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Ambrosy AP, Go AS, Leong TK, Garcia EA, Chang AJ, Slade JJ, McNulty EJ, Mishell JM, Rassi AN, Ku IA, Lange DC, Philip F, Galper BZ, Berry N, Solomon MD. Temporal trends in the prevalence and severity of aortic stenosis within a contemporary and diverse community-based cohort. Int J Cardiol 2023; 384:107-111. [PMID: 37119944 DOI: 10.1016/j.ijcard.2023.04.047] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/21/2023] [Accepted: 04/24/2023] [Indexed: 05/01/2023]
Abstract
BACKGROUND Data on the epidemiology of aortic stenosis (AS) are primarily derived from single center experiences and administrative claims data that do not delineate by degree of disease severity. METHODS An observational cohort study of adults with echocardiographic AS was conducted January 1st, 2013-December 31st, 2019 at an integrated health system. The presence/grade of AS was based on physician interpretation of echocardiograms. RESULTS A total of 66,992 echocardiogram reports for 37,228 individuals were identified. The mean ± standard deviation (SD) age was 77.5 ± 10.5, 50.5% (N = 18,816) were women, and 67.2% (N = 25,016) were non-Hispanic whites. The age-standardized AS prevalence increased from 589 (95% Confidence Interval [CI] 580-598) to 754 (95% CI 744-764) cases per 100,000 during the study period. The age-standardized AS prevalences were similar in magnitude among non-Hispanic whites (820, 95% CI 806-834), non-Hispanic blacks (728, 95% CI 687-769), and Hispanics (789, 95% CI 759-819) and substantially lower for Asian/Pacific Islanders (511, 95% CI 489-533). Finally, the distribution of AS by degree of severity remained relatively unchanged over time. CONCLUSIONS AND RELEVANCE The population prevalence of AS has grown considerably over a short timeframe although the distribution of AS severity has remained stable.
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Affiliation(s)
- Andrew P Ambrosy
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA; Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA.
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA; Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, San Francisco, CA, USA; Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Thomas K Leong
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Elisha A Garcia
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Alex J Chang
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
| | - Justin J Slade
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
| | - Edward J McNulty
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
| | - Jacob M Mishell
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
| | - Andrew N Rassi
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
| | - Ivy A Ku
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
| | - David C Lange
- Department of Cardiology, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA, USA
| | - Femi Philip
- Department of Cardiology, Kaiser Permanente Sacramento Medical Center, Sacramento, CA, USA
| | - Benjamin Z Galper
- Department of Cardiology, Mid-Atlantic Permanente Medical Group, McLean, VA, USA
| | - Natalia Berry
- Department of Cardiology, Mid-Atlantic Permanente Medical Group, McLean, VA, USA
| | - Matthew D Solomon
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA; Department of Cardiology, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
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Slade JJ, Ambrosy AP, Leong TK, Sung SH, Garcia EA, Ku IA, Solomon MD, McNulty EJ, Rassi AN, Lange DC, Philip F, Go AS, Mishell JM. Outcomes of Adults with Severe Aortic Stenosis Undergoing Urgent or Emergent vs. Elective Transcatheter Aortic Valve Replacement Within an Integrated Health Care Delivery System. Structural Heart 2023. [PMID: 37520133 PMCID: PMC10382976 DOI: 10.1016/j.shj.2023.100166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Abstract
Background Transcatheter aortic valve replacement (TAVR) may be used to urgently or emergently treat severe aortic stenosis, but outcomes for this high-risk population have not been well-characterized. We sought to describe the incidence, clinical characteristics, and outcomes of patients undergoing urgent or emergent vs. elective TAVR. Methods We identified all adults who received TAVR for primary aortic stenosis between 2013 and 2019 within an integrated health care delivery system in Northern California. Elective or urgent/emergent procedure status was based on standard Society of Thoracic Surgeons definitions. Data were obtained from electronic health records, the Society of Thoracic Surgeons-American College of Cardiology Transcatheter Valve Therapy Registry, and state/national reporting databases. Logistic regression and Cox proportional hazard models were performed. Results Among 1564 eligible adults that underwent TAVR, 81 (5.2%) were classified as urgent/emergent. These patients were more likely to have heart failure (63.0% vs. 47.4%), reduced left ventricular ejection fraction (21.0% vs. 11.8%), or a prior aortic valve balloon valvuloplasty (13.6% vs. 5.0%) and experienced higher unadjusted rates of 30-day and 1-year morbidity and mortality. Urgent/emergent TAVR status was independently associated with non-improved quality of life at 30-days (hazard ratio, 4.87; p < 0.01) and acute kidney injury within 1-year post-TAVR (hazard ratio, 2.11; p = 0.01). There was not a significant difference in adjusted 1-year mortality with urgent/emergent TAVR. Conclusions Urgent/emergent TAVR status was uncommon and associated with high-risk clinical features and higher unadjusted rates of short- and long-term morbidity and mortality. Procedure status may be useful to identify patients less likely to experience significant short term improvement in health-related quality of life post-TAVR.
