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Damluji AA, Nanna MG, Rymer J, Kochar A, Lowenstern A, Baron SJ, Narins CR, Alkhouli M. Chronological vs Biological Age in Interventional Cardiology: A Comprehensive Approach to Care for Older Adults: JACC Family Series. JACC Cardiovasc Interv 2024; 17:961-978. [PMID: 38597844 DOI: 10.1016/j.jcin.2024.01.284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 01/18/2024] [Accepted: 01/23/2024] [Indexed: 04/11/2024]
Abstract
Aging is the gradual decline in physical and physiological functioning leading to increased susceptibility to stressors and chronic illnesses, including cardiovascular disease. With an aging global population, in which 1 in 6 individuals will be older than 60 years by 2030, interventional cardiologists are increasingly involved in providing complex care for older individuals. Although procedural aspects remain their main clinical focus, interventionalists frequently encounter age-associated risks that influence eligibility for invasive care, decision making during the intervention, procedural adverse events, and long-term management decisions. The unprecedented growth in transcatheter interventions, especially for structural heart diseases at extremes of age, have pushed age-related risks and implications for cardiovascular care to the forefront. In this JACC state-of-the-art review, the authors provide a comprehensive overview of the aging process as it relates to cardiovascular interventions, with special emphasis on the difference between chronological and biological aging. The authors also address key considerations to improve health outcomes for older patients during and after their invasive cardiovascular care. The role of "gerotherapeutics" in interventional cardiology, technological innovation in measuring biological aging, and the integration of patient-centered outcomes in the older adult population are also discussed.
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Affiliation(s)
- Abdulla A Damluji
- Inova Center of Outcomes Research, Fairfax, Virginia, USA; Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael G Nanna
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jennifer Rymer
- Duke University School of Medicine, Durham, North Carolina USA
| | - Ajar Kochar
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Alder MR, Adamek KE, Lowenstern A, Raj LM, Lindley KJ, Sutton NR. Acute Coronary Syndrome in Women: An Update. Curr Cardiol Rep 2024:10.1007/s11886-024-02033-6. [PMID: 38466532 DOI: 10.1007/s11886-024-02033-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/26/2024] [Indexed: 03/13/2024]
Abstract
PURPOSE OF REVIEW The goal of this manuscript is to provide a concise summary of recent developments in the approach to and treatment of women with acute coronary syndrome (ACS). RECENT FINDINGS This review covers terminology updates relating to ACS and myocardial injury and infarction. Updates on disparities in recognition, treatments, and outcomes of women with ACS due to atherosclerotic coronary artery disease are covered. Other causes of ACS, including spontaneous coronary artery dissection and myocardial infarction with non-obstructive coronary artery disease are discussed, given the increased frequency in women compared with men. The review summarizes the latest on the unique circumstance of ACS in women who are pregnant or post-partum, including etiologies, diagnostic approaches, medication safety, and revascularization considerations. Compared with men, women with ACS have unique risk factors, presentations, and pathophysiology. Treatments known to be effective for men with atherosclerosis-related ACS are also effective for women; further work remains on reducing the disparities in diagnosis and treatment. Implementation of multimodality imaging will improve diagnostic accuracy and allow for targeted medical therapy in the setting of myocardial infarction with non-obstructive coronary artery disease.
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Affiliation(s)
- Madeleine R Alder
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kylie E Adamek
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Angela Lowenstern
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Leah M Raj
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kathryn J Lindley
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nadia R Sutton
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA.
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Park DY, Simonato M, Ahmad Y, Banks AZ, Lowenstern A, Nanna MG. Insight Into the Optimal Timing of Percutaneous Coronary Intervention and Transcatheter Aortic Valve Replacement. Curr Probl Cardiol 2024; 49:102050. [PMID: 37643698 PMCID: PMC10924682 DOI: 10.1016/j.cpcardiol.2023.102050] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 08/23/2023] [Indexed: 08/31/2023]
Abstract
Patients being considered for transcatheter aortic valve replacement (TAVR) are frequently diagnosed with coronary artery disease. In patients requiring revascularization, there is a paucity of data informing when to perform percutaneous coronary artery intervention (PCI). We evaluated the impact of PCI timing on clinical outcomes and readmissions after TAVR. From the National Readmissions Database 2016 to 2019, we stratified the duration between PCI and TAVR into 3 groups: same-day PCI and TAVR, TAVR ≤30 days after PCI, and TAVR >30 days after PCI. We then compared primary and secondary outcomes among them. A total of 5207 patients were included, 1413 (27.1%) of whom underwent PCI and TAVR on the same day, while 2161 (41.5%) underwent TAVR ≤30 days after PCI, and 1632 (31.3%) underwent TAVR >30 days after PCI. There was no significant difference for in-hospital mortality among the groups (adjusted odds ratio [aOR] 0.49, 95% confidence interval [CI] 0.16-1.48, p = 0.203 for same-day versus ≤30 days; aOR 2.07, 95% CI 0.68-6.30, p = 0.199 for same-day versus >30 days). Patients who underwent TAVR ≤30 days after PCI had higher odds of acute kidney injury (aOR 1.49, 95% CI 1.05-2.10, p = 0.024), nonhome discharge (aOR 1.53, 95% CI 1.20-1.96, p = 0.001), and 90-day readmission (aOR 1.35, 95% CI 1.04-1.76, p = 0.026) compared with those who underwent same-day PCI and TAVR. Concomitant PCI and TAVR was associated with lower rates of 90-day readmissions and acute kidney injury compared with TAVR shortly after PCI (<30 days) and should be considered in select patients.
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Affiliation(s)
- Dae Yong Park
- Department of Medicine, Cook County Health, Chicago, IL
| | | | - Yousif Ahmad
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | - Adam Z Banks
- Division of Cardiology, Presbyterian Hospital, Albuquerque, NM
| | - Angela Lowenstern
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT.
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Park DY, Jamil Y, Hu JR, Lowenstern A, Frampton J, Abdullah A, Damluji AA, Ahmad Y, Soufer R, Nanna MG. Delirium in older adults after percutaneous coronary intervention: Prevalence, risks, and clinical phenotypes. Cardiovasc Revasc Med 2023; 57:60-67. [PMID: 37414611 PMCID: PMC10730763 DOI: 10.1016/j.carrev.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/02/2023] [Accepted: 06/13/2023] [Indexed: 07/08/2023]
Abstract
INTRODUCTION In-hospital delirium is more common among older adults and is associated with increased mortality and adverse health-related outcomes. We aim to establish the contemporary prevalence of delirium among older adults undergoing percutaneous coronary intervention (PCI) and the impact of delirium on in-hospital complications. METHODS We identified older adults aged ≥75 years in the National Inpatient Sample who underwent inpatient PCI for any reason from 2016 to 2020 and stratified them into those with and without delirium. The primary outcome was in-hospital mortality, and secondary outcomes encompassed post-procedural complications. RESULTS Delirium occurred in 14,130 (2.6 %) hospitalizations in which PCI was performed. Patients who developed delirium were older and had more comorbidities. Patients with in-hospital delirium had higher odds of in-hospital mortality (adjusted odds ratio [aOR] 1.27, p = 0.002) and non-home discharge (aOR 3.17, p < 0.001). Delirium was also associated with higher odds of intracranial hemorrhage (aOR 2.49, p < 0.001), gastrointestinal hemorrhage (aOR 1.25, p = 0.030), need for blood transfusion (aOR 1.52, p < 0.001), acute kidney injury (aOR 1.62, p < 0.001), and fall in hospital (aOR 1.97, p < 0.001). CONCLUSION Delirium among older adults undergoing PCI is relatively common and associated with higher odds of in-hospital mortality and adverse events. This highlights the importance of vigilant delirium prevention and early recognition in the peri-procedural setting, especially for older adults.
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Affiliation(s)
- Dae Yong Park
- Department of Medicine, Cook County Health, Chicago, IL, USA
| | - Yasser Jamil
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jiun-Ruey Hu
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Angela Lowenstern
- Section of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jennifer Frampton
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Ahmed Abdullah
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Abdulla A Damluji
- Johns Hopkins University School of Medicine, Baltimore, MD, USA; Inova Center of Outcomes Research, Falls Church, VA, USA
| | - Yousif Ahmad
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Robert Soufer
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA; Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA; Department of Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA.
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Lowenstern A, Ng N, Takagi H, Rymer JA, Koweek LM, Douglas PS, Duran JM, Rabbat M, Pontone G, Fairbairn T, Chinnaiyan K, Berman DS, De Bruyne B, Bax JJ, Akasaka T, Amano T, Nieman K, Rogers C, Kitabata H, Sand NPR, Kawasaki T, Mullen S, Matsuo H, Norgaard BL, Patel MR, Leipsic J, Daubert MA. Influence of Obesity on Coronary Artery Disease and Clinical Outcomes in the ADVANCE Registry. Circ Cardiovasc Imaging 2023; 16:e014850. [PMID: 37192296 DOI: 10.1161/circimaging.122.014850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 04/11/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND The relationship between body size and cardiovascular events is complex. This study utilized the ADVANCE (Assessing Diagnostic Value of Noninvasive FFRCT in Coronary Care) Registry to investigate the association between body mass index (BMI), coronary artery disease (CAD), and clinical outcomes. METHODS The ADVANCE registry enrolled patients undergoing evaluation for clinically suspected CAD who had >30% stenosis on cardiac computed tomography angiography. Patients were stratified by BMI: normal <25 kg/m2, overweight 25-29.9 kg/m2, and obese ≥30 kg/m2. Baseline characteristics, cardiac computed tomography angiography and computed tomography fractional flow reserve (FFRCT), were compared across BMI groups. Adjusted Cox proportional hazards models assessed the association between BMI and outcomes. RESULTS Among 5014 patients, 2166 (43.2%) had a normal BMI, 1883 (37.6%) were overweight, and 965 (19.2%) were obese. Patients with obesity were younger and more likely to have comorbidities, including diabetes and hypertension (all P<0.001), but were less likely to have obstructive coronary stenosis (65.2% obese, 72.2% overweight, and 73.2% normal BMI; P<0.001). However, the rate of hemodynamic significance, as indicated by a positive FFRCT, was similar across BMI categories (63.4% obese, 66.1% overweight, and 67.8% normal BMI; P=0.07). Additionally, patients with obesity had a lower coronary volume-to-myocardial mass ratio compared with patients who were overweight or had normal BMI (obese BMI, 23.7; overweight BMI, 24.8; and normal BMI, 26.3; P<0.001). After adjustment, the risk of major adverse cardiovascular events was similar regardless of BMI (all P>0.05). CONCLUSIONS Patients with obesity in the ADVANCE registry were less likely to have anatomically obstructive CAD by cardiac computed tomography angiography but had a similar degree of physiologically significant CAD by FFRCT and similar rates of adverse events. An exclusively anatomic assessment of CAD in patients with obesity may underestimate the burden of physiologically significant disease that is potentially due to a significantly lower volume-to-myocardial mass ratio.
