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Patel SS, Raman VK, Zhang S, Deedwania P, Zeng-Treitler Q, Wu WC, Lam PH, Bakris G, Moore H, Heidenreich PA, Rangaswami J, Morgan CJ, Cheng Y, Sheriff HM, Faselis C, Mehta RL, Anker SD, Fonarow GC, Ahmed A. Identification and outcomes of KDIGO-defined chronic kidney disease in 1.4 million U.S. Veterans with heart failure. Eur J Heart Fail 2024. [PMID: 38700246 DOI: 10.1002/ejhf.3210] [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] [Received: 01/02/2024] [Revised: 02/09/2024] [Accepted: 03/10/2024] [Indexed: 05/05/2024] Open
Abstract
AIMS According to the Kidney Disease: Improving Global Outcomes (KDIGO) guideline, the definition of chronic kidney disease (CKD) requires the presence of abnormal kidney structure or function for >3 months with implications for health. CKD in patients with heart failure (HF) has not been defined using this definition, and less is known about the true health implications of CKD in these patients. The objective of the current study was to identify patients with HF who met KDIGO criteria for CKD and examine their outcomes. METHODS AND RESULTS Of the 1 419 729 Veterans with HF not receiving kidney replacement therapy, 828 744 had data on ≥2 ambulatory serum creatinine >90 days apart. CKD was defined as estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2 (n = 185 821) or urinary albumin-to-creatinine ratio (uACR) >30 mg/g (n = 32 730) present twice >3 months apart. Normal kidney function (NKF) was defined as eGFR ≥60 ml/min/1.73 m2, present for >3 months, without any uACR >30 mg/g (n = 365 963). Patients with eGFR <60 ml/min/1.73 m2 were categorized into four stages: 45-59 (n = 72 606), 30-44 (n = 74 812), 15-29 (n = 32 077), and <15 (n = 6326) ml/min/1.73 m2. Five-year all-cause mortality occurred in 40.4%, 57.8%, 65.6%, 73.3%, 69.7%, and 47.5% of patients with NKF, four eGFR stages, and uACR >30mg/g (albuminuria), respectively. Compared with NKF, hazard ratios (HR) (95% confidence intervals [CI]) for all-cause mortality associated with the four eGFR stages and albuminuria were 1.63 (1.62-1.65), 2.00 (1.98-2.02), 2.49 (2.45-2.52), 2.28 (2.21-2.35), and 1.22 (1.20-1.24), respectively. Respective age-adjusted HRs (95% CIs) were 1.13 (1.12-1.14), 1.36 (1.34-1.37), 1.87 (1.84-1.89), 2.24 (2.18-2.31) and 1.19 (1.17-1.21), and multivariable-adjusted HRs (95% CIs) were 1.11 (1.10-1.12), 1.24 (1.22-1.25), 1.46 (1.43-1.48), 1.42 (1.38-1.47), and 1.13 (1.11-1.16). Similar patterns were observed for associations with hospitalizations. CONCLUSION Data needed to define CKD using KDIGO criteria were available in six out of ten patients, and CKD could be defined in seven out of ten patients with data. HF patients with KDIGO-defined CKD had higher risks for poor outcomes, most of which was not explained by abnormal kidney structure or function. Future studies need to examine whether CKD defined using a single eGFR is characteristically and prognostically different from CKD defined using KDIGO criteria.
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Affiliation(s)
- Samir S Patel
- Department of Medicine, Veterans Affairs Medical Center, Washington, DC, USA
- Department of Medicine, George Washington University, Washington, DC, USA
| | - Venkatesh K Raman
- Department of Medicine, Veterans Affairs Medical Center, Washington, DC, USA
- Department of Medicine, Georgetown University, Washington, DC, USA
| | - Sijian Zhang
- Department of Medicine, Veterans Affairs Medical Center, Washington, DC, USA
- Department of Medicine, George Washington University, Washington, DC, USA
| | - Prakash Deedwania
- Department of Medicine, Veterans Affairs Medical Center, Washington, DC, USA
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Qing Zeng-Treitler
- Department of Medicine, Veterans Affairs Medical Center, Washington, DC, USA
- Department of Medicine, George Washington University, Washington, DC, USA
| | - Wen-Chih Wu
- Department of Medicine, Veterans Affairs Medical Center, Providence, RI, USA
- Department of Medicine, Brown University, Providence, RI, USA
| | - Phillip H Lam
- Department of Medicine, Veterans Affairs Medical Center, Washington, DC, USA
- Department of Medicine, Georgetown University, Washington, DC, USA
- Heart & Vascular Institute, MedStar Washington Hospital Center, Washington, DC, USA
| | - George Bakris
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Hans Moore
- Department of Medicine, Veterans Affairs Medical Center, Washington, DC, USA
- Department of Medicine, George Washington University, Washington, DC, USA
- Department of Medicine, Georgetown University, Washington, DC, USA
- Department of Medicine, Uniformed Services University, Washington, DC, USA
| | - Paul A Heidenreich
- Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Janani Rangaswami
- Department of Medicine, Veterans Affairs Medical Center, Washington, DC, USA
- Department of Medicine, George Washington University, Washington, DC, USA
| | - Charity J Morgan
- Department of Medicine, Veterans Affairs Medical Center, Washington, DC, USA
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Yan Cheng
- Department of Medicine, Veterans Affairs Medical Center, Washington, DC, USA
- Department of Medicine, George Washington University, Washington, DC, USA
| | - Helen M Sheriff
- Department of Medicine, Veterans Affairs Medical Center, Washington, DC, USA
- Department of Medicine, George Washington University, Washington, DC, USA
| | - Charles Faselis
- Department of Medicine, Veterans Affairs Medical Center, Washington, DC, USA
- Department of Medicine, George Washington University, Washington, DC, USA
- Department of Medicine, Uniformed Services University, Washington, DC, USA
| | - Ravindra L Mehta
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Stefan D Anker
- Department of Cardiology (CVK) of German Heart Center Charité; German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Gregg C Fonarow
- Department of Medicine, University of California, Los Angeles, CA, USA
| | - Ali Ahmed
- Department of Medicine, Veterans Affairs Medical Center, Washington, DC, USA
- Department of Medicine, George Washington University, Washington, DC, USA
- Department of Medicine, Georgetown University, Washington, DC, USA
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2
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Sayed A, Abramov D, Fonarow GC, Mamas MA, Kobo O, Butler J, Fudim M. Reversals in the Decline of Heart Failure Mortality in the US, 1999 to 2021. JAMA Cardiol 2024:2817830. [PMID: 38656398 PMCID: PMC11044007 DOI: 10.1001/jamacardio.2024.0615] [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: 10/01/2023] [Accepted: 02/25/2024] [Indexed: 04/26/2024]
Abstract
This cohort study evaluates recent reversals in declines in cardiovascular mortality and whether they vary across sociodemographic categories.