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Solomon MD, Tabada GH, Sung SH, Allen A, Mishell JM, Rassi AN, McNulty EJ, Philip F, Lange DC, Ambrosy AP, Zaroff JG, Krishnaswami A, Lee C, DeMaria AN, Go AS. PHYSICIAN ASSESSMENT OF AORTIC STENOSIS SEVERITY AND LONG-TERM OUTCOMES: RESULTS FROM THE KP-VALVE PROJECT. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02393-8] [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: 03/07/2023]
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Sachdeva A, Hung YY, Solomon MD, McNulty EJ. Duration of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention for Chronic Total Occlusion. Am J Cardiol 2020; 132:44-51. [PMID: 32762964 DOI: 10.1016/j.amjcard.2020.06.066] [Citation(s) in RCA: 2] [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: 04/17/2020] [Revised: 06/25/2020] [Accepted: 06/30/2020] [Indexed: 11/29/2022]
Abstract
The optimal duration of dual antiplatelet therapy (DAPT) after treatment of chronic total occlusions (CTO) with percutaneous coronary intervention (PCI) is unknown. We aimed to determine if extended (> 12 months) DAPT was associated with a net clinical benefit. The study population included patients who underwent successful CTO PCI within Kaiser Permanente Northern California between 2009 and 2016. Baseline demographic, clinical, and procedural characteristics were compared for patients on DAPT ≤ versus > 12 months. Clinical outcomes (death, myocardial infarction (MI), and ≥ Academic Research Consortium type 3a bleeding) were compared beginning 12 months after PCI using Cox proportional hazards models. We also adjudicated individual causes of death. 1,069 patients were followed for a median of 3.6 years (Interquartile Range = 2.2 to 5.5) following CTO PCI. Patients on DAPT ≤ 12 months (n = 597, 56%) were more likely to have anemia, end stage renal disease, and previous MI. After adjustment for between group differences, > 12 months of DAPT was associated with lower death or MI (hazard ratio [HR]: 0.66; 95% confidence interval [CI]: 0.47 to 0.93) and lower death (HR: 0.54; 95% CI: 0.36 to 0.82). There were no associations with MI (HR: 0.91; 95% CI: 0.55 to 1.5) or bleeding (HR 1.1; 95% CI: 0.50 to 2.4), but a numerically higher proportion of patients on shorter v. longer DAPT died of a cardiovascular cause (37% vs 20%, p = 0.10). In conclusion, > 12 months of DAPT was associated with lower death or MI, without an increase in bleeding. Prospective studies are needed to evaluate the optimal duration of DAPT in this unique subgroup.
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Affiliation(s)
- Amit Sachdeva
- Division of Cardiology, Kaiser Permanente Northern California, Walnut Creek, California; Division of Research, Kaiser Permanente Northern California, Oakland, California.