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Affiliation(s)
| | - Nicholas Ng
- HeartFlow, Redwood City, CA (N.N., C.R., S.M., J.L.)
| | | | - Jennifer A Rymer
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (J.A.R., L.M.K., P.S.D., J. M. D., M.R.P., M.A.D.)
| | - Lynne M Koweek
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (J.A.R., L.M.K., P.S.D., J. M. D., M.R.P., M.A.D.)
| | - Pamela S Douglas
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (J.A.R., L.M.K., P.S.D., J. M. D., M.R.P., M.A.D.)
| | - Jessica M Duran
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (J.A.R., L.M.K., P.S.D., J. M. D., M.R.P., M.A.D.)
| | - Mark Rabbat
- Loyola University Medical Center, Maywood, IL (M.R.)
| | | | | | | | | | | | - Jeroen J Bax
- Leiden University Medical Center, the Netherlands (J.J.B.)
| | | | | | | | | | | | - Niels P R Sand
- University of Southern Denmark, Odense, Denmark (N.P.R.S.)
| | | | - Sarah Mullen
- HeartFlow, Redwood City, CA (N.N., C.R., S.M., J.L.)
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Japan (H.M.)
| | | | - Manesh R Patel
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (J.A.R., L.M.K., P.S.D., J. M. D., M.R.P., M.A.D.)
| | - Jonathan Leipsic
- HeartFlow, Redwood City, CA (N.N., C.R., S.M., J.L.)
- Department of Radiology, University of British Columbia, Vancouver, Canada (J.L.)
| | - Melissa A Daubert
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (J.A.R., L.M.K., P.S.D., J. M. D., M.R.P., M.A.D.)
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Ibrahim H, Lowenstern A, Goldsweig AM, Rao SV. Integrating Structural Heart Disease Trainees within the Dynamics of the Heart Team: The Case for Multimodality Training. Struct Heart 2023; 7:100167. [PMID: 37273858 PMCID: PMC10236781 DOI: 10.1016/j.shj.2023.100167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 02/02/2023] [Indexed: 06/06/2023]
Abstract
Structural heart disease is a rapidly evolving field. However, training in structural heart disease is still widely variable and has not been standardized. Furthermore, integration of trainees within the heart team has not been fully defined. In this review, we discuss the components and function of the heart team, the challenges of current structural heart disease models, and possible solutions and suggestions for integrating trainees within the heart team.
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Affiliation(s)
- Homam Ibrahim
- NYU Grossman School of Medicine, NYU Langone Health, New York, New York, USA
| | - Angela Lowenstern
- Division of Cardiology, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Andrew M. Goldsweig
- Baystate Medical Center and University of Massachusetts-Baystate, Springfield, Massachusetts, USA
| | - Sunil V. Rao
- NYU Grossman School of Medicine, NYU Langone Health, New York, New York, USA
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Park DY, Sana MK, Shoura S, Hammo H, Hu JR, Forrest JK, Lowenstern A, Cleman M, Ahmad Y, Nanna MG. Readmission and In-Hospital Outcomes After Transcatheter Aortic Valve Replacement in Patients With Dementia. Cardiovasc Revasc Med 2023; 46:70-77. [PMID: 35973922 PMCID: PMC10940024 DOI: 10.1016/j.carrev.2022.08.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 08/10/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND/PURPOSE The prevalence of dementia and aortic stenosis (AS) increases with each decade of age. Transcatheter aortic valve replacement (TAVR) is a definitive treatment for AS, but there are scarce data on morbidity, mortality, and readmission risk after TAVR in patients with dementia. METHODS/MATERIALS We identified all admissions for TAVR in patients with AS in the National Readmissions Database in 2017-2018 and stratified them according to the presence or absence of a secondary diagnosis of dementia. Inpatient outcomes were compared using logistic regression. Cox proportional-hazards models were used to compare 30-, 60-, and 90-day readmissions. RESULTS A total of 48,923 index hospitalizations for TAVR were identified, of which 2192 (4.5 %) had a secondary diagnosis of dementia. Presence of dementia was associated with higher odds of delirium, pacemaker placement, acute kidney injury, and fall in hospital. The hazard of 30-day readmission was not significantly different between patients with and without dementia, but patients with dementia experienced a higher hazard of 60-day readmission (HR 1.15, 95 % CI 1.03-1.26, p = 0.011) in the unadjusted model and higher hazard of 90-day readmission in both unadjusted (HR 1.18, 95 % CI 1.08-1.30, p < 0.001) and adjusted models (aHR 1.14, 95 % CI 1.04-1.25, p = 0.004). CONCLUSIONS Patients with dementia who undergo TAVR are at higher risk of in-hospital adverse outcomes and 60- and 90-day readmissions compared with patients without dementia. These estimates should be integrated into shared decision-making discussions with patients and families.
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Affiliation(s)
- Dae Yong Park
- Department of Medicine, Cook County Health, Chicago, IL, USA
| | | | - Sami Shoura
- Department of Medicine, Cook County Health, Chicago, IL, USA
| | - Hasan Hammo
- Department of Medicine, Cook County Health, Chicago, IL, USA
| | - Jiun-Ruey Hu
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - John K Forrest
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Angela Lowenstern
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael Cleman
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Yousif Ahmad
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA.
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Lowenstern A, Hung A, Manandhar P, Wegermann ZK, Kapadia SR, Lindman BR, Goel K, Levack M, Barker CM, Reed SD, Cohen DJ, Vemulapalli S. Association of Transcatheter Aortic Valve Replacement Reimbursement, New Technology Add-on Payment, and Procedure Volumes With Embolic Protection Device Use. JAMA Cardiol 2022; 7:945-952. [PMID: 35976635 PMCID: PMC9386613 DOI: 10.1001/jamacardio.2022.2608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 06/01/2022] [Indexed: 11/14/2022]
Abstract
Importance In the setting of uncertain efficacy and additional, unreimbursed cost, use of an embolic protection device (EPD) during transcatheter aortic valve replacement (TAVR) has had variable uptake. The Centers for Medicare & Medicaid Services (CMS) instituted a new technology add-on payment to cover EPD use in October 2018. Objective To evaluate the association between CMS TAVR reimbursement rates and EPD use. Design, Setting, and Participants This cohort study used the Society for Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy registry to identify patients who underwent TAVR between January 2018 and September 2019. Analysis took place between July 2020 and February 2022. Main Outcomes and Measures The association between EPD use and CMS reimbursement was assessed using multivariable logistic regression models adjusted for patient characteristics (model 1) and patient/hospital (annualized TAVR volume and teaching status) characteristics (model 2). Results Among 511 institutions, CMS reimbursement for TAVR ranged from $28 062 to $111 280 with a median (IQR) of $45 884 ($40 331-$53 627). Among 84 353 patients (median [IQR] age, 81.0 [75.0-86.0] years; 46 247 male individuals [54.8%]; 3958 [4.7%] of Hispanic or Latino ethnicity; 78 170 White individuals [92.7%]) treated at the sites, 6012 (7.1%) underwent TAVR with EPD. Patient characteristics associated with EPD use included prior stroke (adjusted odds ratio [aOR], 1.13 [95% CI, 1.00-1.27]; P = .048), female sex (aOR, 0.85 [95% CI, 0.78-0.93]; P < .001), hemodialysis (aOR, 0.52 [95% CI, 0.40-0.68]; P < .001), and shock (aOR, 0.62 [95% CI, 0.41-0.94]; P = .03). Higher CMS reimbursement up to $50 000 per TAVR was associated with greater likelihood of EPD use in model 1 (per $1000; aOR, 1.08 [95% CI, 1.01-1.16]; P = .02). However, this association was no longer apparent after adjusting for site characteristics (model 2; aOR, 1.03 [95% CI, 0.96-1.11]; P = .38). Higher TAVR volume was associated with increased EPD use (per 25 TAVRs; aOR, 1.15 [95% CI, 1.09-1.21]; P < .001). There was no significant change in the odds of EPD uptake before vs after institution of the CMS new technology add-on payment across tertiles of CMS TAVR reimbursement (Wald χ2 = 3.59; P = .17). Conclusions and Relevance EPD use during TAVR remains infrequent and is associated with multiple patient and site characteristics. While CMS reimbursement varies significantly across institutions, TAVR case volume, rather than CMS TAVR reimbursement or the CMS new technology add-on payment, appears to be the predominant factor associated with EPD use. Ongoing work is needed to understand the economic drivers that contribute to the association between procedural volume and EPD use.