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Affiliation(s)
- Ahmed Sayed
- Ain Shams University, Faculty of Medicine, Cairo, Egypt
| | - Dmitry Abramov
- Division of Cardiology, Department of Medicine, Loma Linda University Health, Loma Linda, California
| | - Gregg C. Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles, Los Angeles
- Associate Editor for Health Care Quality and Guidelines, JAMA Cardiology
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-On-Trent, United Kingdom
| | - Ofer Kobo
- Department of Cardiology, Hillel Yaffe Medical Center, Hadera, Israel
| | - Javed Butler
- Baylor Scott and White Research Institute, Baylor Scott and White Health, Dallas, Texas
| | - Marat Fudim
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina
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3
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Jawadi Z, He R, Srivastava PK, Fonarow GC, Khalil SO, Krishnan S, Eskin E, Chiang JN, Nsair A. Predicting in-hospital mortality among patients admitted with a diagnosis of heart failure: a machine learning approach. ESC Heart Fail 2024. [PMID: 38637959 DOI: 10.1002/ehf2.14796] [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] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 01/31/2024] [Accepted: 03/25/2024] [Indexed: 04/20/2024] Open
Abstract
Existing risk prediction models for hospitalized heart failure patients are limited. We identified patients hospitalized with a diagnosis of heart failure between 7 May 2013 and 26 April 2022 from a large academic, quaternary care medical centre (training cohort). Demographics, medical comorbidities, vitals, and labs were collected and were used to construct random forest machine learning models to predict in-hospital mortality. Models were compared with logistic regression, and to commonly used heart failure risk scores. The models were subsequently validated in patients hospitalized with a diagnosis of heart failure from a second academic, community medical centre (validation cohort). The entire cohort comprised 21 802 patients, of which 14 539 were in the training cohort and 7263 were in the validation cohort. The median age (25th-75th percentile) was 70 (58-82) for the entire cohort, 43.2% were female, and 6.7% experienced inpatient mortality. In the overall cohort, 7621 (35.0%) patients had heart failure with reduced ejection fraction (EF ≤ 40%), 1271 (5.8%) had heart failure with mildly reduced EF (EF 41-49%), and 12 910 (59.2%) had heart failure with preserved EF (EF ≥ 50%). Random forest models in the validation cohort demonstrated a c-statistic (95% confidence interval) of 0.96 (0.95-0.97), sensitivity (SN) of 87.3%, and specificity (SP) of 90.6% for the prediction of in-hospital mortality. Models for those with HFrEF demonstrated a c-statistic of 0.96 (0.94-0.98), SN 88.2%, and SP 91.0%, and those for patients with HFpEF showed a c-statistic of 0.95 (0.93-0.97), SN 87.4%, and SP 89.5% for predicting in-hospital mortality. The random forest model significantly outperformed logistic regression (c-statistic 0.87, SN 75.9%, and SP 86.9%), and current existing risk scores including the Acute Decompensated Heart Failure National Registry risk score (c-statistic of 0.70, SN 69%, and SP 62%), and the Get With the Guidelines-Heart Failure risk score (c-statistic 0.69, SN 67%, and SP 63%); P < 0.001 for comparison. Machine learning models built from commonly recorded patient information can accurately predict in-hospital mortality among patients hospitalized with a diagnosis of heart failure.
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Affiliation(s)
- Zina Jawadi
- UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Rosemary He
- Department of Computer Science, UCLA, Los Angeles, CA, USA
| | - Pratyaksh K Srivastava
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, MRL 3-760, 675 C.E. Young Dr., Los Angeles, CA, 90095-1760, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, MRL 3-760, 675 C.E. Young Dr., Los Angeles, CA, 90095-1760, USA
| | - Suzan O Khalil
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, MRL 3-760, 675 C.E. Young Dr., Los Angeles, CA, 90095-1760, USA
| | - Srikanth Krishnan
- Division of Cardiology, Lundquist Institute for Biomedical Innovation, Harbor-UCLA Medical Center, Los Angeles, CA, USA
| | - Eleazar Eskin
- Department of Computer Science, UCLA, Los Angeles, CA, USA
- Department of Computational Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Jeffrey N Chiang
- Department of Computational Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
- Department of Neurosurgery, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Ali Nsair
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, MRL 3-760, 675 C.E. Young Dr., Los Angeles, CA, 90095-1760, USA
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4
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Maddox TM, Januzzi JL, Allen LA, Breathett K, Brouse S, Butler J, Davis LL, Fonarow GC, Ibrahim NE, Lindenfeld J, Masoudi FA, Motiwala SR, Oliveros E, Walsh MN, Wasserman A, Yancy CW, Youmans QR. 2024 ACC Expert Consensus Decision Pathway for Treatment of Heart Failure With Reduced Ejection Fraction: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2024; 83:1444-1488. [PMID: 38466244 DOI: 10.1016/j.jacc.2023.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
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5
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Zheng J, Ambrosy AP, Bhatt AS, Collins SP, Flint KM, Fonarow GC, Fudim M, Greene SJ, Lala A, Testani JM, Varshney AS, Wi RSK, Sandhu AT. Contemporary Decongestion Strategies in Patients Hospitalized for Heart Failure: A National Community-Based Cohort Study. JACC Heart Fail 2024:S2213-1779(24)00267-1. [PMID: 38678466 DOI: 10.1016/j.jchf.2024.04.002] [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] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/01/2024] [Accepted: 04/02/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Heart failure (HF) is a leading cause of hospitalization in the United States. Decongestion remains a central goal of inpatient management, but contemporary decongestion practices and associated weight loss have not been well characterized nationally. OBJECTIVES This study aimed to describe contemporary inpatient diuretic practices and clinical predictors of weight loss in patients hospitalized for HF. METHODS The authors identified HF hospitalizations from 2015 to 2022 in a U.S. national database aggregating deidentified patient-level electronic health record data across 31 geographically diverse community-based health systems. The authors report patient characteristics and inpatient weight change as a primary indicator of decongestion. Predictors of weight loss were evaluated using multivariable models. Temporal trends in inpatient diuretic practices, including augmented diuresis strategies such as adjunctive thiazides and continuous diuretic infusions, were assessed. RESULTS The study cohort included 262,673 HF admissions across 165,482 unique patients. The median inpatient weight loss was 5.3 pounds (Q1-Q3: 0.0-12.8 pounds) or 2.4 kg (Q1-Q3: 0.0-5.8 kg). Discharge weight was higher than admission weight in 20% of encounters. An increase of ≥0.3 mg/dL in serum creatinine from admission to inpatient peak occurred in >30% of hospitalizations and was associated with less weight loss. Adjunctive diuretic agents were utilized in <20% of encounters but were associated with greater weight loss. CONCLUSIONS In a large-scale U.S. community-based cohort study of HF hospitalizations, estimated weight loss from inpatient decongestion remains highly variable, with weight gain observed across many admissions. Augmented diuresis strategies were infrequently used. Comparative effectiveness trials are needed to establish optimal strategies for inpatient decongestion for acute HF.
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Affiliation(s)
- Jimmy Zheng
- Department of Medicine, Stanford University, Stanford, California, USA
| | - Andrew P Ambrosy
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA; Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Ankeet S Bhatt
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA; Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Geriatric Research, Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Kelsey M Flint
- Rocky Mountain Regional VA Medical Center, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Gregg C Fonarow
- Division of Cardiology, Department of Medicine, Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Marat Fudim
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Anuradha Lala
- Zena and Michael A. Wiener Cardiovascular Institute and Department of Population Health Science and Policy, Mount Sinai, New York, New York, USA
| | - Jeffrey M Testani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Anubodh S Varshney
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - Ryan S K Wi
- Department of Medicine, Albany Medical College, Albany, New York, USA
| | - Alexander T Sandhu
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA; Division of Cardiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA.
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6
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Haywood HB, Graham AJ, Chermak D, Achanta A, Butler J, Fonarow GC, Greene SJ. Estimating the Proportion of Heart Failure Admissions Potentially Eligible for Hospital at Home. J Card Fail 2024:S1071-9164(24)00108-8. [PMID: 38588859 DOI: 10.1016/j.cardfail.2024.03.004] [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] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 02/27/2024] [Accepted: 03/12/2024] [Indexed: 04/10/2024]
Affiliation(s)
- Hubert B Haywood
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC
| | - Aubrey Jolly Graham
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC
| | | | - Aditya Achanta
- Department of Internal Medicine, Massachusetts General Hospital, Boston, MA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX; Department of Medicine, University of Mississippi, Jackson, MI
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles, Los Angeles, CA
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, NC; Division of Cardiology, Duke University School of Medicine, Durham, NC..
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7
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Saha A, Li S, de Lemos JA, Pandey A, Bhatt DL, Fonarow GC, Nallamothu BK, Wang TY, Navar AM, Peterson E, Matsouaka RA, Bavry AA, Das SR, Grodin JL, Khera R, Drazner MH, Kumbhani DJ. Characteristics of High-Performing Hospitals in Cardiogenic Shock Following Acute Myocardial Infarction. Am J Cardiol 2024:S0002-9149(24)00237-6. [PMID: 38583700 DOI: 10.1016/j.amjcard.2024.04.002] [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: 10/21/2023] [Revised: 03/06/2024] [Accepted: 04/01/2024] [Indexed: 04/09/2024]
Abstract
Cardiogenic shock after acute myocardial infarction (AMI-CS) carries significant mortality despite advances in revascularization and mechanical circulatory support. We sought to identify the process-based and structural characteristics of centers with lower mortality in AMI-CS. We analyzed 16,337 AMI-CS cases across 440 centers enrolled in the Chest Pain-MI Registry, a retrospective cohort database between January 1, 2015 and December 31, 2018. Centers were stratified across tertiles of risk-adjusted in-hospital mortality rate (RAMR) for comparison. Risk-adjusted multivariable logistic regression was also performed to identify hospital-level characteristics associated with decreased mortality. The median participant age was 66.0 (interquartile range 57.0 to 75.0) years, and 33.0% (n = 5,390) were women. The median RAMR was 33.4% (interquartile range 26.0% to 40.0%) and ranged from 26.9% to 50.2% across tertiles. Even after risk adjustment, lower-RAMR centers saw patients with fewer co-morbidities. Lower-RAMR centers performed more revascularization (92.8% vs 90.6% vs 85.9%, p <0.001) and demonstrated better adherence to associated process measures. Left ventricular assist device capability (odds ratio [OR] 0.78 [0.67 to 0.92], p = 0.002), more frequent revascularization (OR 0.93 [0.88 to 0.98], p = 0.006), and higher AMI-CS volume (OR 0.95 [0.91 to 0.99], p = 0.009) were associated with lower in-hospital mortality. However, several such characteristics were not more frequently observed at low-RAMR centers, despite potentially reflecting greater institutional experience or resources. This may reflect the heterogeneity of AMI-CS even after risk adjustment. In conclusion, low-RAMR centers do not necessarily exhibit factors associated with decreased mortality in AMI-CS, which may reflect the challenges in performing outcomes research in this complex population.