| | - Yun-Yi Hung
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Matthew D Solomon
- Division of Research, Kaiser Permanente Northern California, Oakland, California; Division of Cardiology, Kaiser Permanente Northern California, Oakland, California
| | - Edward J McNulty
- Division of Research, Kaiser Permanente Northern California, Oakland, California; Division of Cardiology, Kaiser Permanente Northern California, San Francisco, California
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Solomon MD, McNulty EJ, Rana JS, Leong TK, Lee C, Sung SH, Ambrosy AP, Sidney S, Go AS. The Covid-19 Pandemic and the Incidence of Acute Myocardial Infarction. N Engl J Med 2020; 383:691-693. [PMID: 32427432 DOI: 10.1056/nejmc2015630] [Citation(s) in RCA: 470] [Impact Index Per Article: 117.5] [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] [Indexed: 12/15/2022]
Affiliation(s)
| | - Edward J McNulty
- Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - Jamal S Rana
- Kaiser Permanente Oakland Medical Center, Oakland, CA
| | | | | | - Sue-Hee Sung
- Kaiser Permanente Northern California, Oakland, CA
| | - Andrew P Ambrosy
- Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | | | - Alan S Go
- Kaiser Permanente Northern California, Oakland, CA
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Iribarren C, Round AD, Lu M, Okin PM, McNulty EJ. Cohort Study of ECG Left Ventricular Hypertrophy Trajectories: Ethnic Disparities, Associations With Cardiovascular Outcomes, and Clinical Utility. J Am Heart Assoc 2017; 6:JAHA.116.004954. [PMID: 28982671 PMCID: PMC5721817 DOI: 10.1161/jaha.116.004954] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [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: 12/31/2022]
Abstract
Background ECG left ventricular hypertrophy (LVH) is a well‐known predictor of cardiovascular disease. However, no prior study has characterized patterns of presence/absence of ECG LVH (“ECG LVH trajectories”) across the adult lifespan in both sexes and across ethnicities. We examined: (1) correlates of ECG LVH trajectories; (2) the association of ECG LVH trajectories with incident coronary heart disease, transient ischemic attack, ischemic stroke, hemorrhagic stroke, and heart failure; and (3) reclassification of cardiovascular disease risk using ECG LVH trajectories. Methods and Results We performed a cohort study among 75 412 men and 107 954 women in the Northern California Kaiser Permanente Medical Care Program who had available longitudinal exposures of ECG LVH and covariates, followed for a median of 4.8 (range <1–9.3) years. ECG LVH was measured by Cornell voltage‐duration product. Adverse trajectories of ECG LVH (persistent, new development, or variable pattern) were more common among blacks and Native American men and were independently related to incident cardiovascular disease with hazard ratios ranging from 1.2 for ECG LVH variable pattern and transient ischemic attack in women to 2.8 for persistent ECG LVH and heart failure in men. ECG LVH trajectories reclassified 4% and 7% of men and women with intermediate coronary heart disease risk, respectively. Conclusions ECG LVH trajectories were significant indicators of coronary heart disease, stroke, and heart failure risk, independently of level and change in cardiovascular disease risk factors, and may have clinical utility.
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Affiliation(s)
| | | | - Meng Lu
- Division of Research, Kaiser Permanente, Oakland, CA
| | - Peter M Okin
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Edward J McNulty
- Cardiology Department, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
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Jang JS, Spertus JA, Arnold SV, Shafiq A, Grodzinsky A, Fendler TJ, Salisbury AC, Tang F, McNulty EJ, Grantham JA, Cohen DJ, Amin AP. Impact of multivessel revascularization on health status outcomes in patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease. J Am Coll Cardiol 2016; 66:2104-2113. [PMID: 26541921 DOI: 10.1016/j.jacc.2015.08.873] [Citation(s) in RCA: 10] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Revised: 08/21/2015] [Accepted: 08/25/2015] [Indexed: 01/24/2023]
Abstract
BACKGROUND Up to 65% of patients with ST-segment elevation myocardial infarction (STEMI) have multivessel coronary artery disease (MVCAD). Long-term health status of STEMI patients after multivessel revascularization is unknown. OBJECTIVES This study investigated the relationship between multivessel revascularization and health status outcomes (symptoms and quality of life [QoL]) in STEMI patients with MVCAD. METHODS Using a U.S. myocardial infarction registry and the Seattle Angina Questionnaire (SAQ), we determined the health status of patients with STEMI and MVCAD at the time of STEMI and 1 year later. We assessed the association of multivessel revascularization during index hospitalization with 1-year health status using multivariable linear regression analysis, and also examined demographic, clinical, and angiographic factors associated with multivessel revascularization. RESULTS Among 664 STEMI patients with MVCAD, 251 (38%) underwent multivessel revascularization. Most revascularizations were staged during the index hospitalization (64.1%), and 8.0% were staged after discharge, with 27.9% performed during primary percutaneous coronary intervention. Multivessel revascularization was associated with age and more diseased vessels. At 1 year, multivessel revascularization was independently associated with improved symptoms (4.5 points higher SAQ angina frequency score; 95% confidence interval [CI]: 1.0 to 7.9) and QoL (6.6 points higher SAQ QoL score; 95% CI: 2.7 to 10.6). One-year mortality was not different between those who did and did not undergo multivessel revascularization (3.6% vs. 3.4%; log-rank test p = 0.88). CONCLUSIONS Multivessel revascularization improved angina and QoL in STEMI patients with MVCAD. Patient-centered outcomes should be considered in future trials of multivessel revascularization.