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Affiliation(s)
- Angela Lowenstern
- Duke Clinical Research Institute, Durham, North Carolina
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anna Hung
- Duke Clinical Research Institute, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | | | - Zachary K. Wegermann
- Duke Clinical Research Institute, Durham, North Carolina
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Samir R. Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brian R. Lindman
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kashish Goel
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Melissa Levack
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Colin M. Barker
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shelby D. Reed
- Duke Clinical Research Institute, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - David J. Cohen
- Cardiovascular Research Foundation, New York, New York
- St Francis Hospital and Heart Center, Roslyn, New York
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
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Lowenstern A, Alexander KP, Pagidipati NJ, Hill CL, Pellikka PA, Cooper LS, Alhanti B, Hoffmann U, Mark DB, Douglas PS. Presenting Symptoms in Patients Undergoing Coronary Artery Disease Evaluation: Association With Noninvasive Test Results and Clinical Outcomes in the PROMISE Trial. Circ Cardiovasc Qual Outcomes 2022; 15:e008298. [PMID: 35369715 PMCID: PMC9117448 DOI: 10.1161/circoutcomes.121.008298] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients evaluated for coronary artery disease have a range of symptoms and underlying risk. The relationships between patient-described symptoms, clinician conclusions, and subsequent clinical management and outcomes remain incompletely described. METHODS In this secondary analysis, we examined the association between 4 types of presenting symptoms (substernal/left-sided chest pain, other chest/neck/arm pain, dyspnea, and other symptoms) and patient risk, noninvasive test results, clinical management, and outcomes for stable outpatients randomized in the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial. Multivariable regression models were used to evaluate differences in noninvasive test result, all-cause death/myocardial infarction/unstable angina hospitalization and cardiovascular death/myocardial infarction by symptom type. RESULTS Among 9996 patients, most presented with chest pain (47.2% substernal, 29.2% other), followed by dyspnea (14.9%), and other symptoms (8.7%). Patients with dyspnea were older (median age 63 versus 60, P≤0.02) with higher baseline risk (78.2% with atherosclerotic cardiovascular disease >7.5% versus 67.6%, P≤0.02). Using patients with substernal chest pain as a reference, there was no difference in noninvasive test positivity across symptom groups (all P>0.05), but test-positive patients with dyspnea (adjusted odds ratio, 0.66 [95% CI, 0.51-0.85]) or other symptoms (adjusted odds ratio, 0.65 [95% CI, 0.47-0.90]) were less likely to be referred for cardiac catheterization. While symptom type alone was not associated with outcomes, symptom presentation with chest pain or dyspnea did modify the association between a positive noninvasive test and clinical outcome (interaction P=0.025 for both all-cause death/myocardial infarction/unstable angina hospitalization and cardiovascular death/MI). CONCLUSIONS Among low-risk outpatients evaluated for coronary artery disease, typicality of symptoms was not closely associated with higher baseline risk but was related to differences in processes of care and the prognostic value of a positive test. Adverse events were not associated with clinician risk estimates or symptoms alone. These unexpected findings highlight the limitation of relying solely on symptom presentation or clinician risk estimation to evaluate patients for suspected coronary artery disease. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01174550.
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Affiliation(s)
- Angela Lowenstern
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.L., K.P.A., N.J.P., C.L.H., B.A., D.B.M., P.S.D.).,Vanderbilt University Medical Center (A.L.)
| | - Karen P Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.L., K.P.A., N.J.P., C.L.H., B.A., D.B.M., P.S.D.)
| | - Neha J Pagidipati
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.L., K.P.A., N.J.P., C.L.H., B.A., D.B.M., P.S.D.)
| | - C Larry Hill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.L., K.P.A., N.J.P., C.L.H., B.A., D.B.M., P.S.D.)
| | | | - Lawton S Cooper
- National Heart, Lung, and Blood Institute, Bethesda, MD (L.S.C.)
| | - Brooke Alhanti
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.L., K.P.A., N.J.P., C.L.H., B.A., D.B.M., P.S.D.)
| | - Udo Hoffmann
- Massachusetts General Hospital, Harvard Medical School, Boston (U.H.)
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.L., K.P.A., N.J.P., C.L.H., B.A., D.B.M., P.S.D.)
| | - Pamela S Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.L., K.P.A., N.J.P., C.L.H., B.A., D.B.M., P.S.D.)
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Lindman BR, Lowenstern A. The Alarm Blares for Undertreatment of Aortic Stenosis: How Will We Respond? J Am Coll Cardiol 2022; 79:878-881. [PMID: 35241221 DOI: 10.1016/j.jacc.2021.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 12/06/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Brian R Lindman
- Structural Heart and Valve Center, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| | - Angela Lowenstern
- Structural Heart and Valve Center, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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11
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Tanaka J, Patolia H, Lobaugh B, Vleet CV, Klem I, Borawski J, Doshi P, Lowenstern A, Newby LK, Tcheng JE, Rymer J. TWO YEAR EXPERIENCE WITH HIGH-SENSITIVITY TROPONIN TESTING:INTERPRETATIVE VALUES FOR IMPROVING PATIENT DISPOSITION. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)01973-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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12
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Rymer J, Takagi H, Lowenstern A, Rabbat M, Fairbairn T, Chinnaiyan K, Douglas P, Koweek L, Berman D, De Bruyne B, Bax J, Akasaka T, Amano T, Nieman K, Rogers C, Kitabata H, Rønnow Sand NP, Kawasaki T, Mullen S, Matsuo H, Norgaard B, Leipsic J, Patel M, Daubert M. TCT-86 Anatomic and Functional Discordance Among Patients With Nonobstructive Coronary Disease. J Am Coll Cardiol 2021. [DOI: 10.1016/j.jacc.2021.09.936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Brennan JM, Lowenstern A, Sheridan P, Boero IJ, Thourani VH, Vemulapalli S, Wang TY, Liska O, Gander S, Jager J, Leon MB, Peterson ED. Association Between Patient Survival and Clinician Variability in Treatment Rates for Aortic Valve Stenosis. J Am Heart Assoc 2021; 10:e020490. [PMID: 34387116 PMCID: PMC8475044 DOI: 10.1161/jaha.120.020490] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Patients with symptomatic severe aortic stenosis (ssAS) have a high mortality risk and compromised quality of life. Surgical/transcatheter aortic valve replacement (AVR) is a Class I recommendation, but it is unclear if this recommendation is uniformly applied. We determined the impact of managing cardiologists on the likelihood of ssAS treatment. Methods and Results Using natural language processing of Optum electronic health records, we identified 26 438 patients with newly diagnosed ssAS (2011-2016). Multilevel, multivariable Fine-Gray competing risk models clustered by cardiologists were used to determine the impact of cardiologists on the likelihood of 1-year AVR treatment. Within 1 year of diagnosis, 35.6% of patients with ssAS received an AVR; however, rates varied widely among managing cardiologists (0%, lowest quartile; 100%, highest quartile [median, 29.6%; 25th-75th percentiles, 13.3%-47.0%]). The odds of receiving AVR varied >2-fold depending on the cardiologist (median odds ratio for AVR, 2.25; 95% CI, 2.14-2.36). Compared with patients with ssAS of cardiologists with the highest treatment rates, those treated by cardiologists with the lowest AVR rates experienced significantly higher 1-year mortality (lowest quartile, adjusted hazard ratio, 1.22, 95% CI, 1.13-1.33). Conclusions Overall AVR rates for ssAS were low, highlighting a potential challenge for ssAS management in the United States. Cardiologist AVR use varied substantially; patients treated by cardiologists with lower AVR rates had higher mortality rates than those treated by cardiologists with higher AVR rates.
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Affiliation(s)
- J Matthew Brennan
- Duke Clinical Research Institute Duke University School of Medicine Durham NC
| | - Angela Lowenstern
- Duke Clinical Research Institute Duke University School of Medicine Durham NC
| | - Paige Sheridan
- Department of Family Medicine and Public Health University of California, San Diego School of Medicine San Diego CA.,Boston Consulting Group Boston MA
| | | | - Vinod H Thourani
- Department of Cardiovascular Surgery Piedmont Heart Institute Atlanta GA
| | | | - Tracy Y Wang
- Duke Clinical Research Institute Duke University School of Medicine Durham NC
| | | | | | | | - Martin B Leon
- Columbia University Irving Medical Center and New York Presbyterian Hospital New York NY
| | - Eric D Peterson
- Duke Clinical Research Institute Duke University School of Medicine Durham NC
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14
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Lowenstern A, Sheridan P, Wang TY, Boero I, Vemulapalli S, Thourani VH, Leon MB, Peterson ED, Brennan JM. Sex disparities in patients with symptomatic severe aortic stenosis. Am Heart J 2021; 237:116-126. [PMID: 33722584 DOI: 10.1016/j.ahj.2021.01.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 01/28/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND We evaluated whether there is equitable distribution across sexes of treatment and outcomes for aortic valve replacement (AVR), via surgical (SAVR) or transcatheter (TAVR) methods, in symptomatic severe aortic stenosis (ssAS) patients. METHODS Using de-identified data, we identified 43,822 patients with ssAS (2008-2016). Multivariate competing risk models were used to determine the likelihood of any AVR, while accounting for the competing risk of death. Association between sex and 1-year mortality, stratified by AVR status, was evaluated using multivariate Cox regression models with AVR as a time-dependent variable. RESULTS Among patients with ssAS, 20,986 (47.9%) were female. Females were older (median age 81 vs. 78, P<0.001), more likely to have body mass index <20 (8.5% vs. 3.5%), and home oxygen use (4.4% vs. 3.4%, P<0001 for all). Overall, 12,129 (27.7%) patients underwent AVR for ssAS. Females were less likely to undergo AVR compared with males (24.1% vs. 31.0%, adjusted hazard ratio [HR] 0.80, 95% confidence interval [CI] 0.77-0.83), but when treated, were more likely to undergo TAVR (37.9% vs. 30.9%, adjusted HR 1.21, 95% CI 1.15-1.27). Untreated females and males had similarly high rates of mortality at 1 year (31.1% vs. 31.3%, adjusted HR 0.98, 95% CI 0.94-1.03). Among those undergoing AVR, females had significantly higher mortality (10.2% vs. 9.4%, adjusted HR 1.24, 95% CI 1.10-1.41), driven by increased SAVR-associated mortality (9.0% vs. 7.6%, adjusted HR 1.43, 95% CI 1.21-1.69). CONCLUSIONS Treatment rates for ssAS patients remain suboptimal with disparities in female treatment.