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Affiliation(s)
- Amit Saha
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Shuang Li
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - James A de Lemos
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ambarish Pandey
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Deepak L Bhatt
- Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Gregg C Fonarow
- Department of Medicine, Division of Cardiology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
| | - Brahmajee K Nallamothu
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Michigan, Ann Arbor, Michigan
| | - Tracy Y Wang
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Ann Marie Navar
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Eric Peterson
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Roland A Matsouaka
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Anthony A Bavry
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sandeep R Das
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Justin L Grodin
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Rohan Khera
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut; Department of Biostatistics, Section of Health Informatics, Yale School of Public Health, New Haven, Connecticut; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Mark H Drazner
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Dharam J Kumbhani
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas.
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Shoji S, Kaltenbach LA, Granger BB, Fonarow GC, Al-Khalidi H, Albert NM, Butler J, Allen LA, Michael Felker G, Harrison RW, Fudim M, Nelson AJ, Granger CB, Hernandez AF, DeVore AD. Remote Follow-up in a Heart Failure Pragmatic Trial: Insights From the CONNECT-HF. J Card Fail 2024:S1071-9164(24)00109-X. [PMID: 38599459 DOI: 10.1016/j.cardfail.2024.03.006] [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] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 03/26/2024] [Accepted: 03/28/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Randomized controlled trials typically require study-specific visits, which can burden participants and sites. Remote follow-up, such as centralized call centers for participant-reported or site-reported, holds promise for reducing costs and enhancing the pragmatism of trials. In this secondary analysis of the CONNECT-HF trial, we aimed to evaluate the completeness and validity of the remote follow-up process. METHODS AND RESULTS CONNECT-HF evaluated the effect of a post-discharge quality improvement intervention for heart failure compared to usual care for up to 1 year. Suspected events were reported either by participants or healthcare proxies through a centralized call center, or by sites through medical record queries. When potential hospitalization events were suspected, additional medical records were collected and adjudicated. Among 5,942 potential hospitalizations, 18% were only participant-reported, 28% were reported by both participants and sites, and 50% were only site-reported. Concordance rates between the participant/site reports and adjudication for hospitalization were high: 87% participant-reported, 86% both, and 86% site-reported. Rates of adjudicated heart failure hospitalization events among adjudicated all-cause hospitalization were lower but also consistent: 45% participant-reported, 50% both, and 50% site-reported. CONCLUSIONS Participant-only and site-only reports missed a substantial number of hospitalization events. We observed similar concordance between participant/site reports and adjudication for hospitalizations. Combining participant-reported and site-reported outcomes data are important to effectively capture and validate hospitalizations within pragmatic heart failure trials.
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Affiliation(s)
- Satoshi Shoji
- Duke Clinical Research Institute, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC; Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | | | | | - Gregg C Fonarow
- Division of Cardiology, Department of Medicine, Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | - Nancy M Albert
- Associate Chief of Nursing, Research and Innovation- Nursing Institute and Clinical Nurse Specialist- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland OH
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson
| | - Larry A Allen
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - G Michael Felker
- Duke Clinical Research Institute, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Robert W Harrison
- Duke Clinical Research Institute, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Marat Fudim
- Duke Clinical Research Institute, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC; Department of Cardiology, University of Wroclaw, Wroclaw, Poland
| | - Adam J Nelson
- Duke Clinical Research Institute, Durham, NC; Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia
| | - Christopher B Granger
- Duke Clinical Research Institute, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Adam D DeVore
- Duke Clinical Research Institute, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC.
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9
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Tang AB, Brownell NK, Roberts JS, Haidar A, Osuna-Garcia A, Cho DJ, Bokhoor P, Fonarow GC. Interventions for Optimization of Guideline-Directed Medical Therapy: A Systematic Review. JAMA Cardiol 2024; 9:397-404. [PMID: 38381449 DOI: 10.1001/jamacardio.2023.5627] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Indexed: 02/22/2024]
Abstract
Importance Implementation of guideline-directed medical therapy (GDMT) in real-world practice remains suboptimal. It is unclear which interventions are most effective at addressing current barriers to GDMT in patients with heart failure with reduced ejection fraction (HFrEF). Objective To perform a systematic review to identify which types of system-level initiatives are most effective at improving GDMT use among patients with HFrEF. Evidence Review PubMed, Embase, Cochrane, CINAHL, and Web of Science databases were queried from January 2010 to November 2023 for randomized clinical trials that implemented a quality improvement intervention with GDMT use as a primary or secondary outcome. References from related review articles were also included for screening. Quality of studies and bias assessment were graded based on the Cochrane Risk of Bias tool and Oxford Centre for Evidence-Based Medicine. Findings Twenty-eight randomized clinical trials were included with an aggregate sample size of 19 840 patients. Studies were broadly categorized as interdisciplinary interventions (n = 15), clinician education (n = 5), electronic health record initiatives (n = 6), or patient education (n = 2). Overall, interdisciplinary titration clinics were associated with significant increases in the proportion of patients on target doses of GDMT with a 10% to 60% and 2% to 53% greater proportion of patients on target doses of β-blockers and renin-angiotensin-aldosterone system inhibitors, respectively, in intervention groups compared with usual care. Other interventions, such as audits, clinician and patient education, or electronic health record alerts, were also associated with some improvements in GDMT utilization, though these findings were inconsistent across studies. Conclusions and Relevance This review summarizes interventions aimed at optimization of GDMT in clinical practice. Initiatives that used interdisciplinary teams, largely comprised of nurses and pharmacists, most consistently led to improvements in GDMT. Additional large, randomized studies are necessary to better understand other types of interventions, as well as their long-term efficacy and sustainability.
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Affiliation(s)
- Amber B Tang
- Department of Medicine, University of California Los Angeles
| | - Nicholas K Brownell
- Department of Medicine, Division of Cardiology, University of California Los Angeles
| | - Jacob S Roberts
- Department of Medicine, University of California Los Angeles
| | - Amier Haidar
- Department of Medicine, University of California Los Angeles
| | - Antonia Osuna-Garcia
- Louise M. Darling Biomedical Library, UCLA Library, University of California Los Angeles
| | - David J Cho
- Department of Medicine, Division of Cardiology, University of California Los Angeles
| | - Pooya Bokhoor
- Department of Medicine, Division of Cardiology, University of California Los Angeles
| | - Gregg C Fonarow
- Department of Medicine, Division of Cardiology, University of California Los Angeles
- Associate Section Editor, JAMA Cardiology
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10
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Agarwal A, Tromp J, Almahmeed W, Angermann C, Chandramouli C, Cho H, Choi DJ, Damasceno A, Filippatos G, Fonarow GC, Harikrishnan S, Lund L, Masoudi F, Mensah GA, Pathan A, Perel P, Pinto F, Ribeiro AL, Rich S, Sakata Y, Sliwa K, Sundstrom J, Wong R, Yancy C, Yiu K, Zhang J, Zhang Y, Lam CSP, Roth GA. Toward a Universal Definition of Etiologies in Heart Failure: Categorizing Causes and Advancing Registry Science. Circ Heart Fail 2024; 17:e011095. [PMID: 38626067 PMCID: PMC11027941 DOI: 10.1161/circheartfailure.123.011095] [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: 08/14/2023] [Accepted: 02/26/2024] [Indexed: 04/18/2024]
Abstract
Heart failure (HF) is a well-described final common pathway for a broad range of diseases however substantial confusion exists regarding how to describe, study, and track these underlying etiologic conditions. We describe (1) the overlap in HF etiologies, comorbidities, and case definitions as currently used in HF registries led or managed by members of the global HF roundtable; (2) strategies to improve the quality of evidence on etiologies and modifiable risk factors of HF in registries; and (3) opportunities to use clinical HF registries as a platform for public health surveillance, implementation research, and randomized registry trials to reduce the global burden of noncommunicable diseases. Investment and collaboration among countries to improve the quality of evidence in global HF registries could contribute to achieving global health targets to reduce noncommunicable diseases and overall improvements in population health.