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Affiliation(s)
- Jae-Sik Jang
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri; Department of Cardiology, Busan Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - John A Spertus
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri.
| | - Suzanne V Arnold
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - Ali Shafiq
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - Anna Grodzinsky
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - Timothy J Fendler
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - Adam C Salisbury
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - Fengming Tang
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Edward J McNulty
- Division of Cardiology, Kaiser Permanente Medical Center, San Francisco, California
| | - J Aaron Grantham
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - David J Cohen
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - Amit P Amin
- Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri; Barnes-Jewish Hospital, St. Louis, Missouri
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Solomon MD, Leong TK, Sung SH, Inveiss A, Hernandez JB, White RM, Sosa M, McNulty EJ, Go AS. TCT-443 Cost and Utilization Among Patients After Incident Percutaneous Coronary Intervention. J Am Coll Cardiol 2015. [DOI: 10.1016/j.jacc.2015.08.459] [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: 10/23/2022]
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Spertus JA, Decker C, Gialde E, Jones PG, McNulty EJ, Bach R, Chhatriwalla AK. Precision medicine to improve use of bleeding avoidance strategies and reduce bleeding in patients undergoing percutaneous coronary intervention: prospective cohort study before and after implementation of personalized bleeding risks. BMJ 2015; 350:h1302. [PMID: 25805158 PMCID: PMC4462518 DOI: 10.1136/bmj.h1302] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To examine whether prospective bleeding risk estimates for patients undergoing percutaneous coronary intervention could improve the use of bleeding avoidance strategies and reduce bleeding. DESIGN Prospective cohort study comparing the use of bleeding avoidance strategies and bleeding rates before and after implementation of prospective risk stratification for peri-procedural bleeding. SETTING Nine hospitals in the United States. PARTICIPANTS All patients undergoing percutaneous coronary intervention for indications other than primary reperfusion for ST elevation myocardial infarction. MAIN OUTCOME MEASURES Use of bleeding avoidance strategies, including bivalirudin, radial approach, and vascular closure devices, and peri-procedural bleeding rates, stratified by bleeding risk. Observed changes were adjusted for changes observed in a pool of 1135 hospitals without access to pre-procedural risk stratification. Hospital level and physician level variability in use of bleeding avoidance strategies was examined. RESULTS In a comparison of 7408 pre-intervention procedures with 3529 post-intervention procedures, use of bleeding avoidance strategies within intervention sites increased with pre-procedural risk stratification (odds ratio 1.81, 95% confidence interval 1.44 to 2.27), particularly among higher risk patients (2.03, 1.58 to 2.61; 1.41, 1.09 to 1.83 in low risk patients, after adjustment for control sites; P for interaction = 0.05). Bleeding rates within intervention sites were significantly lower after implementation of risk stratification (1.0% v 1.7%; odds ratio 0.56, 0.40 to 0.78; 0.62, 0.44 to 0.87, after adjustment); the reduction in bleeding was greatest in high risk patients. Marked variability in use of bleeding avoidance strategies was observed across sites and physicians, both before and after implementation. CONCLUSIONS Prospective provision of individualized bleeding risk estimates was associated with increased use of bleeding avoidance strategies and lower bleeding rates. Marked variability between providers highlights an important opportunity to improve the consistency, safety, and quality of care. Study registration Clinicaltrials.gov NCT01383382.