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Affiliation(s)
- Angela Lowenstern
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Paige Sheridan
- Department of Family Medicine and Public Health, University of San Diego, San Diego, CA; Boston Consulting Group, Boston, MA
| | - Tracy Y Wang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | | | - Vinod H Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center, Piedmont Heart Institute, Atlanta, GA
| | - Martin B Leon
- Columbia University Medical Center and New York Presbyterian Hospital, New York, NY
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - J Matthew Brennan
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
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15
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Lowenstern A, Li S, Navar AM, Virani SS, Roger VL, Robinson JG, Goldberg AC, Kampman W, Peterson ED, Wang TY. Patient perceptions and use of non-statin lipid lowering therapy among patients with or at risk for atherosclerotic cardiovascular disease: Insights from the PALM registry. Clin Cardiol 2021; 44:863-870. [PMID: 34008247 PMCID: PMC8207979 DOI: 10.1002/clc.23625] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/27/2021] [Accepted: 04/30/2021] [Indexed: 12/18/2022] Open
Abstract
Background Non‐statin lipid lowering therapies (LLTs) provide additional treatment options for patients. Use patterns and patient perceptions of non‐statin LLT remain incompletely described. Hypothesis The guideline‐recommended statin intensity remains underutilized in patients treated with and without non‐statin LLT. Methods The PALM Registry collected LLT information on patients with or at risk of ASCVD treated at 125 US clinics in 2015. We compared patient perceptions, lipid levels and statin use among patients treated with and without non‐statin LLT. Results Among 7720 patients, 1930 (25.0%) were treated with a non‐statin LLT (1249 fish oil, 417 fibrates, 329 ezetimibe, 196 niacin). Concurrent statin treatment occurred in 73.7%, of which 45.4% were dosed under the guideline‐recommended intensity. Compared with patients on statin alone, patients receiving both a statin and non‐statin LLT (n = 1423) were more likely to be male, white race and to perceive themselves as higher risk of ASCVD compared with their peers (38.5% vs. 34.9%, p = .047). Only 27.4% of patients treated with non‐statin LLT alone perceived themselves at higher risk. Most (75.7%) patients treated with a non‐statin LLT alone reported never being treated with a statin, despite ASCVD in 30.8% of these patients. Among those previously treated with a statin, 59.3% reported being willing to try a statin again. Conclusions Non‐statin LLT is used in one in four patients with or at risk for ASCVD; its use is frequently in place of statin therapy or in the absence of guideline‐recommended statin intensity. More work is needed to establish statins as first line therapy.
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Affiliation(s)
- Angela Lowenstern
- Duke Clinical Research Institute, Durham, North Carolina, USA.,Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Shuang Li
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Ann Marie Navar
- Duke Clinical Research Institute, Durham, North Carolina, USA.,Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Salim S Virani
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Veronique L Roger
- Department of Health Sciences Research and Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Anne C Goldberg
- Department of internal medicine, division of endocrinology, Washington University, St. Louis, Missouri, USA
| | - Wendy Kampman
- Medical affairs, Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA
| | - Eric D Peterson
- Duke Clinical Research Institute, Durham, North Carolina, USA.,Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Tracy Y Wang
- Duke Clinical Research Institute, Durham, North Carolina, USA.,Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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16
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Lowenstern A, Alexander KP, Hill CL, Alhanti B, Pellikka PA, Nanna MG, Mehta RH, Cooper LS, Bullock-Palmer RP, Hoffmann U, Douglas PS. Age-Related Differences in the Noninvasive Evaluation for Possible Coronary Artery Disease: Insights From the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) Trial. JAMA Cardiol 2021; 5:193-201. [PMID: 31738382 DOI: 10.1001/jamacardio.2019.4973] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Importance Although cardiovascular (CV) disease represents the leading cause of morbidity and mortality that increases with age, the best noninvasive test to identify older patients at risk for CV events remains unknown. Objective To determine whether the prognostic utility of anatomic vs functional testing varies based on patient age. Design, Setting, and Participants Prespecified analysis of the Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) study, which used a pragmatic comparative effectiveness design. Participants were enrolled from 193 sites across North America and comprised outpatients without known coronary artery disease (CAD) but with symptoms suggestive of CAD. Data were analyzed between October 2018 and April 2019. Interventions Randomization to noninvasive testing with coronary computed tomographic angiography or functional testing. Main Outcomes and Measures The composite of CV death/myocardial infarction (MI) over a median follow-up of 25 months. Results Among 10 003 PROMISE patients, we included the 8966 who received the noninvasive test to which they were randomized and had interpretable results; 6378 (71.1%) were younger than 65 years, 2062 (23.0%) were between ages 65 and 74 years, and 526 (5.9%) were 75 years and older. More than half of participants were women (4720 of 8966 [52.6%]). Only a minority of patients were of nonwhite race/ethnicity, a proportion that was lower among the older age groups (1071 of 6378 [16.8%] for <65 years; 258 of 2062 [12.5%] for age 65-74 years; 41 of 526 [7.8%] for ≥75 years). Compared with patients younger than 65 years, older patients were more likely to have a positive test result (age 65-74 years: odds ratio, 1.65; 95% CI, 1.42-1.91; age ≥75 years: odds ratio, 2.32; 95% CI, 1.83-2.95), regardless of noninvasive test completed. A positive functional test result was not associated with CV death/MI in patients younger than 65 years (hazard ratio [HR], 1.09; 95% CI, 0.43-2.82) but it was among older patients (age 65-74 years: HR, 3.18; 95% CI, 1.44-7.01; age ≥75 years: HR, 6.55; 95% CI, 1.46-29.35). Conversely, a positive anatomic test result was associated with CV death/MI among patients younger than 65 years (HR, 3.04; 95% CI, 1.46-6.34) but not among older patients (age, 65-74 years: HR, 0.67; 95% CI, 0.15-2.94; age ≥75 years: HR, 1.07; 95% CI, 0.22-5.34; P for interaction = .01). An elevated coronary artery calcium score was predictive of events in patients younger than 65 years (HR, 2.73; 95% CI, 1.31-5.69) but not for older patients (age 65-74 years: HR, 0.44; 95% CI, 0.14-1.42; age ≥75 years: HR, 1.31; 95% CI, 0.25-6.88). Conclusions and Relevance Older patients with stable symptoms suggestive of CAD are more likely to have a positive noninvasive test result and more coronary artery calcium. However, only a positive functional test result was associated with risk of CV death/MI. Age-specific approaches to noninvasive evaluation of CAD should be further examined. Trial Registration ClinicalTrials.gov identifier: NCT01174550.
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Affiliation(s)
- Angela Lowenstern
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Karen P Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - C Larry Hill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Brooke Alhanti
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | - Michael G Nanna
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Rajendra H Mehta
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Lawton S Cooper
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | | | - Udo Hoffmann
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Pamela S Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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17
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Chew DS, Loring Z, Anand J, Fudim M, Lowenstern A, Rymer JA, Weimer KED, Atwater BD, DeVore AD, Exner DV, Noseworthy PA, Yancy CW, Mark DB, Piccini JP. Economic Evaluation of Catheter Ablation of Atrial Fibrillation in Patients with Heart Failure With Reduced Ejection Fraction. Circ Cardiovasc Qual Outcomes 2020; 13:e007094. [PMID: 33280436 DOI: 10.1161/circoutcomes.120.007094] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Randomized clinical trials have demonstrated that catheter ablation for atrial fibrillation in patients with heart failure with reduced ejection fraction may improve survival and other cardiovascular outcomes. METHODS We constructed a decision-analytic Markov model to estimate the costs and benefits of catheter ablation and medical management in patients with symptomatic heart failure with reduced ejection fraction (left ventricular ejection fraction ≤35%) and atrial fibrillation over a lifetime horizon. Evidence from the published literature informed the model inputs, including clinical effectiveness data from meta-analyses. Probabilistic and deterministic sensitivity analyses were performed. A 3% discount rate was applied to both future costs and benefits. The primary outcome was the incremental cost-effectiveness ratio assessed from the US health care sector perspective. RESULTS Catheter ablation was associated with 6.47 (95% CI, 5.89-6.93) quality-adjusted life years (QALYs) and a total cost of $105 657 (95% CI, $55 311-$191 934; 2018 US dollars), compared with 5.30 (95% CI, 5.20-5.39) QALYs and $63 040 (95% CI, $37 624-$102 260) for medical management. The incremental cost-effectiveness ratio for catheter ablation compared with medical management was $38 496 (95% CI, $5583-$117 510) per QALY gained. Model inputs with the greatest variation on incremental cost-effectiveness ratio estimates were the cost of ablation and the effect of catheter ablation on mortality reduction. When assuming a more conservative estimate of the treatment effect of catheter ablation on mortality (hazard ratio of 0.86), the estimated incremental cost-effectiveness ratio was $74 403 per QALY gained. At a willingness-to-pay threshold of $100 000 per QALY gained, atrial fibrillation ablation was found to be economically favorable compared with medical management in 95% of simulations. CONCLUSIONS Catheter ablation in patients with heart failure with reduced ejection fraction patients and atrial fibrillation may be considered economically attractive at current benchmarks for societal willingness-to-pay in the United States.
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Affiliation(s)
- Derek S Chew
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., Z.L., M.F., A.L., J.A.R., A.D.D., D.B.M., J.P.P.)
| | - Zak Loring
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., Z.L., M.F., A.L., J.A.R., A.D.D., D.B.M., J.P.P.).,Division of Cardiology (Z.L., M.F., A.L., J.A.R., B.D.A., A.D.D., D.B.M., J.P.P.), Duke University Medical Center, Durham, NC
| | - Jatin Anand
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery (J.A.), Duke University Medical Center, Durham, NC
| | - Marat Fudim
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., Z.L., M.F., A.L., J.A.R., A.D.D., D.B.M., J.P.P.).,Division of Cardiology (Z.L., M.F., A.L., J.A.R., B.D.A., A.D.D., D.B.M., J.P.P.), Duke University Medical Center, Durham, NC
| | - Angela Lowenstern
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., Z.L., M.F., A.L., J.A.R., A.D.D., D.B.M., J.P.P.).,Division of Cardiology (Z.L., M.F., A.L., J.A.R., B.D.A., A.D.D., D.B.M., J.P.P.), Duke University Medical Center, Durham, NC
| | - Jennifer A Rymer
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., Z.L., M.F., A.L., J.A.R., A.D.D., D.B.M., J.P.P.).,Division of Cardiology (Z.L., M.F., A.L., J.A.R., B.D.A., A.D.D., D.B.M., J.P.P.), Duke University Medical Center, Durham, NC
| | - Kristin E D Weimer
- Department of Pediatrics (K.E.D.W.), Duke University Medical Center, Durham, NC
| | - Brett D Atwater
- Division of Cardiology (Z.L., M.F., A.L., J.A.R., B.D.A., A.D.D., D.B.M., J.P.P.), Duke University Medical Center, Durham, NC
| | - Adam D DeVore
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., Z.L., M.F., A.L., J.A.R., A.D.D., D.B.M., J.P.P.).,Division of Cardiology (Z.L., M.F., A.L., J.A.R., B.D.A., A.D.D., D.B.M., J.P.P.), Duke University Medical Center, Durham, NC
| | - Derek V Exner
- Department of Cardiac Sciences, University of Calgary, Alberta, Canada (D.V.E.)
| | - Peter A Noseworthy
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (P.A.N.)
| | - Clyde W Yancy
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (C.W.Y.)