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Affiliation(s)
- Anubha Agarwal
- Washington University in St. Louis School of Medicine, MO (A.A.)
| | - Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System (J.T.)
| | - Wael Almahmeed
- Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates (W.A.)
| | - Christiane Angermann
- Comprehensive Heart Failure Center, University Hospital Wuerzburg, Germany (C.A.)
| | | | - Hyunjai Cho
- Seoul National University Hospital, Korea (H.C., D.-J.C.)
| | - Don-Ju Choi
- Seoul National University Hospital, Korea (H.C., D.-J.C.)
| | | | - Gerasimos Filippatos
- University of Cyprus, School of Medicine and National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Greece (G.F.)
| | | | | | - Lars Lund
- Karolinska University Hospital, Stockholm, Sweden (L.L.)
| | - Fred Masoudi
- University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora (F.M.)
| | - George A Mensah
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (G.A.M.)
| | - Asad Pathan
- Tabba Heart Institute Karachi, Pakistan (A.P.)
| | - Pablo Perel
- London School of Hygiene and Tropical Medicine, United Kingdom (P.P.)
| | - Fausto Pinto
- Santa Maria University Hospital, University of Lisbon, Portugal (F.P.)
| | - Antonio Luiz Ribeiro
- Hospital das Clinicas and School of Medicine, Unversidade Federal de Minas Gerais, Belo Horizonte, Brazil (A.L.R.)
| | - Stuart Rich
- Northwestern University Feinberg School of Medicine, Chicago, IL (S.R., C.Y.)
| | - Yasuhiko Sakata
- Tohoku University Graduate School of Medicine, Sendai, Japan (Y.S.)
- National Cerebral and Cardiovascular Center, Suita, Japan (Y.S.)
| | - Karen Sliwa
- University of Cape Town, South Africa (K.S.)
| | | | - Renee Wong
- Heart Failure and Arrhythmias Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (R.W.)
| | - Clyde Yancy
- Northwestern University Feinberg School of Medicine, Chicago, IL (S.R., C.Y.)
| | - Kelvin Yiu
- Institute of Cardiovascular Science and Medicine, Hong Kong University, Hong Kong and Department of Medicine, University of Hong Kong-Shenzhen Hospital, China (K.Y.)
| | - Jian Zhang
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (J.Z., Y.Z.)
| | - Yuhui Zhang
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (J.Z., Y.Z.)
| | - Carolyn S P Lam
- National Heart Centre Singapore, Singapore (C.S.P.L.)
- Duke-NUS Medical School, Singapore and University Medical Centre Groningen, the Netherlands (C.S.P.L.)
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11
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Greene SJ, Ayodele I, Pierce JB, Khan MS, Lewsey SC, Yancy CW, Alhanti B, Van Spall HGC, Allen LA, Fonarow GC. Eligibility and Projected Benefits of Rapid Initiation of Quadruple Medical Therapy for Newly Diagnosed Heart Failure. JACC Heart Fail 2024:S2213-1779(24)00244-0. [PMID: 38597866 DOI: 10.1016/j.jchf.2024.03.001] [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] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/12/2024] [Accepted: 03/13/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND U.S. nationwide estimates of the proportion of patients newly diagnosed with heart failure with reduced ejection fraction (HFrEF) eligible for quadruple medical therapy, and the associated benefits of rapid implementation, are not well characterized. OBJECTIVES This study sought to characterize the degree to which patients newly diagnosed with HFrEF are eligible for quadruple medical therapy, and the projected benefits of in-hospital initiation. METHODS Among patients hospitalized for newly diagnosed HFrEF in the Get With The Guidelines-Heart Failure registry from 2016 to 2023, eligibility criteria based on regulatory labeling, guidelines, and expert consensus documents were applied for angiotensin receptor-neprilysin inhibitor, beta-blocker, mineralocorticoid receptor antagonist, and sodium-glucose cotransporter 2 inhibitor therapies. Of those eligible, the projected effect of quadruple therapy on 12-month mortality was modeled using treatment effects from pivotal clinical trials utilized by the AHA/ACC/HFSA Guideline for the Management of Heart Failure, and compared with observed outcomes among patients treated with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and beta-blockers. RESULTS Of 33,036 patients newly diagnosed with HFrEF, 27,158 (82%) were eligible for quadruple therapy, and 30,613 (93%) were eligible for ≥3 components. From 2021 to 2023, of patients eligible for quadruple therapy, 15.3% were prescribed quadruple therapy and 41.5% were prescribed triple therapy. Among Medicare beneficiaries eligible for quadruple therapy, 12-month incidence of mortality was 24.7% and HF hospitalization was 22.2%. Applying the relative risk reductions in clinical trials, complete implementation of quadruple therapy by time of discharge was projected to yield absolute risk reductions in 12-month mortality of 10.4% (number needed to treat = 10) compared with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and beta-blocker, and 24.8% (number needed to treat = 4) compared with no GDMT. CONCLUSIONS In this nationwide U.S. cohort of patients hospitalized for newly diagnosed HFrEF, >4 of 5 patients were projected as eligible for quadruple therapy at discharge; yet, <1 in 6 were prescribed it. If clinical trial benefits can be fully realized, in-hospital initiation of quadruple medical therapy for newly diagnosed HFrEF would yield large absolute reductions in mortality.
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Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Jacob B Pierce
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Muhammad Shahzeb Khan
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sabra C Lewsey
- Division of Cardiovascular Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Clyde W Yancy
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Brooke Alhanti
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Harriette G C Van Spall
- Department of Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Larry A Allen
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles, California, USA.
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12
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Oddleifson DA, Holmes DN, Alhanti B, Xu X, Heidenreich PA, Wadhera RK, Allen LA, Greene SJ, Fonarow GC, Spatz ES, Desai NR. Bundled Payments for Care Improvement and Quality of Care and Outcomes in Heart Failure. JAMA Cardiol 2024; 9:222-232. [PMID: 38170516 PMCID: PMC10765313 DOI: 10.1001/jamacardio.2023.5009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/03/2023] [Indexed: 01/05/2024]
Abstract
Importance The Centers for Medicare & Medicaid Services (CMS) Bundled Payments for Care Improvement (BPCI) program was launched in 2013 with a goal to improve care quality while lowering costs to Medicare. Objective To compare changes in the quality and outcomes of care for patients hospitalized with heart failure according to hospital participation in the BPCI program. Design, Setting, and Participants This cross-sectional study used a difference-in-difference approach to evaluate the BPCI program in 18 BPCI hospitals vs 211 same-state non-BPCI hospitals for various process-of-care measures and outcomes using American Heart Association Get With The Guidelines-Heart Failure registry and CMS Medicare claims data from November 1, 2008, to August 31, 2018. Data were analyzed from May 2022 to May 2023. Exposures Hospital participation in CMS BPCI Model 2 Heart Failure, which paid hospitals in a fee-for-service process and then shared savings or required reimbursement depending on how the total cost of an episode of care compared with a target price. Main Outcomes and Measures Primary end points included 7 quality-of-care measures. Secondary end points included 9 outcome measures, including in-hospital mortality and hospital-level risk-adjusted 30-day and 90-day all-cause readmission rate and mortality rate. Results During the study period, 8721 patients were hospitalized in the 23 BPCI hospitals and 94 530 patients were hospitalized in the 224 same-state non-BPCI hospitals. Less than a third of patients (30 723 patients, 29.8%) were 75 years or younger; 54 629 (52.9%) were female, and 48 622 (47.1%) were male. Hospital participation in BPCI Model 2 was not associated with significant differential changes in the odds of various process-of-care measures, except for a decreased odds of evidence-based β-blocker at discharge (adjusted odds ratio [aOR], 0.63; 95% CI, 0.41-0.98; P = .04). Participation in the BPCI was not associated with a significant differential change in the odds of receiving angiotensin-converting enzyme inhibitors/angiotensin receptor blockers or angiotensin receptor-neprilysin inhibitors at discharge, receiving an aldosterone antagonist at discharge, having a cardiac resynchronization therapy (CRT)-defibrillator or CRT pacemaker placed or prescribed at discharge, having implantable cardioverter-defibrillator (ICD) counseling or an ICD placed or prescribed at discharge, heart failure education being provided among eligible patients, or having a follow-up visit within 7 days or less. Participation in the BPCI was associated with a significant decrease in odds of in-hospital mortality (aOR, 0.67; 95% CI, 0.51-0.86; P = .002). Participation was not associated with a significant differential change in hospital-level risk-adjusted 30-day or 90-day all-cause readmission rate and 30-day or 90-day all-cause mortality rate. Conclusion and Relevance In this study, hospital participation in the BPCI Model 2 Heart Failure program was not associated with improvement in process-of-care quality measures or 30-day or 90-day risk-adjusted all-cause mortality and readmission rates.