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Affiliation(s)
- John A Spertus
- Saint Luke's Mid America Heart Institute, 4401 Wornall Road, Kansas City, MO 64111, USA University of Missouri-Kansas City, Kansas City, MO, USA
| | - Carole Decker
- Saint Luke's Mid America Heart Institute, 4401 Wornall Road, Kansas City, MO 64111, USA University of Missouri-Kansas City, Kansas City, MO, USA
| | - Elizabeth Gialde
- Saint Luke's Mid America Heart Institute, 4401 Wornall Road, Kansas City, MO 64111, USA
| | - Philip G Jones
- Saint Luke's Mid America Heart Institute, 4401 Wornall Road, Kansas City, MO 64111, USA
| | | | | | - Adnan K Chhatriwalla
- Saint Luke's Mid America Heart Institute, 4401 Wornall Road, Kansas City, MO 64111, USA University of Missouri-Kansas City, Kansas City, MO, USA
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Spertus JA, Bach R, Bethea C, Chhatriwalla A, Curtis JP, Gialde E, Guerrero M, Gosch K, Jones PG, Kugelmass A, Leonard BM, McNulty EJ, Shelton M, Ting HH, Decker C. Improving the process of informed consent for percutaneous coronary intervention: patient outcomes from the Patient Risk Information Services Manager (ePRISM) study. Am Heart J 2015; 169:234-241.e1. [PMID: 25641532 DOI: 10.1016/j.ahj.2014.11.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 11/11/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND While the process of informed consent is designed to transfer knowledge of the risks and benefits of treatment and to engage patients in shared medical decision-making, this is poorly done in routine clinical care. We assessed the impact of a novel informed consent form for percutaneous coronary intervention (PCI) that is more simply written, includes images of the procedure, and embeds individualized estimates of outcomes on multiple domains of successful informed consent and shared decision-making. METHODS We interviewed 590 PCI patients receiving traditional consent documents and 527 patients receiving novel ePRISM consents at 9 US centers and compared patients' perceptions, knowledge transfer, and engagement in medical decision-making. Heterogeneity across sites was assessed and adjusted for using hierarchical models. RESULTS Site-adjusted analyses revealed more frequent review (72% for ePRISM vs 45% for original consents) and better understanding of the ePRISM consents (ORs=1.8-3.0, depending upon the outcome) with marked heterogeneity across sites (median relative difference [MRD] in the ORs of ePRISM's effect =2-3.2). Patients receiving ePRISM consents better understood the purposes and risks of the procedure (ORs=1.9-3.9, MRDs=1.1-6.2), engaged more in shared decision-making (proportional OR=2.1 [95% CI=1.02-4.4], MRD=2.2) and discussed stent options with their physicians (58% vs. 31%; site-adjusted odds ratio=2.7 [95% CI=1.2, 6.3], MRD=2.6) more often. CONCLUSIONS A personalized consent document improved the process of informed consent and shared decision-making. Marked heterogeneity across hospitals highlights that consent documents are but one aspect of engaging patients in understanding and participating in treatment.
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Waldo SW, Secemsky EA, O'Brien C, Kennedy KF, Pomerantsev E, Sundt TM, McNulty EJ, Scirica BM, Yeh RW. Surgical ineligibility and mortality among patients with unprotected left main or multivessel coronary artery disease undergoing percutaneous coronary intervention. Circulation 2014; 130:2295-301. [PMID: 25391519 DOI: 10.1161/circulationaha.114.011541] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Decisions to proceed with surgical versus percutaneous revascularization for multivessel coronary artery disease are often based on subtle clinical information that may not be captured in contemporary registries. The present study sought to evaluate the association between surgical ineligibility documented in the medical record and long-term mortality among patients with unprotected left main or multivessel coronary artery disease undergoing percutaneous coronary intervention. METHODS AND RESULTS All subjects undergoing nonemergent percutaneous coronary intervention for unprotected left main or multivessel coronary artery disease were identified at 2 academic medical centers from 2009 to 2012. Documentation of surgical ineligibility was assessed through review of electronic medical records. Cox proportional hazard models adjusted for known mortality risk factors were created to assess long-term mortality in patients with and without documentation of surgical ineligibility. Among 1013 subjects with multivessel coronary artery disease, 218 (22%) were deemed ineligible for coronary artery bypass graft surgery. The most common explicitly cited reasons for surgical ineligibility in the medical record were poor surgical targets (24%), advanced age (16%), and renal insufficiency (16%). After adjustment for known risk factors, documentation of surgical ineligibility remained independently associated with an increased risk of in-hospital (odds ratio, 6.26; 95% confidence interval, 2.16-18.15; P<0.001) and long-term mortality (hazard ratio, 2.98; 95% confidence interval, 1.88-4.72, P<0.001) after percutaneous coronary intervention. CONCLUSIONS Documented surgical ineligibility is common and associated with significantly increased long-term mortality among patients undergoing percutaneous coronary intervention with unprotected left main or multivessel coronary disease, even after adjustment for known risk factors for adverse events during percutaneous revascularization.