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., Z.L., M.F., A.L., J.A.R., A.D.D., D.B.M., J.P.P.).,Division of Cardiology (Z.L., M.F., A.L., J.A.R., B.D.A., A.D.D., D.B.M., J.P.P.), Duke University Medical Center, Durham, NC
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., Z.L., M.F., A.L., J.A.R., A.D.D., D.B.M., J.P.P.).,Division of Cardiology (Z.L., M.F., A.L., J.A.R., B.D.A., A.D.D., D.B.M., J.P.P.), Duke University Medical Center, Durham, NC
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18
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Lowenstern A, Alexander KP, Douglas PS. Should We Simplify Computed Tomography Angiography Reporting as Black or White vs Describing All Shades of Gray?-Reply. JAMA Cardiol 2020; 5:1450-1451. [PMID: 32902566 DOI: 10.1001/jamacardio.2020.3733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Angela Lowenstern
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Karen P Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Pamela S Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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19
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Dalgaard F, Xu H, Matsouaka RA, Russo AM, Curtis AB, Rasmussen PV, Ruwald MH, Fonarow GC, Lowenstern A, Hansen ML, Pallisgaard JL, Alexander KP, Alexander JH, Lopes RD, Granger CB, Lewis WR, Piccini JP, Al-Khatib SM. Management of Atrial Fibrillation in Older Patients by Morbidity Burden: Insights From Get With The Guidelines-Atrial Fibrillation. J Am Heart Assoc 2020; 9:e017024. [PMID: 33241750 PMCID: PMC7763767 DOI: 10.1161/jaha.120.017024] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background Knowledge is scarce regarding how multimorbidity is associated with therapeutic decisions regarding oral anticoagulants (OACs) in patients with atrial fibrillation. Methods and Results We conducted a cross-sectional study of hospitalized patients with atrial fibrillation using the Get With The Guidelines-Atrial Fibrillation registry from 2013 to 2019. We identified patients ≥65 years and eligible for OAC therapy. Using 16 available comorbidity categories, patients were stratified by morbidity burden. A multivariable logistic regression model was used to determine the odds of receiving OAC prescription at discharge by morbidity burden. We included 34 174 patients with a median (interquartile range) age of 76 (71-83) years, 56.6% women, and 41.9% were not anticoagulated at admission. Of these patients, 38.6% had 0 to 2 comorbidities, 50.7% had 3 to 5 comorbidities, and 10.7% had ≥6 comorbidities. The overall discharge OAC prescription was high (85.6%). The prevalence of patients with multimorbidity increased from 59.7% in 2014 to 64.3% in 2019 (P trend=0.002). Using 0 to 2 comorbidities as the reference, the adjusted odds ratio (95% CI) of OAC prescription were 0.93 (0.82, 1.05) for patients with 3 to 5 comorbidities and 0.72 (0.60, 0.86) for patients with ≥6 comorbidities. In those with ≥6 comorbidities, the most common reason for nonprescription of OACs were frequent falls/frailty (31.0%). Conclusions In a contemporary quality-of-care database of hospitalized patients with atrial fibrillation eligible for OAC therapy, multimorbidity was common. A higher morbidity burden was associated with a lower odds of OAC prescription. This highlights the need for interventions to improve adherence to guideline-recommended anticoagulation in multimorbid patients with atrial fibrillation.
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Affiliation(s)
- Frederik Dalgaard
- Department of Cardiology Herlev and Gentofte Hospital Hellerup Denmark.,Duke Clinical Research Institute Duke University Durham NC
| | - Haolin Xu
- Duke Clinical Research Institute Duke University Durham NC
| | - Roland A Matsouaka
- Duke Clinical Research Institute Duke University Durham NC.,Department of Biostatistics and Bioinformatics Duke University Durham NC
| | | | | | | | - Martin H Ruwald
- Department of Cardiology Herlev and Gentofte Hospital Hellerup Denmark
| | - Gregg C Fonarow
- Division of Cardiology Department of Medicine Ahmanson-UCLA Cardiomyopathy CenterRonald Reagan-UCLA Medical Center Los Angeles CA
| | | | - Morten L Hansen
- Department of Cardiology Herlev and Gentofte Hospital Hellerup Denmark
| | | | | | | | - Renato D Lopes
- Duke Clinical Research Institute Duke University Durham NC
| | | | - William R Lewis
- Division of Cardiology MetroHealth CampusCase Western Reserve University Cleveland OH
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Matthew Brennan J, Leon MB, Sheridan P, Boero IJ, Chen Q, Lowenstern A, Thourani V, Vemulapalli S, Thomas K, Wang TY, Peterson ED. Racial Differences in the Use of Aortic Valve Replacement for Treatment of Symptomatic Severe Aortic Valve Stenosis in the Transcatheter Aortic Valve Replacement Era. J Am Heart Assoc 2020; 9:e015879. [PMID: 32777969 PMCID: PMC7660794 DOI: 10.1161/jaha.119.015879] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Aortic valve replacement (AVR) is a life‐saving treatment for patients with symptomatic severe aortic valve stenosis. We sought to determine whether transcatheter AVR has resulted in a more equitable treatment rate by race in the United States. Methods and Results A total of 32 853 patients with symptomatic severe aortic valve stenosis were retrospectively identified via Optum’s deidentified electronic health records database (2007–2017). AVR rates in non‐Hispanic Black and White patients were assessed in the year after diagnosis. Multivariate Fine‐Gray hazards models were used to evaluate the likelihood of AVR by race, with adjustment for patient factors and the managing cardiologist. Time‐trend and 1‐year symptomatic severe aortic valve stenosis survival analyses were also performed. From 2011 to 2016, the rate of AVR increased from 20.1% to 37.1%. Overall, Black individuals were less likely than Whites to receive AVR (22.9% versus 31.0%; unadjusted hazard ratio [HR], 0.70; 95% CI, 0.62–0.79; fully adjusted HR, 0.76; 95% CI, 0.67–0.85). Yet, during 2015 to 2016, AVR racial differences were attenuated (29.5% versus 35.2%; adjusted HR, 0.86; 95% CI, 0.74–1.02) because of greater uptake of transcatheter AVR in Blacks than Whites (53.4% of AVRs versus 47.3%; P=0.128). Untreated patients had significantly higher 1‐year mortality than those treated (adjusted HR, 0.57; 95% CI, 0.53–0.61), which was consistent by race (interaction P value=0.52). Conclusions Although transcatheter AVR has increased the use of AVR in the United States, treatment rates remain low. Black patients with symptomatic severe aortic valve stenosis were less likely than White patients to receive AVR, yet these differences have recently narrowed.
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Affiliation(s)
| | - Martin B Leon
- Columbia University Medical Center and New York Presbyterian Hospital New York NY
| | - Paige Sheridan
- Department of Family Medicine and Public Health University of San Diego San Diego CA.,Boston Consulting Group Boston MA
| | | | | | | | - Vinod Thourani
- Georgetown University School of MedicineMedstar Heart and Vascular Institute Washington DC
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Truby LK, O'Connor C, Fiuzat M, Stebbins A, Coles A, Patel CB, Granger B, Pagidipati N, Agarwal R, Rymer J, Lowenstern A, Douglas PS, Tulsky J, Rogers JG, Mentz RJ. Sex Differences in Quality of Life and Clinical Outcomes in Patients With Advanced Heart Failure: Insights From the PAL-HF Trial. Circ Heart Fail 2020; 13:e006134. [PMID: 32268795 DOI: 10.1161/circheartfailure.119.006134] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Palliative care improves quality of life in patients with heart failure. Whether men and women with heart failure derive similar benefit from palliative care interventions remains unknown. METHODS In a secondary analysis of the PAL-HF trial (Palliative Care in Heart Failure), we analyzed differences in quality of life among men and women with heart failure and assessed for differential effects of the palliative care intervention by sex. Differences in clinical characteristics and quality-of-life metrics were compared between men and women at serial time points. The primary outcome was change in Kansas City Cardiomyopathy Questionnaire score between baseline and 24 weeks. RESULTS Among the 71 women and 79 men, there was a significant difference in baseline Kansas City Cardiomyopathy Questionnaire (24.5 versus 36.2, respectively; P=0.04) but not Functional Assessment of Chronic Illness Therapy-Palliative Care scale (115.7 versus 120.3; P=0.27) scores. Among those who received the palliative care intervention (33 women and 42 men), women's quality-of-life score remained lower than that of men after enrollment. Treated men's scores were significantly higher than those untreated (6-month Kansas City Cardiomyopathy Questionnaire, 68.0 [interquartile range, 52.6-85.7] versus 41.1[interquartile range, 32.0-78.3]; P=0.047), whereas the difference between treated and untreated women was not significantly different (P=0.39). Rates of death and rehospitalization, as well as the composite end point, were similar between treated and untreated women and men. CONCLUSIONS In the PAL-HF trial, women with heart failure experienced a greater symptom burden and poorer quality of life as compared with men. The change in treated men's Kansas City Cardiomyopathy Questionnaire score between baseline and 24 weeks was significantly higher than those untreated; this trend was not observed in women. Thus, there may be a sex disparity in response to palliative care intervention, suggesting that sex-specific approaches to palliative care may be needed to improve outcomes. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT0158960.