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Affiliation(s)
- D. August Oddleifson
- Yale School of Medicine, New Haven, Connecticut
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Brooke Alhanti
- Duke Clinical Research Institute, Durham, North Carolina
| | - Xiao Xu
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Paul A. Heidenreich
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
| | - Rishi K. Wadhera
- Section of Health Policy and Equity at the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Larry A. Allen
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora
| | - Stephen J. Greene
- Duke Clinical Research Institute, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Gregg C. Fonarow
- Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles Medical Center, Los Angeles
- Associate Section Editor, JAMA Cardiology
| | - Erica S. Spatz
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Nihar R. Desai
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
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13
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Segar MW, Khan MS, Patel KV, Butler J, Ravichandran AK, Walsh MN, Willett D, Fonarow GC, Drazner MH, Mentz RJ, Hall J, Farr MA, Hedayati SS, Yancy C, Allen LA, Tang WHW, Pandey A. A Phenomapping Tool and Clinical Score to Identify Low Diuretic Efficiency in Acute Decompensated Heart Failure. JACC Heart Fail 2024; 12:508-520. [PMID: 38099890 DOI: 10.1016/j.jchf.2023.09.029] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 09/19/2023] [Accepted: 09/27/2023] [Indexed: 03/08/2024]
Abstract
BACKGROUND Individuals with acute decompensated heart failure (ADHF) have a varying response to diuretic therapy. Strategies for the early identification of low diuretic efficiency to inform decongestion therapies are lacking. OBJECTIVES The authors sought to develop and externally validate a machine learning-based phenomapping approach and integer-based diuresis score to identify patients with low diuretic efficiency. METHODS Participants with ADHF from ROSE-AHF, CARRESS-HF, and ATHENA-HF were pooled in the derivation cohort (n = 794). Multivariable finite-mixture model-based phenomapping was performed to identify phenogroups based on diuretic efficiency (urine output over the first 72 hours per total intravenous furosemide equivalent loop diuretic dose). Phenogroups were externally validated in other pooled ADHF trials (DOSE/ESCAPE). An integer-based diuresis score (BAN-ADHF score: blood urea nitrogen, creatinine, natriuretic peptide levels, atrial fibrillation, diastolic blood pressure, hypertension and home diuretic, and heart failure hospitalization) was developed and validated based on predictors of the diuretic efficiency phenogroups to estimate the probability of low diuretic efficiency using the pooled ADHF trials described earlier. The associations of the BAN-ADHF score with markers and symptoms of congestion, length of stay, in-hospital mortality, and global well-being were assessed using adjusted regression models. RESULTS Clustering identified 3 phenogroups based on diuretic efficiency: phenogroup 1 (n = 370; 47%) had lower diuretic efficiency (median: 13.1 mL/mg; Q1-Q3: 7.7-19.4 mL/mg) than phenogroups 2 (n = 290; 37%) and 3 (n = 134; 17%) (median: 17.8 mL/mg; Q1-Q3: 10.8-26.1 mL/mg and median: 35.3 mL/mg; Q1-Q3: 17.5-49.0 mL/mg, respectively) (P < 0.001). The median urine output difference in response to 80 mg intravenous twice-daily furosemide between the lowest and highest diuretic efficiency group (phenogroup 1 vs 3) was 3,520 mL/d. The BAN-ADHF score demonstrated good model performance for predicting the lowest diuretic efficiency phenogroup membership (C-index: 0.92 in DOSE/ESCAPE validation cohort) that was superior to measures of kidney function (creatinine or blood urea nitrogen), natriuretic peptide levels, or home diuretic dose (DeLong P < 0.001 for all). Net urine output in response to 80 mg intravenous twice-daily furosemide among patients with a low vs high (5 vs 20) BAN-ADHF score was 2,650 vs 660 mL per 24 hours, respectively. Participants with higher BAN-ADHF scores had significantly lower global well-being, higher natriuretic peptide levels on discharge, a longer in-hospital stay, and a higher risk of in-hospital mortality in both derivation and validation cohorts. CONCLUSIONS The authors developed and validated a phenomapping strategy and diuresis score for individuals with ADHF and differential response to diuretic therapy, which was associated with length of stay and mortality.
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Affiliation(s)
- Matthew W Segar
- Department of Cardiology, Texas Heart Institute, Houston, Texas, USA
| | | | - Kershaw V Patel
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA; Baylor Scott and White Research Institute, Dallas, Texas, USA
| | | | - Mary Norine Walsh
- Department of Cardiology, St Vincent Heart Center, Indianapolis, Indiana, USA
| | - DuWayne Willett
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Gregg C Fonarow
- Ronald Reagan UCLA Medical Center, Ahmanson-UCLA Cardiomyopathy Center, Division of Cardiology, Los Angeles, California, USA
| | - Mark H Drazner
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Robert J Mentz
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Jennifer Hall
- Institute for Precision Cardiovascular Medicine at the American Heart Association, Dallas, Texas, USA
| | - Maryjane A Farr
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - S Susan Hedayati
- Division of Nephrology, Department of Medicine, Stony Brook University School of Medicine, Stony Brook, New York, USA
| | - Clyde Yancy
- Division of Cardiology, Department of Internal Medicine, Northwestern University School of Medicine, Chicago, Illinois, USA
| | - Larry A Allen
- Division of Cardiology, University of Colorado, Aurora, Colorado, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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14
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Mignone JL, Alexander KM, Dobbles M, Eberst K, Fonarow GC, Ellenbogen KA. Outcomes with guideline-directed medical therapy and cardiac implantable electronic device therapies for patients with heart failure with reduced ejection fraction. Heart Rhythm O2 2024; 5:168-173. [PMID: 38560378 PMCID: PMC10980920 DOI: 10.1016/j.hroo.2024.01.004] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
Background Limited real-world evidence exists for outcomes with contemporary guideline-directed medical therapy (GDMT) or GDMT with implantable cardioverter-defibrillator (ICD)/cardiac resynchronization therapy defibrillator (CRT-D) therapy for patients with heart failure with reduced ejection fraction (HFrEF) and left ventricular ejection fraction (LVEF) ≤35%. Objective The present study aimed to assess survival associated with GDMT or GDMT with ICD/CRT-D therapy. Methods This retrospective observational study included real-world de-identified data from January 1, 2016, to December 19, 2023, from 24 U.S. institutions per participating institutional agreements (egnite Database; egnite, Inc.). Patients with a diagnosis of HFrEF and an echocardiographic study documenting LVEF ≤35% were included for analysis. Results Of 43,591 patients with eligible index event of LVEF ≤35%, prescription history through ≥1 year preindex, and no ICD/CRT-D therapy preindex, mean ± standard deviation age at index was 71.2 ± 13.2 years; 14,805 (34.0%) patients were female. At 24 months, an estimated 99.1% (95% confidence interval [CI] 99.0%-99.2%), 89.9% (95% CI 89.7%-90.1%), 54.8% (95% CI 54.4%-55.2%), and 17.2% (95% CI 16.9%-17.5%), had ≥1, 2, 3, or all 4 GDMT classes prescribed, respectively; an estimated 15.7% (95% CI 15.3%-16.1%) had device placement. Of those without a device, by 24 months, an estimated 45.1% (95% CI 44.4%-45.7%) had a documented LVEF >35%. Counts of GDMT classes prescribed as well as ICD/CRT-D device therapy were associated with lower mortality risk in this population, even after adjustment for patient age, sex, and comorbidities. Conclusion Both GDMT classes prescribed and device therapy were independently associated with lower mortality risk, even in the presence of more GDMT options for this more contemporary population.