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Affiliation(s)
- Stephen W Waldo
- From the Department of Medicine, Division of Cardiology (S.W.W., E.A.S., C.O., E.P., R.W.Y.) and Division of Cardiac Surgery (T.M.S.), Massachusetts General Hospital, Boston; Saint Luke's Mid-America Heart Institute, Kansas City, MO (K.F.K.); Division of Cardiology, Kaiser Permanente Medical Center, San Francisco, CA (E.J.M.); and Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (B.M.S.)
| | - Eric A Secemsky
- From the Department of Medicine, Division of Cardiology (S.W.W., E.A.S., C.O., E.P., R.W.Y.) and Division of Cardiac Surgery (T.M.S.), Massachusetts General Hospital, Boston; Saint Luke's Mid-America Heart Institute, Kansas City, MO (K.F.K.); Division of Cardiology, Kaiser Permanente Medical Center, San Francisco, CA (E.J.M.); and Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (B.M.S.)
| | - Cashel O'Brien
- From the Department of Medicine, Division of Cardiology (S.W.W., E.A.S., C.O., E.P., R.W.Y.) and Division of Cardiac Surgery (T.M.S.), Massachusetts General Hospital, Boston; Saint Luke's Mid-America Heart Institute, Kansas City, MO (K.F.K.); Division of Cardiology, Kaiser Permanente Medical Center, San Francisco, CA (E.J.M.); and Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (B.M.S.)
| | - Kevin F Kennedy
- From the Department of Medicine, Division of Cardiology (S.W.W., E.A.S., C.O., E.P., R.W.Y.) and Division of Cardiac Surgery (T.M.S.), Massachusetts General Hospital, Boston; Saint Luke's Mid-America Heart Institute, Kansas City, MO (K.F.K.); Division of Cardiology, Kaiser Permanente Medical Center, San Francisco, CA (E.J.M.); and Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (B.M.S.)
| | - Eugene Pomerantsev
- From the Department of Medicine, Division of Cardiology (S.W.W., E.A.S., C.O., E.P., R.W.Y.) and Division of Cardiac Surgery (T.M.S.), Massachusetts General Hospital, Boston; Saint Luke's Mid-America Heart Institute, Kansas City, MO (K.F.K.); Division of Cardiology, Kaiser Permanente Medical Center, San Francisco, CA (E.J.M.); and Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (B.M.S.)
| | - Thoralf M Sundt
- From the Department of Medicine, Division of Cardiology (S.W.W., E.A.S., C.O., E.P., R.W.Y.) and Division of Cardiac Surgery (T.M.S.), Massachusetts General Hospital, Boston; Saint Luke's Mid-America Heart Institute, Kansas City, MO (K.F.K.); Division of Cardiology, Kaiser Permanente Medical Center, San Francisco, CA (E.J.M.); and Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (B.M.S.)
| | - Edward J McNulty
- From the Department of Medicine, Division of Cardiology (S.W.W., E.A.S., C.O., E.P., R.W.Y.) and Division of Cardiac Surgery (T.M.S.), Massachusetts General Hospital, Boston; Saint Luke's Mid-America Heart Institute, Kansas City, MO (K.F.K.); Division of Cardiology, Kaiser Permanente Medical Center, San Francisco, CA (E.J.M.); and Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (B.M.S.)
| | - Benjamin M Scirica
- From the Department of Medicine, Division of Cardiology (S.W.W., E.A.S., C.O., E.P., R.W.Y.) and Division of Cardiac Surgery (T.M.S.), Massachusetts General Hospital, Boston; Saint Luke's Mid-America Heart Institute, Kansas City, MO (K.F.K.); Division of Cardiology, Kaiser Permanente Medical Center, San Francisco, CA (E.J.M.); and Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (B.M.S.)
| | - Robert W Yeh
- From the Department of Medicine, Division of Cardiology (S.W.W., E.A.S., C.O., E.P., R.W.Y.) and Division of Cardiac Surgery (T.M.S.), Massachusetts General Hospital, Boston; Saint Luke's Mid-America Heart Institute, Kansas City, MO (K.F.K.); Division of Cardiology, Kaiser Permanente Medical Center, San Francisco, CA (E.J.M.); and Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (B.M.S.).