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Affiliation(s)
- Lauren K Truby
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (L.K.T., M.F., A.S., A.C., C.B.P., B.G., N.P., R.A., J.R., A.L., P.S.D., J.G.R., R.J.M.)
| | | | - Mona Fiuzat
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (L.K.T., M.F., A.S., A.C., C.B.P., B.G., N.P., R.A., J.R., A.L., P.S.D., J.G.R., R.J.M.)
| | - Amanda Stebbins
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (L.K.T., M.F., A.S., A.C., C.B.P., B.G., N.P., R.A., J.R., A.L., P.S.D., J.G.R., R.J.M.)
| | - Adrian Coles
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (L.K.T., M.F., A.S., A.C., C.B.P., B.G., N.P., R.A., J.R., A.L., P.S.D., J.G.R., R.J.M.)
| | - Chetan B Patel
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (L.K.T., M.F., A.S., A.C., C.B.P., B.G., N.P., R.A., J.R., A.L., P.S.D., J.G.R., R.J.M.)
| | - Bradi Granger
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (L.K.T., M.F., A.S., A.C., C.B.P., B.G., N.P., R.A., J.R., A.L., P.S.D., J.G.R., R.J.M.)
| | - Neha Pagidipati
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (L.K.T., M.F., A.S., A.C., C.B.P., B.G., N.P., R.A., J.R., A.L., P.S.D., J.G.R., R.J.M.)
| | - Richa Agarwal
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (L.K.T., M.F., A.S., A.C., C.B.P., B.G., N.P., R.A., J.R., A.L., P.S.D., J.G.R., R.J.M.)
| | - Jennifer Rymer
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (L.K.T., M.F., A.S., A.C., C.B.P., B.G., N.P., R.A., J.R., A.L., P.S.D., J.G.R., R.J.M.)
| | - Angela Lowenstern
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (L.K.T., M.F., A.S., A.C., C.B.P., B.G., N.P., R.A., J.R., A.L., P.S.D., J.G.R., R.J.M.)
| | - Pamela S Douglas
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (L.K.T., M.F., A.S., A.C., C.B.P., B.G., N.P., R.A., J.R., A.L., P.S.D., J.G.R., R.J.M.)
| | - James Tulsky
- Division of Palliative Medicine, Department of Medicine, Dana Farber Cancer Institute, Brigham and Women's Hospital, Boston, MA (J.T.)
| | - Joseph G Rogers
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (L.K.T., M.F., A.S., A.C., C.B.P., B.G., N.P., R.A., J.R., A.L., P.S.D., J.G.R., R.J.M.)
| | - Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (L.K.T., M.F., A.S., A.C., C.B.P., B.G., N.P., R.A., J.R., A.L., P.S.D., J.G.R., R.J.M.)
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22
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Varshney AS, Manandhar P, Vemulapalli S, Kirtane AJ, Mathew V, Shah B, Lowenstern A, Kosinski AS, Kaneko T, Thourani VH, Bhatt DL. Left Ventricular Hypertrophy Does Not Affect 1-Year Clinical Outcomes in Patients Undergoing Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2020; 12:373-382. [PMID: 30784643 DOI: 10.1016/j.jcin.2018.11.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 10/21/2018] [Accepted: 11/13/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the association between pre-procedural left ventricular hypertrophy (LVH) patterns and clinical outcomes after transcatheter aortic valve replacement (TAVR). BACKGROUND The association between pre-procedural LVH pattern and severity and clinical outcomes after TAVR is uncertain. METHODS Patients (n = 31,199) across 422 sites who underwent TAVR from November 2011 through June 2016 as part of the Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapies) Registry linked with the Centers for Medicare and Medicaid Services database were evaluated by varying LVH patterns, according to sex-specific cutoffs for left ventricular mass index and relative wall thickness. The association between LVH pattern (concentric remodeling, concentric LVH, and eccentric LVH) and outcomes (rates of mortality, myocardial infarction [MI], stroke, new dialysis requirement) at 1-year follow-up were evaluated using multivariate hazard models. RESULTS There were no significant associations between concentric remodeling (death: adjusted hazard ratio [HR]: 1.03; 95% confidence interval [CI]: 0.93 to 1.15; MI: HR: 1.05; 95% CI: 0.76 to 1.46; stroke: HR: 1.11; 95% CI: 0.89 to 1.39; new dialysis: HR: 0.86; 95% CI: 0.64 to 1.15), concentric LVH (death: HR: 1.04; 95% CI: 0.95 to 1.15; MI: HR: 1.12; 95% CI: 0.82 to 1.52; stroke: HR: 1.14; 95% CI: 0.92 to 1.40; new dialysis: HR: 1.17; 95% CI: 0.90 to 1.52), or eccentric LVH (death: HR: 0.98; 95% CI: 0.87 to 1.10; MI: HR: 1.07; 95% CI: 0.71 to 1.63; stroke: HR: 1.01; 95% CI: 0.78 to 1.32; new dialysis: HR: 1.25; 95% CI: 0.92 to 1.70) and outcomes at 1 year compared with patients without LVH. CONCLUSIONS In a contemporary cohort of patients who underwent TAVR, pre-procedural LVH according to left ventricular mass index and relative wall thickness was not associated with adverse outcomes at 1-year follow-up. TAVR is likely to benefit patients with severe aortic stenosis regardless of the presence of LVH.
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Affiliation(s)
- Anubodh S Varshney
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts
| | | | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University, Durham, North Carolina
| | - Ajay J Kirtane
- Division of Cardiology, Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Verghese Mathew
- Division of Cardiology, Stritch School of Medicine, Loyola University, Chicago, Illinois
| | - Binita Shah
- Division of Cardiology, VA New York Harbor Healthcare System and New York University School of Medicine, New York, New York
| | - Angela Lowenstern
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University, Durham, North Carolina
| | - Andrzej S Kosinski
- Duke Clinical Research Institute, Durham, North Carolina; Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Tsuyoshi Kaneko
- Department of Cardiac Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Vinod H Thourani
- Department of Cardiac Surgery, Medstar Heart and Vascular Institute/Georgetown University, Washington, DC
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts.
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23
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Lowenstern A, Gupta R, Patel M, Granger T, Wixted D, Alexander K, Kumar D, Newby LK. MOLECULAR MARKERS OF SURVIVAL TO ADVANCED AGE WITH CARDIOVASCULAR DISEASE: RESULTS FROM THE MURDOCK STUDY. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)30774-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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24
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Kiani S, Stebbins A, Thourani VH, Forcillo J, Vemulapalli S, Kosinski AS, Babaliaros V, Cohen D, Kodali SK, Kirtane AJ, Hermiller JB, Stewart J, Lowenstern A, Mack MJ, Guyton RA, Devireddy C. The Effect and Relationship of Frailty Indices on Survival After Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2020; 13:219-231. [DOI: 10.1016/j.jcin.2019.08.015] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/31/2019] [Accepted: 08/07/2019] [Indexed: 11/26/2022]
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25
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Lowenstern A, Newby LK. In STEMI with multivessel CAD, complete revascularization reduced CV death or MI more than culprit lesion-only PCI. Ann Intern Med 2019; 171:JC63. [PMID: 31842221 DOI: 10.7326/acpj201912170-063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Abstract
See Article by Gu et al
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Affiliation(s)
- Angela Lowenstern
- 1 Duke Clinical Research Institute Durham NC.,2 Division of Cardiology Department of Medicine Duke University School of Medicine Durham NC
| | - Tracy Y Wang
- 1 Duke Clinical Research Institute Durham NC.,2 Division of Cardiology Department of Medicine Duke University School of Medicine Durham NC
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27
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Lowenstern A, Wu J, Bradley SM, Fanaroff AC, Tcheng JE, Wang TY. Current landscape of hybrid revascularization: A report from the NCDR CathPCI Registry. Am Heart J 2019; 215:167-177. [PMID: 31349108 DOI: 10.1016/j.ahj.2019.06.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 06/24/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Hybrid revascularization, combining percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), may be used differently across hospitals. How outcomes compare with multivessel PCI is unknown. METHODS We studied hybrid revascularization use in patients in the National Cardiovascular Data Registry from 2009 to 2017 who underwent PCI for multivessel coronary artery disease (CAD) at 711 hospitals, excluding patients with prior CABG, acute ST-elevation myocardial infarction, emergency/salvage CABG, or PCI without stent placement. In-hospital mortality associated with hybrid revascularization versus multivessel PCI was compared using a multivariable logistic model. RESULTS Among 775,000 patients with multivessel CAD, 1,126 (0.2%) underwent hybrid revascularization and 256,865 (33%) were treated with multivessel PCI. Although 358 (50.4%) hospitals performed hybrid revascularizations, most (97.3%) performed <1 per year. Most patients (68.7%) treated with hybrid revascularization underwent CABG after PCI; only 79.4% of these patients were discharged on P2Y12 inhibitors. Patients who underwent hybrid revascularization were younger and more likely to have significant left main or proximal left anterior descending disease. Unadjusted in-hospital mortality rates were higher among patients treated with hybrid revascularization than multivessel PCI (1.5% vs 0.9%, P = .02), a difference that was not significant after multivariable adjustment (odds ratio = 1.54, 95% CI = 0.92-2.59). CONCLUSIONS Hybrid revascularization remains an infrequently used treatment modality for multivessel CAD. Risk-adjusted in-hospital mortality was no different between hybrid revascularization and multivessel PCI; however, patients who underwent hybrid revascularization were less likely to be discharged on P2Y12 inhibitor therapy despite stent implantation.