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Affiliation(s)
- John L. Mignone
- Division of Cardiology, Swedish Medical Center, Seattle, Washington
| | - Kevin M. Alexander
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
| | | | | | - Gregg C. Fonarow
- Ahmanson–UCLA Cardiomyopathy Center, University of California, Los Angeles, Los Angeles, California
| | - Kenneth A. Ellenbogen
- Department of Cardiology, Virginia Commonwealth School of Medicine, Richmond, Virginia
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15
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Sohn A, Turner AM, Speier W, Fonarow GC, Ong M, Arnold C. Patients with Heart Failure: Internet Use and Mobile Health Perceptions. Appl Clin Inform 2024. [PMID: 38382633 DOI: 10.1055/a-2273-5278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Heart failure is a complex clinical syndrome noted on approximately 1 in 8 death certificates in the United States. Vital to reducing complications of heart failure and preventing hospital readmissions is adherence to heart failure self-care routines. Mobile health offers promising opportunities for enhancing self-care behaviors by facilitating tracking and timely reminders. OBJECTIVE We sought to investigate three characteristics of heart failure patients with respect to their heart failure self-care behaviors: (1) internet use to search for heart failure information; (2) familiarity with mobile health apps and devices; and (3) perceptions of using activity trackers or smartwatches to aid in their heart failure self-care. METHODS Forty-nine heart failure patients were asked about their internet and mobile health usage. The structured interview included questions adapted from the Health Information National Trends Survey. RESULTS Over 50% of the patients had utilized the internet to search for heart failure information in the past 12 months, experience using health-related apps, and thoughts that an activity tracker or smartwatch could help them manage heart failure. Qualitative analysis of the interviews revealed six themes: trust in their physicians, alternatives to mobile health apps, lack of need for mobile health devices, financial barriers to activity tracker and smartwatch ownership, benefits of tracking and reminders, and uncertainty of their potential due to lack of knowledge. CONCLUSIONS Trust in their physicians was a major factor for heart failure patients who reported not searching for health information on the internet. While those who used mobile health technologies found them useful, patients who did not use them were generally unaware of or unknowledgeable about them. Considering patients' preferences for recommendations from their physicians and tendency to search for heart failure information including treatment and management options, patient-provider discussions about mobile health may improve patient knowledge and impact their usage.
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Affiliation(s)
- Albert Sohn
- Medical Education and Clinical Sciences, Washington State University - Spokane, Spokane, United States
| | - Anne M Turner
- Biomedical Informatics and Medical Education and Health Services, University of Washington, Seattle, United States
| | - William Speier
- Radiological Sciences, University of California Los Angeles, Los Angeles, United States
| | - Gregg C Fonarow
- Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles, United States
| | - Michael Ong
- Medicine, University of California Los Angeles, Los Angeles, United States
| | - C Arnold
- Radiology, Pathology, Bioengineering, University of California Los Angeles, Los Angeles, United States
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16
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Sumarsono A, Xie L, Keshvani N, Zhang C, Patel L, Alonso WW, Thibodeau JT, Fonarow GC, Van Spall HGC, Messiah SE, Pandey A. Sex Disparities in Longitudinal Use and Intensification of Guideline-Directed Medical Therapy Among Patients With Newly Diagnosed Heart Failure With Reduced Ejection Fraction. Circulation 2024; 149:510-520. [PMID: 38258605 DOI: 10.1161/circulationaha.123.067489] [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: 10/06/2023] [Accepted: 12/28/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND Guideline-directed medical therapies (GDMTs) are the mainstay of treatment for heart failure with reduced ejection fraction (HFrEF), but they are underused. Whether sex differences exist in the initiation and intensification of GDMT for newly diagnosed HFrEF is not well established. METHODS Patients with incident HFrEF were identified from the 2016 to 2020 Optum deidentified Clinformatics Data Mart Database, which is derived from a database of administrative health claims for members of large commercial and Medicare Advantage health plans. The primary outcome was the use of optimal GDMT within 12 months of HFrEF diagnosis. Consistent with the guideline recommendations during the time period of the study, optimal GDMT was defined as ≥50% of the target dose of evidence-based beta-blocker plus ≥50% of the target dose of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, or any dose of angiotensin receptor neprilysin inhibitor plus any dose of mineralocorticoid receptor antagonist. The probability of achieving optimal GDMT on follow-up and predictors of optimal GDMT were evaluated with time-to-event analysis with adjusted Cox proportional hazard models. RESULTS The study cohort included 63 759 patients (mean age, 71.3 years; 15.2% non-Hispanic Black race; 56.6% male). Optimal GDMT use was achieved by 6.2% of patients at 12 months after diagnosis. Female (compared with male) patients with HFrEF had lower use across every GDMT class and lower use of optimal GDMT at each time point at follow-up. In an adjusted Cox model, female sex was associated with a 23% lower probability of achieving optimal GDMT after diagnosis (hazard ratio [HR], 0.77 [95% CI, 0.71-0.83]; P<0.001). The sex disparities in GDMT use after HFrEF diagnosis were most pronounced among patients with commercial insurance (females compared with males; HR, 0.66 [95% CI, 0.58-0.76]) compared with Medicare (HR, 0.85 [95% CI, 0.77-0.92]); Pinteraction sex×insurance status=0.005) and for younger patients (age <65 years: HR, 0.65 [95% CI, 0.58-0.74]) compared with older patients (age ≥65 years: HR, 87 [95% CI, 80-96]) Pinteraction sex×age=0.009). CONCLUSIONS Overall use of optimal GDMT after HFrEF diagnosis was low, with significantly lower use among female (compared with male) patients. These findings highlight the need for implementation efforts directed at improving GDMT initiation and titration.
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Affiliation(s)
- Andrew Sumarsono
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (A.S., N.K., L.B.P., J.T.T., A.P.)
| | - Luyu Xie
- School of Public Health, University of Texas Health Science Center at Houston (L.X., C.Z., S.E.M.)
| | - Neil Keshvani
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (A.S., N.K., L.B.P., J.T.T., A.P.)
| | - Chenguang Zhang
- School of Public Health, University of Texas Health Science Center at Houston (L.X., C.Z., S.E.M.)
| | | | - Windy W Alonso
- College of Nursing, University of Nebraska Medical Center, Omaha (W.W.A.)
| | - Jennifer T Thibodeau
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (A.S., N.K., L.B.P., J.T.T., A.P.)
| | - Gregg C Fonarow
- Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles Medical Center (G.C.F.)
| | - Harriette G C Van Spall
- Population Health Research Institute, Hamilton, Ontario, Canada (H.G.C.V.S.)
- McMaster University, Hamilton, Ontario, Canada (H.G.C.V.S.)
- Research Institute of St. Joseph's, Hamilton, Ontario, Canada (H.G.C.V.S.)
| | - Sarah E Messiah
- School of Public Health, University of Texas Health Science Center at Houston (L.X., C.Z., S.E.M.)
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX (A.S., N.K., L.B.P., J.T.T., A.P.)