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Affiliation(s)
- Edward J McNulty
- Division of Cardiology, Kaiser Permanente Medical Center, San Francisco, California
| | - Yun-Yi Hung
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Lucy M Almers
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Robert W Yeh
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
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Ren X, Banki NM, Shaw RE, McNulty EJ, Williams SC, Pencina M, Schiller NB. Doppler-detected valve movement in aortic stenosis: a predictor of adverse outcome. Clin Cardiol 2014; 37:167-71. [PMID: 24399781 DOI: 10.1002/clc.22236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 10/09/2013] [Accepted: 11/27/2013] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The absence of auscultatory aortic valve closure sound is associated with severe aortic stenosis. The absence of Doppler-derived aortic opening (Aop ) or closing (Acl ) may be a sign of advanced severe aortic stenosis. HYPOTHESIS Absent Doppler-detected Aop or Acl transient is indicative of very severe aortic stenosis and is associated with adverse outcome. METHODS A total of 118 consecutive patients with moderate (n = 63) or severe aortic stenosis (n = 55) were included. Aop and Acl signals were identified in a blinded fashion by continuous-wave Doppler. Patients with and without Aop and Acl were compared using χ(2) test for dichotomous variables and analysis of variance for continuous variables. The associations of Aop and Acl with aortic valve replacement were determined. RESULTS Aop or Acl were absent in 22 of 118 patients. The absence of Aop or Acl was associated with echocardiographic parameters of severe aortic stenosis. The absence of Aop or Acl was associated with incident aortic valve replacement (36.4% vs 7.3%, respectively, P < 0.001). Even in patients with aortic valve area <1 cm(2) , the absence of Aop or Acl was still associated with increased rate of aortic valve replacement (42.1% vs 13.9%, respectively, P = 0.019) and provided incremental predictive value over peak velocity. CONCLUSIONS In a typical population of patients with aortic stenosis, approximately 1 in 6 has no detectible aortic valve opening or closing Doppler signal. The absence of an Aop or Acl signal is a highly specific sign of severe aortic stenosis and is associated with incident aortic valve replacement.
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Affiliation(s)
- Xiushui Ren
- Cardiology Department, Kaiser Permanente Medical Center, Redwood City, California; Cardiology Department, California Pacific Medical Center, San Francisco, California
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Coylewright M, Gosch KL, McNulty EJ, Spertus J, Ting HH. Abstract 233: Patient Factors Minimally Impact Experience with Informed Consent Documents for Percutaneous Coronary Intervention. Circ Cardiovasc Qual Outcomes 2012. [DOI: 10.1161/circoutcomes.5.suppl_1.a233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/16/2022]
Abstract
Background:
In light of well-known deficiencies in the process of informed consent for percutaneous coronary intervention (PCI), we developed and tested a personalized consent form, PRISM; this was shown to improve patients' participation in the consent process, understanding of procedural risks, and engagement in shared decision-making when compared to original PCI consent forms. It is unknown whether patient factors traditionally known to impair the consent process, including socioeconomic status, literacy and numeracy, were associated with greater benefit from the PRISM consents.
Methods:
We interviewed 590 patients receiving original consent documents and 527 receiving PRISM consents and compared the rates of reviewing the consent form, recalling a risk of bleeding and engaging in discussions about stent type using hierarchical modified Poisson regression analysis. The interaction of patient factors (age, gender, education level, insurance status, literacy and numeracy) with PRISM on outcomes was assessed.
Results:
Overall, few patient characteristics were associated with outcomes, including review of consent forms, knowledge transfer, or engagement in shared decision-making (see Table), although older patients were less likely to discuss stent types with their doctors (RR=0.84/decade for original and 0.93/decade for PRISM). Those with more than a high school education were less likely to review original consents (RR=0.77; 95% CI=0.66, 0.89) compared to those with less education; this difference was eliminated with the PRISM consents (RR=1.0; 95%CI=0.82, 1.23; p-value for interaction = 0.01).