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Affiliation(s)
- Angela Lowenstern
- Duke Clinical Research Institute, Durham, NC; Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC.
| | - Jingjing Wu
- Duke Clinical Research Institute, Durham, NC
| | | | - Alexander C Fanaroff
- Duke Clinical Research Institute, Durham, NC; Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC
| | - James E Tcheng
- Duke Clinical Research Institute, Durham, NC; Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Tracy Y Wang
- Duke Clinical Research Institute, Durham, NC; Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC
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28
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Lowenstern A, Lippmann SJ, Brennan JM, Wang TY, Curtis LH, Feldman T, Glower DD, Hammill BG, Vemulapalli S. Use of Medicare Claims to Identify Adverse Clinical Outcomes After Mitral Valve Repair. Circ Cardiovasc Interv 2019; 12:e007451. [PMID: 31084236 PMCID: PMC6760250 DOI: 10.1161/circinterventions.118.007451] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 02/25/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Clinical event committees are commonly employed for event validation in clinical studies, but little is known about the comparative performance of administrative claims data versus clinician-triggered event adjudication for ascertainment of adverse events in structural heart disease studies. METHODS AND RESULTS Medicare claims were linked to 418 patients >65 years of age who underwent transcatheter mitral valve repair (MitraClip) for severe mitral regurgitation from 2007 to 2013 as part of the EVEREST II (Endovascular Valve Edge-to-Edge Repair Study II) High-Risk Registry or the REALISM (Real World Expanded Multicenter Study of the MitraClip System) Continued-Access Registry. Each registry adjudicated mortality, heart failure hospitalization, renal failure, ventilation, and bleeding/transfusion within 1 year. Concordance of claims-based outcomes with events was assessed in 3 ways: 1-year occurrence, cumulative incidence, and synchrony of first events. For event occurrence, positive predictive value (PPV) of claims versus adjudication was the highest for mortality (PPV=97%) and heart failure hospitalization (PPV=69%) but lower for bleeding (PPV=40%) and renal failure (PPV=19%). Whereas claims-based cumulative incidence for mortality, heart failure hospitalization, and renal failure were consistent with clinician-triggered adjudication, incidence curves for bleeding events and ventilation diverged, with claims identifying a greater number of events. When events were detected by both methods, however, over 75% of event dates matched exactly. Mitral valve reinterventions were identified through claims with perfect sensitivity and specificity relative to physician adjudication. CONCLUSIONS Ascertainment of mortality, heart failure hospitalization, and renal failure was highly concordant between physician adjudication and administrative claims. Further work is necessary to determine the role of administrative claims in event ascertainment in both prospective and retrospective studies of structural heart disease.
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Affiliation(s)
- Angela Lowenstern
- Division of Cardiology, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | - Steven J. Lippmann
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - J. Matthew Brennan
- Division of Cardiology, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | - Tracy Y. Wang
- Division of Cardiology, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | - Lesley H. Curtis
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | - Ted Feldman
- Evanston Hospital, Northshore University Health System, Evanston, IL
| | - Donald D. Glower
- Division of Cardiothoracic Surgery, Duke University School of Medicine, Durham, NC
| | - Bradley G. Hammill
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | - Sreekanth Vemulapalli
- Division of Cardiology, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Durham, NC
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Lowenstern A, Navar AM, Li S, Virani SS, Goldberg AC, Louie MJ, Lee LV, Peterson ED, Wang TY. Association of Clinician Knowledge and Statin Beliefs With Statin Therapy Use and Lipid Levels (A Survey of US Practice in the PALM Registry). Am J Cardiol 2019; 123:1011-1018. [PMID: 30660354 DOI: 10.1016/j.amjcard.2018.12.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 12/21/2018] [Accepted: 12/27/2018] [Indexed: 10/27/2022]
Abstract
Guideline implementation requires clinician knowledge but may be influenced by pre-existing beliefs and biases. We assessed the association of these clinician factors with lipid management following the release of the 2013 American College of Cardiology/American Heart Association cholesterol guidelines. In the PALM registry, 774 clinicians completed a survey to assess their knowledge of the 2013 American College of Cardiology/American Heart Association guidelines, belief in statin benefit, and statin safety concerns. The association of these factors with statin use, statin dosing, and low-density lipoprotein cholesterol (LDL-C) levels were assessed in the 6,839 patients treated by these clinicians between May and November 2015. Overall, 63.9% of clinicians responded to at least 3 out of 4 hypothetical scenarios in concordance with guideline recommendations (good tested knowledge), 88.4% reported belief in statin benefit, and 15.4% raised concerns about statin safety. Belief in statin benefit was more prevalent among cardiologists, who represented 48.8% of the clinicians surveyed, and concerns regarding statin safety were higher among noncardiologists and clinicians in an academic setting. Guideline knowledge was not associated with a difference in statin use (74.1% vs 73.8%, p = 0.84) and achievement of LDL-C level <100 mg/dl (54.7% vs 52.4%, p = 0.07). However, patients treated by clinicians who reported belief in statin benefit were more likely to receive guideline-recommended statin intensity (41.9% vs 36.9%, p = 0.03), whereas patients treated by clinicians expressing statin safety concerns were less likely receive statins of at least guideline-recommended intensity (36.8% vs 42.5%, p = 0.001) and to achieve an LDL-C <100 mg/dl (44.1% vs 56.1%, p <0.001); the latter persisted after multivariable adjustment (odds ratio 0.75, 95% confidence interval 0.63 to 0.89). In conclusion, clinician beliefs regarding benefits and risks of statins were significantly associated with guideline adherence and patients' achieved LDL-C levels, whereas clinician knowledge of guideline recommendations was not.
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Rymer J, Kennedy K, Lowenstern A, Secemsky E, Aronow H, Gray B, Prasad A, Armstrong E, Rosenfield K, Shishehbor M, Jones S, Patel M. IN-HOSPITAL OUTCOMES AND DISCHARGE MEDICATION USE AMONG PATIENTS PRESENTING WITH CRITICAL LIMB ISCHEMIA VERSUS CLAUDICATION: INSIGHTS FROM THE NCDR PVI REGISTRY. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)32642-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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31
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Lowenstern A, Al-Khatib SM, Sharan L, Chatterjee R, Allen LaPointe NM, Shah B, Borre ED, Raitz G, Goode A, Yapa R, Davis JK, Lallinger K, Schmidt R, Kosinski AS, Sanders GD. Interventions for Preventing Thromboembolic Events in Patients With Atrial Fibrillation: A Systematic Review. Ann Intern Med 2018; 169:774-787. [PMID: 30383133 PMCID: PMC6825839 DOI: 10.7326/m18-1523] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The comparative safety and effectiveness of treatments to prevent thromboembolic complications in atrial fibrillation (AF) remain uncertain. PURPOSE To compare the effectiveness of medical and procedural therapies in preventing thromboembolic events and bleeding complications in adults with nonvalvular AF. DATA SOURCES English-language studies in several databases from 1 January 2000 to 14 February 2018. STUDY SELECTION Two reviewers independently screened citations to identify comparative studies of treatments to prevent stroke in adults with nonvalvular AF who reported thromboembolic or bleeding complications. DATA EXTRACTION Two reviewers independently abstracted data, assessed study quality and applicability, and rated strength of evidence. DATA SYNTHESIS Data from 220 articles were included. Dabigatran and apixaban were superior and rivaroxaban and edoxaban were similar to warfarin in preventing stroke or systemic embolism. Apixaban and edoxaban were superior and rivaroxaban and dabigatran were similar to warfarin in reducing the risk for major bleeding. Treatment effects with dabigatran were similar in patients with renal dysfunction (interaction P > 0.05), and patients younger than 75 years had lower bleeding rates with dabigatran (interaction P < 0.001). The benefit of treatment with apixaban was consistent in many subgroups, including those with renal impairment, diabetes, and prior stroke (interaction P > 0.05 for all). The greatest bleeding risk reduction was observed in patients with a glomerular filtration rate less than 50 mL/min/1.73 m2 (P = 0.003). Similar treatment effects were observed for rivaroxaban and edoxaban in patients with prior stroke, diabetes, or heart failure (interaction P > 0.05 for all). LIMITATION Heterogeneous study populations, interventions, and outcomes. CONCLUSION The available direct-acting oral anticoagulants (DOACs) are at least as effective and safe as warfarin for patients with nonvalvular AF. The DOACs had similar benefits across several patient subgroups and seemed safe and efficacious for a wide range of patients with nonvalvular AF. PRIMARY FUNDING SOURCE Patient-Centered Outcomes Research Institute. (PROSPERO: CRD42017069999).
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Affiliation(s)
- Angela Lowenstern
- Duke University School of Medicine, Durham, North Carolina (A.L., S.M.A., L.S., R.C., E.D.B., G.R., A.G., K.L., R.S., A.S.K.)
| | - Sana M Al-Khatib
- Duke University School of Medicine, Durham, North Carolina (A.L., S.M.A., L.S., R.C., E.D.B., G.R., A.G., K.L., R.S., A.S.K.)
| | - Lauren Sharan
- Duke University School of Medicine, Durham, North Carolina (A.L., S.M.A., L.S., R.C., E.D.B., G.R., A.G., K.L., R.S., A.S.K.)
| | - Ranee Chatterjee
- Duke University School of Medicine, Durham, North Carolina (A.L., S.M.A., L.S., R.C., E.D.B., G.R., A.G., K.L., R.S., A.S.K.)
| | - Nancy M Allen LaPointe
- Duke University School of Medicine, Durham, and Premier, Charlotte, North Carolina (N.M.A.)
| | - Bimal Shah
- Duke University School of Medicine, Durham, North Carolina, and Livongo, Mountain View, California (B.S.)
| | - Ethan D Borre
- Duke University School of Medicine, Durham, North Carolina (A.L., S.M.A., L.S., R.C., E.D.B., G.R., A.G., K.L., R.S., A.S.K.)
| | - Giselle Raitz
- Duke University School of Medicine, Durham, North Carolina (A.L., S.M.A., L.S., R.C., E.D.B., G.R., A.G., K.L., R.S., A.S.K.)
| | - Adam Goode
- Duke University School of Medicine, Durham, North Carolina (A.L., S.M.A., L.S., R.C., E.D.B., G.R., A.G., K.L., R.S., A.S.K.)
| | | | | | - Kathryn Lallinger
- Duke University School of Medicine, Durham, North Carolina (A.L., S.M.A., L.S., R.C., E.D.B., G.R., A.G., K.L., R.S., A.S.K.)
| | - Robyn Schmidt
- Duke University School of Medicine, Durham, North Carolina (A.L., S.M.A., L.S., R.C., E.D.B., G.R., A.G., K.L., R.S., A.S.K.)
| | - Andrzej S Kosinski
- Duke University School of Medicine, Durham, North Carolina (A.L., S.M.A., L.S., R.C., E.D.B., G.R., A.G., K.L., R.S., A.S.K.)
| | - Gillian D Sanders
- Duke University School of Medicine and Duke University, Durham, North Carolina (G.D.S.)