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Minhas AMK, Talha KM, Abramov D, Johnson HM, Antoine S, Rodriguez F, Fudim M, Michos ED, Misra A, Abushamat L, Nambi V, Fonarow GC, Ballantyne CM, Virani SS. Racial and ethnic disparities in cardiovascular disease - analysis across major US national databases. J Natl Med Assoc 2024:S0027-9684(24)00022-1. [PMID: 38342731 DOI: 10.1016/j.jnma.2024.01.022] [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] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 01/14/2024] [Accepted: 01/16/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND There are several studies that have analyzed disparities in cardiovascular disease (CVD) health using a variety of different administrative databases; however, a unified analysis of major databases does not exist. In this analysis of multiple publicly available datasets, we sought to examine racial and ethnic disparities in different aspects of CVD, CVD-related risk factors, CVD-related morbidity and mortality, and CVD trainee representation in the US. METHODS We used National Health and Nutrition Examination Survey, National Ambulatory Medical Care Survey, National Inpatient Sample, Centers for Disease Control and Prevention Wide-Ranging OnLine Data for Epidemiologic Research, United Network for Organ Sharing, and American Commission for Graduate Medical Education data to evaluate CVD-related disparities among Non-Hispanic (NH) White, NH Black and Hispanic populations. RESULTS The prevalence of most CVDs and associated risk factors was higher in NH Black adults compared to NH White adults, except for dyslipidemia and ischemic heart disease (IHD). Statins were underutilized in IHD in NH Black and Hispanic patients. Hospitalizations for HF and stroke were higher among Black patients compared to White patients. All-cause, CVD, heart failure, acute myocardial infarction, IHD, diabetes mellitus, hypertension and cerebrovascular disease related mortality was highest in NH Black or African American individuals. The number of NH Black and Hispanic trainees in adult general CVD fellowship programs was disproportionately lower than NH White trainees. CONCLUSION Racial disparities are pervasive across the spectrum of CVDs with NH Black adults at a significant disadvantage compared to NH White adults for most CVDs.
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Affiliation(s)
| | - Khawaja M Talha
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Dmitry Abramov
- Division of Cardiology, Department of Medicine, Loma Linda University Health, Loma Linda, CA, USA
| | - Heather M Johnson
- Christine E. Lynn Women's Health & Wellness Institute, Baptist Health South Florida, Boca Raton, FL, USA
| | - Steve Antoine
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Fatima Rodriguez
- Stanford University Division of Cardiovascular Medicine and Cardiovascular Institute, Department of Medicine, Stanford University, Center for Academic Medicine, Stanford, CA, USA
| | - Marat Fudim
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA; Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Erin D Michos
- Division of Cardiology Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Arunima Misra
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Layla Abushamat
- Section of Cardiovascular Research, Baylor College of Medicine, Houston, TX, USA
| | - Vijay Nambi
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA; Section of Cardiovascular Research, Baylor College of Medicine, Houston, TX, USA
| | - Gregg C Fonarow
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles CA, USA
| | - Christie M Ballantyne
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA; Section of Cardiovascular Research, Baylor College of Medicine, Houston, TX, USA
| | - Salim S Virani
- Section of Cardiovascular Research, Baylor College of Medicine, Houston, TX, USA; Department of Medicine, Aga Khan University, Karachi, Pakistan
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18
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Sheth KN, Solomon N, Alhanti B, Messe SR, Xian Y, Bhatt DL, Hemphill JC, Frontera JA, Chang RC, Danelich IM, Huang J, Schwamm L, Smith EE, Goldstein JN, Mac Grory B, Fonarow GC, Saver JL. Time to Anticoagulation Reversal and Outcomes After Intracerebral Hemorrhage. JAMA Neurol 2024; 81:2815044. [PMID: 38335064 PMCID: PMC11002694 DOI: 10.1001/jamaneurol.2024.0221] [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] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/19/2024] [Indexed: 02/12/2024]
Abstract
Importance Intracerebral hemorrhage (ICH) is the deadliest stroke subtype, and mortality rates are especially high in anticoagulation-associated ICH. Recently, specific anticoagulation reversal strategies have been developed, but it is not clear whether there is a time-dependent treatment effect for door-to-treatment (DTT) times in clinical practice. Objective To evaluate whether DTT time is associated with outcome among patients with anticoagulation-associated ICH treated with reversal interventions. Design, Setting, and Participants This cohort study used data from the American Heart Association Get With The Guidelines-Stroke quality improvement registry. Patients with ICH who presented within 24 hours of symptom onset across 465 US hospitals from 2015 to 2021 were included. Data were analyzed from January to September 2023. Exposures Anticoagulation-associated ICH. Main Outcomes and Measures DTT times and outcomes were analyzed using logistic regression modeling, adjusted for demographic, history, baseline, and hospital characteristics, with hospital-specific random intercepts to account for clustering by site. The primary outcome of interest was the composite inpatient mortality and discharge to hospice. Additional prespecified secondary outcomes, including functional outcome (discharge modified Rankin Scale score, ambulatory status, and discharge venue), were also examined. Results Of 9492 patients with anticoagulation-associated ICH and documented reversal intervention status, 4232 (44.6%) were female, and the median (IQR) age was 77 (68-84) years. A total of 7469 (78.7%) received reversal therapy, including 4616 of 5429 (85.0%) taking warfarin and 2856 of 4069 (70.2%) taking a non-vitamin K antagonist oral anticoagulant. For the 5224 patients taking a reversal intervention with documented workflow times, the median (IQR) onset-to-treatment time was 232 (142-482) minutes and the median (IQR) DTT time was 82 (58-117) minutes, with a DTT time of 60 minutes or less in 1449 (27.7%). A DTT time of 60 minutes or less was associated with decreased mortality and discharge to hospice (adjusted odds ratio, 0.82; 95% CI, 0.69-0.99) but no difference in functional outcome (ie, a modified Rankin Scale score of 0 to 3; adjusted odds ratio, 0.91; 95% CI, 0.67-1.24). Factors associated with a DTT time of 60 minutes or less included White race, higher systolic blood pressure, and lower stroke severity. Conclusions and Relevance In US hospitals participating in Get With The Guidelines-Stroke, earlier anticoagulation reversal was associated with improved survival for patients with ICH. These findings support intensive efforts to accelerate evaluation and treatment for patients with this devastating form of stroke.
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Affiliation(s)
- Kevin N. Sheth
- Yale Center for Brain and Mind Health, Yale University School of Medicine, New Haven, Connecticut
| | - Nicole Solomon
- 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
| | - Steven R. Messe
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia
| | - Ying Xian
- Department of Neurology, University of Texas at Southwestern, Dallas
| | - Deepak L. Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | | | | | | | - Lee Schwamm
- Department of Biomedical Informatics and Data Sciences, Yale School of Medicine, New Haven, Connecticut
| | - Eric E. Smith
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Alberta, Canada
| | - Joshua N. Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina
| | - Gregg C. Fonarow
- Division of Cardiology, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Jeffrey L. Saver
- Department of Neurology, Ronald Reagan UCLA Medical Center, Los Angeles, California
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19
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Hamid A, Fonarow GC, Butler J, Hall ME. How do breast cancer clinical trials approach cardiovascular safety: targeted or generalized? Cardiooncology 2024; 10:6. [PMID: 38321579 PMCID: PMC10848621 DOI: 10.1186/s40959-024-00201-9] [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] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 01/05/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND Different breast cancer pharmacotherapy agents cause different forms of cardiovascular toxicity. We aim to assess if breast cancer pharmacotherapy trials approach cardiovascular safety in a targeted or generalized manner when administering different agents. METHODS We searched Embase and Medline for phase 2 and 3 breast cancer pharmacotherapy trials. We examined exclusion criterion for cardiovascular conditions and cardiovascular safety assessment through cardiovascular imaging, electrocardiogram, troponin, or natriuretic peptides. Fisher's exact test was utilized to compare reporting. RESULTS Fifty breast cancer clinical trials were included in this study. Trials administering microtubule inhibitors were most likely to exclude patients with any CV condition compared with trials administering other agents (93.5% vs. 68.4%; p < 0.05), particularly coronary artery disease (77.4% vs. 36.8%; p < 0.01) but reported performing an electrocardiogram in 13 (41.9%) trials. Trials administering anti-HER 2 agents excluded all patients with at least one CV condition, particularly patients with heart failure (100.0% vs. 62.9%) and were more likely to perform echocardiograms (80.0% vs. 22.9%, p < 0.001) compared with other agents. Other agents excluded participants in a generalized manner and do not frequently perform targeted safety assessments. CONCLUSIONS Only trials administering microtubule inhibitors or anti-HER 2 therapy exclude patients with cardiovascular disease in a targeted approach. However, anti-HER 2 therapy trials are the only breast cancer clinical trials that perform targeted safety assessments. Breast cancer clinical trials need to develop a targeted approach to cardiovascular safety assessments to permit inclusion of high-risk participants and generate clinical trial data generalizable to patients with cardiovascular disease undergoing cancer therapy.