Conclusions:
PRISM consent forms led to improved participation in the consent process and knowledge transfer in a 9-center study; there was little variance by sociodemographic, economic, literacy or numeracy factors, both with original consents and with PRISM.
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Affiliation(s)
| | - Kensey L Gosch
- Saint Luke's Mid America Heart Institute/UMKC, Kansas City, MO
| | | | - John Spertus
- Saint Luke's Mid America Heart Institute/UMKC, Kansas City, MO
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McNulty EJ, Ng W, Spertus JA, Zaroff JG, Yeh RW, Ren XM, Lundstrom RJ. Surgical candidacy and selection biases in nonemergent left main stenting: implications for observational studies. JACC Cardiovasc Interv 2012; 4:1020-7. [PMID: 21939943 DOI: 10.1016/j.jcin.2011.06.010] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [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] [Received: 02/28/2011] [Revised: 06/01/2011] [Accepted: 06/14/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVES This study sought to characterize reasons for surgical ineligibility in patients undergoing nonemergent unprotected left main (ULM) percutaneous coronary intervention (PCI) and to assess the potential for these reasons to confound comparative effectiveness studies of coronary revascularization. BACKGROUND Although both PCI and coronary artery bypass graft surgery are treatments for ULM disease, some patients are not eligible for both treatments, which may result in treatment selection biases. METHODS In 101 consecutive patients undergoing nonemergent ULM PCI, mixed methods were used to determine the prevalence of treatment selection dictated by surgical ineligibility and to identify the reasons cited for avoiding coronary artery bypass graft surgery. We then determined whether these reasons were captured by the ACC-NCDR (American College of Cardiology-National Cardiovascular Data Registry) Cath-PCI dataset to assess the ability of this registry to account for biases in treatment selection. Finally, the association of surgical eligibility with long-term outcomes after ULM PCI was assessed. RESULTS Treatment selection was dictated by surgical ineligibility in over half the ULM PCI cohort with the majority having reasons for ineligibility not captured by the ACC-NCDR. Surgical ineligibility was a significant predictor of mortality after adjustment for Society of Thoracic Surgeons (hazard ratio [HR]: 5.4, 95% confidence interval [CI]: 1.2 to 25), EuroSCORE (European System for Cardiac Operative Risk Evaluation) (HR: 5.9, 95% CI: 1.3 to 27), or NCDR mortality scores (HR: 6.2, 95% CI: 1.4 to 27). CONCLUSIONS Surgical ineligibility dictating treatment selection is common in patients undergoing nonemergent ULM PCI, occurs on the basis of risk factors not captured by the ACC-NCDR, and is independently associated with worse long-term outcomes after adjusting for standard risk scores.
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Affiliation(s)
- Edward J McNulty
- Division of Cardiology, Kaiser Permanente Medical Center, San Francisco, California 94115, USA.
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Affiliation(s)
- Edward J. McNulty
- From the Kaiser Permanente San Francisco Medical Center and University of California San Francisco School of Medicine, San Francisco, CA
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McNulty EJ, Spektor G, Chou E, Parikh M, Minutello R, Bergman G, Iacovone F, Hong MK, Chiu Wong S. 1025-46 Prior statin therapy reduces myocardial injury in patients undergoing rotational atherectomy. J Am Coll Cardiol 2004. [DOI: 10.1016/s0735-1097(04)90160-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: 11/17/2022]
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McNulty EJ, Cutlip D, Tierstein P, Holmes D, Leon M, Moses J, Lansky A, Chen X, Kuntz R, Minutello R, Wong S. 1121-56 Earlier time to restenosis predicts outcomes following gamma vascular brachytherapy. J Am Coll Cardiol 2004. [DOI: 10.1016/s0735-1097(04)90327-0] [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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Mittal S, McNulty EJ, Stein KM, Markowitz SM, Stotwiner DJ, Iwai S, Das MK, Cohen JD, Hao SC, Lerman BB. Clinical utility of an adenosine-nitroglycerin tilt test protocol. J Am Coll Cardiol 2002. [DOI: 10.1016/s0735-1097(02)80501-0] [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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