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Borre ED, Goode A, Raitz G, Shah B, Lowenstern A, Chatterjee R, Sharan L, Allen LaPointe NM, Yapa R, Davis JK, Lallinger K, Schmidt R, Kosinski A, Al-Khatib SM, Sanders GD. Predicting Thromboembolic and Bleeding Event Risk in Patients with Non-Valvular Atrial Fibrillation: A Systematic Review. Thromb Haemost 2018; 118:2171-2187. [PMID: 30376678 DOI: 10.1055/s-0038-1675400] [Citation(s) in RCA: 137] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is a common cardiac arrhythmia that increases the risk of stroke. Medical therapy for decreasing stroke risk involves anticoagulation, which may increase bleeding risk for certain patients. In determining the optimal therapy for stroke prevention for patients with AF, clinicians use tools with various clinical, imaging and patient characteristics to weigh stroke risk against therapy-associated bleeding risk. AIM This article reviews published literature and summarizes available risk stratification tools for stroke and bleeding prediction in patients with AF. METHODS We searched for English-language studies in PubMed, Embase and the Cochrane Database of Systematic Reviews published between 1 January 2000 and 14 February 2018. Two reviewers screened citations for studies that examined tools for predicting thromboembolic and bleeding risks in patients with AF. Data regarding study design, patient characteristics, interventions, outcomes, quality, and applicability were extracted. RESULTS Sixty-one studies were relevant to predicting thromboembolic risk and 38 to predicting bleeding risk. Data suggest that CHADS2, CHA2DS2-VASc and the age, biomarkers, and clinical history (ABC) risk scores have the best evidence for predicting thromboembolic risk (moderate strength of evidence for limited prediction ability of each score) and that HAS-BLED has the best evidence for predicting bleeding risk (moderate strength of evidence). LIMITATIONS Studies were heterogeneous in methodology and populations of interest, setting, interventions and outcomes analysed. CONCLUSION CHADS2, CHA2DS2-VASc and ABC scores have the best prediction for stroke events, and HAS-BLED provides the best prediction for bleeding risk. Future studies should define the role of imaging tools and biomarkers in enhancing the accuracy of risk prediction tools. PRIMARY FUNDING SOURCE Patient-Centered Outcomes Research Institute (PROSPERO #CRD42017069999).
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Affiliation(s)
- Ethan D Borre
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States
| | - Adam Goode
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States.,Department of Orthopedic Surgery, Duke University School of Medicine, Durham, North Carolina, United States
| | - Giselle Raitz
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States
| | - Bimal Shah
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States.,Livongo, Mountain View, California, United States
| | - Angela Lowenstern
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States.,Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Ranee Chatterjee
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States
| | - Lauren Sharan
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States
| | - Nancy M Allen LaPointe
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States.,Premier Inc., Charlotte, North Carolina, United States
| | - Roshini Yapa
- Department of Medicine, University of Colorado, Aurora, Colorado, United States
| | - J Kelly Davis
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, United States
| | - Kathryn Lallinger
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States.,Evidence-Based Practice Center, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States
| | - Robyn Schmidt
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States.,Evidence-Based Practice Center, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States
| | - Andrzej Kosinski
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, United States
| | - Sana M Al-Khatib
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States.,Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Gillian D Sanders
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States.,Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina, United States.,Evidence-Based Practice Center, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States
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Lowenstern A, Storey RF, Neely M, Sun JL, Angiolillo DJ, Cannon CP, Himmelmann A, Huber K, James SK, Katus HA, Morais J, Siegbahn A, Steg PG, Wallentin L, Becker RC. Platelet-related biomarkers and their response to inhibition with aspirin and p2y 12-receptor antagonists in patients with acute coronary syndrome. J Thromb Thrombolysis 2018; 44:145-153. [PMID: 28608165 DOI: 10.1007/s11239-017-1516-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The PLATelet inhibition and patient Outcomes (PLATO) trial showed that treatment with ticagrelor reduced the rate of death due to vascular causes, myocardial infarction and stroke when compared to clopidogrel in patients with ST-elevation or non-ST-elevation acute coronary syndrome (ACS). While the comparative benefit of ticagrelor over clopidogrel increased over time, event rates accrued in both groups during the study period. The purpose of our biomarker-based exploratory analysis was to determine whether long-term platelet inhibition may be associated with platelet adaptation. A sample of 4000 participants from the PLATO trial also consented to participate in a prospectively designed biomarker substudy. Blood samples were procured at baseline, immediately prior to hospital discharge and at 1 and 6 months. Markers of platelet activity, including platelet count, serum CD40-ligand and soluble P-selectin were analyzed. Mean levels were compared at discharge, 1 and 6 months following study drug initiation-first for all patients and subsequently stratified by treatment group. A linear mixed model was used to estimate the short-term change rate (baseline to 1 month) and long-term change rate (1-6 months) for each biomarker. A Cox proportional hazards model was used to calculate hazard ratios for each change in biomarker over the two time periods examined: baseline to 1 month and 1 to 6 months. Prior to randomized treatment (baseline), sCD40 ligand and sP-selectin levels were elevated above the normal range of the assay (0.39 and 33.5 µg/L, respectively). The mean level of each biomarker was significantly different at 1 month compared to baseline (p < 0.0001). When stratified by treatment group, at 1 month patients treated with ticagrelor had a larger increase in platelet count compared to those treated with clopidogrel (p < 0.0001). Similarly, when comparing biomarker levels for all patients at 6 months with those at 1 month, each differed significantly (p < 0.05). There was no significant difference between treatment groups during this time period. The rate of change for both platelet count and sP-selectin were significantly different between baseline and 1 month when compared to the 1 to 6-month time period (p < 0.0001). When comparing treatment groups, the rate of increase in platelets from baseline to 1 month was greater for patients treated with ticagrelor (p < 0.0001). This was no longer observed in the 1 to 6-month interval. Using a Cox proportional hazard model, the increase in platelet count from 1 to 6 months was associated with ischemic-thrombotic events, while sCD40 ligand decrease from 1 to 6 months was associated with hemorrhagic events. There were no differences between treatment groups for the associations with clinical endpoints. Dynamic changes in platelet count, sCD-40 ligand and sP-selectin occur over time among patients with ACS. Platelet-directed therapy with a P2Y12 receptor inhibitor in combination with aspirin modestly impacts the expression of these biomarkers. Platelet count and sCD40 ligand may offer modest overall predictive value for future ischemic-thrombotic or hemorrhagic clinical events, respectively. The existence of a platelet adaptome and its overall clinical significance among patients at risk for thrombotic events will require a more in-depth and platelet-biology specific investigation.
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Affiliation(s)
- Angela Lowenstern
- Duke Clinical Research Institute, Duke University, Medical Center, 2301 Erwin Road, DUMC Box 2845, Durham, NC, 27710, USA.
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Megan Neely
- Duke Clinical Research Institute, Duke University, Medical Center, 2301 Erwin Road, DUMC Box 2845, Durham, NC, 27710, USA
| | - Jie-Lena Sun
- Duke Clinical Research Institute, Duke University, Medical Center, 2301 Erwin Road, DUMC Box 2845, Durham, NC, 27710, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | | | | | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care, Wilhelminen Hospital, Vienna, Austria.,Sigmund Freud Private University, Medical School, Vienna, Austria
| | - Stefan K James
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Hugo A Katus
- Medizinishe Klinik, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | | | - Agneta Siegbahn
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.,Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Phillippe Gabriel Steg
- Département Hospitalo-Universitaire FIRE, AP-HP, Hôpital Bichat, Paris, France.,Paris Diderot University, Sorbonne Paris Cité, Paris, France.,NHLI Imperial College, ICMS, Royal Brompton Hospital, London, UK.,FACT (French Alliance for Cardiovascular Trials), an F-CRIN network, INSERM U1148, Paris, France
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Richard C Becker
- Division of Cardiovascular Health and Disease, Heart, Lung and Vascular Institute, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Kiani S, Stebbins A, Thourani VH, Forcillo J, Vemulapalli S, Kosinski A, Babaliaros V, Cohen D, Kodali SK, Kirtane A, Hermiller J, Stewart J, Lowenstern A, Mavromatis K, Mack MJ, Guyton RA, Devireddy C. THE EFFECT AND RELATIONSHIP OF AGE AND FRAILTY ON SURVIVAL IN PATIENTS UNDERGOING TRANSCATHETER AORTIC VALVE REPLACEMENT. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)31533-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lowenstern A, Mandawat A, Newby LK. In-hospital cardiac arrest: Complex clinical challenges in need of unique solutions. Am Heart J 2017; 193:104-107. [PMID: 29129248 DOI: 10.1016/j.ahj.2017.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 07/21/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Angela Lowenstern
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Anant Mandawat
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC
| | - L Kristin Newby
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC.
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Affiliation(s)
- Angela Lowenstern
- Division of Cardiology, Department of Medicine and the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - L Kristin Newby
- Division of Cardiology, Department of Medicine and the Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
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Lowenstern A, Newby LK. In PCI-treated ACS, switching from aspirin + a newer P2Y12 blocker to aspirin + clopidogrel reduced adverse events. Ann Intern Med 2017; 167:JC28. [PMID: 28975318 DOI: 10.7326/acpjc-2017-167-6-028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Lowenstern A, Newby LK. Review: In CAD without HF, RAS inhibitors reduce deaths more than placebo but not active control. Ann Intern Med 2017; 166:JC43. [PMID: 28418545 DOI: 10.7326/acpjc-2017-166-8-043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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