therapy) if LDL is ≥100 mg/dL. We examined possible overtreatment for patients ≥18 years of age by examining the proportion of patients without ischemic heart disease who were on a high-dose statin. We then examined variability in measure attainment across 881 facilities using 2-level hierarchical multivariable logistic models. Of 668 209 patients with diabetes mellitus who were 50 to 75 years of age, 84.6% passed the clinical action measure: 67.2% with LDL <100 mg/dL, 13.0% with LDL ≥100 mg/dL and either on a moderate-dose statin (7.5%) or with appropriate clinical action (5.5%), and 4.4% with no index LDL on at least a moderate-dose statin. Of the entire cohort ≥18 years of age, 13.7% were potentially overtreated. Facilities with higher rates of meeting the current threshold measure (LDL <100 mg/dL) had higher rates of potential overtreatment (P<0.001).

CONCLUSIONS

Use of a performance measure that credits appropriate clinical action indicates that almost 85% of diabetic veterans 50 to 75 years of age are receiving appropriate dyslipidemia management. However, many patients are potentially overtreated with high-dose statins.

Olmesartan/amlodipine/hydrochlorothiazide in participants with hypertension and diabetes, chronic kidney disease, or chronic cardiovascular disease: a subanalysis of the multicenter, randomized, double-blind, parallel-group TRINITY study

BACKGROUND

Patients with hypertension and cardiovascular disease (CVD), diabetes, or chronic kidney disease (CKD) usually require two or more antihypertensive agents to achieve blood pressure (BP) goals.

METHODS

The efficacy/safety of olmesartan (OM) 40 mg, amlodipine besylate (AML) 10 mg, and hydrochlorothiazide (HCTZ) 25 mg versus the component dual-combinations (OM 40/AML 10 mg, OM 40/HCTZ 25 mg, and AML 10/HCTZ 25 mg) was evaluated in participants with diabetes, CKD, or chronic CVD in the Triple Therapy with Olmesartan Medoxomil, Amlodipine, and Hydrochlorothiazide in Hypertensive Patients Study (TRINITY). The primary efficacy end point was least squares (LS) mean reduction from baseline in seated diastolic BP (SeDBP) at week 12. Secondary end points included LS mean reduction in SeSBP and proportion of participants achieving BP goal (<130/80 mm Hg) at week 12 (double-blind randomized period), and LS mean reduction in SeBP and BP goal achievement at week 52/early termination (open-label period).

RESULTS

At week 12, OM 40/AML 10/HCTZ 25 mg resulted in significantly greater SeBP reductions in participants with diabetes (-37.9/22.0 mm Hg vs -28.0/17.6 mm Hg for OM 40/AML 10 mg, -26.4/14.7 mm Hg for OM 40/HCTZ 25 mg, and -27.6/14.8 mm Hg for AML 10/HCTZ 25 mg), CKD (-44.3/25.5 mm Hg vs -39.5/23.8 mm Hg for OM 40/AML 10 mg, -25.3/17.0 mm Hg for OM 40/HCTZ 25 mg, and -33.4/20.6 mm Hg for AML 10/HCTZ 25 mg), and chronic CVD (-37.8/20.6 mm Hg vs -31.7/18.2 mm Hg for OM 40/AML 10 mg, -30.9/17.1 mm Hg for OM 40/HCTZ 25 mg, and -27.5/16.1 mm Hg for AML 10/HCTZ 25 mg) (P<0.05 for all subgroups vs dual-component treatments). BP goal achievement was greater for participants receiving triple-combination treatment compared with the dual-combination treatments, and was achieved in 41.1%, 55.0%, and 38.9% of participants with diabetes, CKD, and chronic CVD on OM 40/AML 10/HCTZ 25 mg, respectively. At week 52, there was sustained BP lowering with the OM/AML/HCTZ regimen. Overall, the triple combination was well tolerated.

CONCLUSIONS

In patients with diabetes, CKD, or chronic CVD, short-term (12 weeks) and long-term treatment with OM 40/AML 10/HCTZ 25 mg was well tolerated, lowered BP more effectively, and enabled more participants to reach BP goal than the corresponding 2-component regimens. TRIAL IDENTIFICATION NUMBER: NCT00649389.

Monitoring performance for blood pressure management among patients with diabetes mellitus: too much of a good thing?

BACKGROUND

Performance measures that reward achieving blood pressure (BP) thresholds may contribute to overtreatment. We developed a tightly linked clinical action measure designed to encourage appropriate medical management and a marker of potential overtreatment, designed to monitor overly aggressive treatment of hypertension in the face of low diastolic BP.

METHODS

We conducted a retrospective cohort study in 879 Department of Veterans Affairs (VA) medical centers and smaller community-based outpatient clinics. The clinical action measure for hypertension was met if the patient had a passing index BP at the visit or had an appropriate action. We examined the rate of passing the action measure and of potential overtreatment in the Veterans Health Administration during 2009-2010.

RESULTS

There were 977,282 established VA patients, 18 years and older, with diabetes mellitus (DM). A total of 713,790 patients were eligible for the action measure; 94% passed the measure (82% because they had a BP <140/90 mm Hg at the visit and an additional 12% with a BP ≥140/90 mm Hg and appropriate clinical actions). Facility pass rates varied from 77% to 99% (P < .001). Among all patients with DM, 197,291 (20%) had a BP lower than 130/65 mm Hg; of these, 80 903 (8% of all patients with DM) had potential overtreatment. Facility rates of potential overtreatment varied from 3% to 20% (P < .001). Facilities with higher rates of meeting the current threshold measure (<140/90 mm Hg) had higher rates of potential overtreatment (P < .001).

CONCLUSIONS

While 94% of diabetic veterans met the action measure, rates of potential overtreatment are currently approaching the rate of undertreatment, and high rates of achieving current threshold measures are directly associated with overtreatment. Implementing a clinical action measure for hypertension management, as the Veterans Health Administration is planning to do, may result in more appropriate care and less overtreatment.

Management of hypertension in women

A gender-specific approach to cardiovascular (CV) diseases has been practiced for decades, although not always to the advantage of women. Based on population data showing that women are at lower risk for CV events than men female gender has generally been regarded as a protective factor for CV disease. Unfortunately, CV risk assessment has therefore received less attention in women. Despite the lower absolute risk of CV events in women compared with age-matched men, the majority of women die from CV diseases. In absolute numbers, since 1984, more women than men died of CV disease each year. Most CV events occur in women with known traditional CV risk factors. Improving risk factor management in women of all ages therefore yields an enormous potential to reduce CV morbidity and mortality in the population. Aside from smoking cessation, hypertension (HTN) control is the single most important intervention to reduce the risk of future CV events in women. This review highlights peculiarities of HTN as they pertain to women, and points out where diagnosis and management of HTN may require a gender-specific focus.