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Affiliation(s)
- Arsalan Hamid
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA.
| | - Gregg C Fonarow
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
- Baylor Scott and White Research Institute, Dallas, TX, USA
| | - Michael E Hall
- Department of Medicine, Division of Cardiology, University of Mississippi Medical Center, Jackson, MS, USA
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20
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Man S, Solomon N, Mac Grory B, Alhanti B, Saver JL, Smith EE, Xian Y, Bhatt DL, Schwamm LH, Uchino K, Fonarow GC. Trends in Stroke Thrombolysis Care Metrics and Outcomes by Race and Ethnicity, 2003-2021. JAMA Netw Open 2024; 7:e2352927. [PMID: 38324315 PMCID: PMC10851100 DOI: 10.1001/jamanetworkopen.2023.52927] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 09/26/2023] [Accepted: 12/04/2023] [Indexed: 02/08/2024] Open
Abstract
Importance Understanding is needed of racial and ethnic-specific trends in care quality and outcomes associated with the US nationwide quality initiative Target: Stroke (TS) in targeting thrombolysis treatment for acute ischemic stroke. Objective To examine whether the TS quality initiative was associated with improvement in thrombolysis metrics and outcomes across racial and ethnic groups. Design, Setting, and Participants This retrospective cohort study included patients who presented within 4.5 hours of ischemic stroke onset at hospitals participating in the Get With The Guidelines-Stroke initiative from January 1, 2003, to December 31, 2021. The data analysis was performed between December 15, 2022, and November 27, 2023. Exposures TS phases I (2010-2013), II (2014-2018), and III (2019-2021). Main Outcomes and Measures The primary outcomes were thrombolysis rates and time metrics. Patient function and mortality were secondary outcomes. Results Analyses included 1 189 234 patients, of whom 1 053 539 arrived to the hospital within 4.5 hours. The cohort included 50.4% female and 49.6% male patients and 2.8% Asian [median (IQR) age, 72 (61-82) years], 15.2% Black [median (IQR) age, 64 (54-75) years], 7.3% Hispanic [median (IQR) age, 68 (56-79) years], and 74.1% White [median (IQR) age, 75 (63-84) years] patients). Unadjusted thrombolysis rates increased in both the pre-TS (2003-2009) and TS periods in all racial and ethnic groups from 10% to 15% in 2003 to 43% to 46% in 2021, but disparities were observed in adjusted analyses and persisted in TS phase III, with Asian, Black, and Hispanic patients having significantly lower odds of receiving thrombolysis than White patients (adjusted odds ratio, 0.85 [95% CI, 0.81-0.90], 0.76 [95% CI, 0.74-0.78], and 0.86 [95% CI, 0.83-0.89], respectively). Door-to-needle (DTN) times improved in all racial and ethnic groups during TS, with DTN times of 60 minutes or less increasing from 26% to 28% in 2009 to 66% to 72% in 2021. However, in adjusted analyses, racial and ethnic disparities emerged. During TS phase III, compared with White patients, Asian, Black, and Hispanic patients had significantly lower odds of receiving thrombolysis with a DTN time of 60 minutes or less compared with White patients (risk-adjusted odds ratios, 0.91 [95% CI, 0.84-0.98], 0.78 [95% CI, 0.75-0.81], and 0.87 [95% CI, 0.83-0.92], respectively). During TS, clinical outcomes improved for all racial and ethnic groups from pre-TS, with TS phase III showing higher odds of ambulation at discharge among Asian, Black, Hispanic, and White patients. Asian, Black, and Hispanic patients were less likely to present within 4.5 hours. Conclusions and Relevance In this cohort study of patients with ischemic stroke, the TS quality initiative was associated with improvement in thrombolysis frequency, timeliness, and outcomes for all racial and ethnic groups. However, disparities persisted, indicating a need for further interventions.
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Affiliation(s)
- Shumei Man
- Cerebrovascular Center, Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nicole Solomon
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina
| | - Brooke Alhanti
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | | | - Eric E. Smith
- Hotchkiss Brain Institute, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Ying Xian
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Deepak L. Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lee H. Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Ken Uchino
- Cerebrovascular Center, Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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21
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Li Z, Zhang X, Ding L, Jing J, Gu HQ, Jiang Y, Meng X, Du C, Wang C, Wang M, Xu M, Zhang Y, Hu M, Li H, Gong X, Dong K, Zhao X, Wang Y, Liu L, Xian Y, Peterson E, Fonarow GC, Schwamm LH, Wang Y. Rationale and design of the GOLDEN BRIDGE II: a cluster-randomised multifaceted intervention trial of an artificial intelligence-based cerebrovascular disease clinical decision support system to improve stroke outcomes and care quality in China. Stroke Vasc Neurol 2024:svn-2023-002411. [PMID: 37699726 DOI: 10.1136/svn-2023-002411] [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] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 08/11/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Given the swift advancements in artificial intelligence (AI), the utilisation of AI-based clinical decision support systems (AI-CDSSs) has become increasingly prevalent in the medical domain, particularly in the management of cerebrovascular disease. AIMS To describe the design, rationale and methods of a cluster-randomised multifaceted intervention trial aimed at investigating the effect of cerebrovascular disease AI-CDSS on the clinical outcomes of patients who had a stroke and on stroke care quality. DESIGN The GOLDEN BRIDGE II trial is a multicentre, open-label, cluster-randomised multifaceted intervention study. A total of 80 hospitals in China were randomly assigned to the AI-CDSS intervention group or the control group. For eligible participants with acute ischaemic stroke in the AI-CDSS intervention group, cerebrovascular disease AI-CDSS will provide AI-assisted imaging analysis, auxiliary stroke aetiology and pathogenesis analysis, and guideline-based treatment recommendations. In the control group, patients will receive the usual care. The primary outcome is the occurrence of new vascular events (composite of ischaemic stroke, haemorrhagic stroke, myocardial infarction or vascular death) at 3 months after stroke onset. The sample size was estimated to be 21 689 with a 26% relative reduction in the incidence of new composite vascular events at 3 months by using multiple quality-improving interventions provided by AI-CDSS. All analyses will be performed according to the intention-to-treat principle and accounted for clustering using generalised estimating equations. CONCLUSIONS Once the effectiveness is verified, the cerebrovascular disease AI-CDSS could improve stroke care and outcomes in China. TRIAL REGISTRATION NUMBER NCT04524624.
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Affiliation(s)
- Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Chinese Institute for Brain Research, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Xinmiao Zhang
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Lingling Ding
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hong-Qiu Gu
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong Jiang
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Chunying Du
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Chunjuan Wang
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Meng Wang
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Man Xu
- Hanalytics Artificial Intelligence Research Centre for Neurological Disorders, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yanxu Zhang
- Hanalytics Artificial Intelligence Research Centre for Neurological Disorders, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Meera Hu
- Hanalytics Artificial Intelligence Research Centre for Neurological Disorders, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hao Li
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiping Gong
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Kehui Dong
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ying Xian
- Department of Neurology, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Eric Peterson
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Gregg C Fonarow
- Cardiology, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
- Clinical Center for Precision Medicine in Stroke, Capital Medical Universit, Beijing, China
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22
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Averbuch T, Lee SF, Zagorski B, Mebazaa A, Fonarow GC, Thabane L, Van Spall HGC. Effect of a transitional care model following hospitalization for heart failure: 3-year outcomes of the Patient-Centered Care Transitions in Heart Failure (PACT-HF) randomized controlled trial. Eur J Heart Fail 2024. [PMID: 38303550 DOI: 10.1002/ejhf.3134] [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] [Received: 09/30/2023] [Revised: 11/17/2023] [Accepted: 12/25/2023] [Indexed: 02/03/2024] Open
Abstract
AIMS Patients are at high risk of death or readmission following hospitalization for heart failure (HF). We tested the effect of a transitional care model that included month-long nurse-led home visits and long-term heart function clinic visits - with services titrated to estimated risk of clinical events - on 3-year outcomes following hospitalization. METHODS AND RESULTS In a pragmatic, stepped-wedge cluster randomized trial, 10 hospitals were randomized to the intervention versus usual care. The primary outcome was a composite of all-cause death, readmission, or emergency department (ED) visit. Secondary outcomes included components of the primary composite outcomes, HF readmissions and healthcare resource utilization. There were 2494 patients (50.4% female) with mean age of 77.7 years. The primary outcome was reached in 1040 (94.2%) patients in the intervention and 1314 (94.5%) in the usual care group at 3 years. The intervention did not reduce the risk of the primary composite outcome (hazard ratio [HR] 0.92, 95% confidence interval [CI] 0.81-1.05) nor the component outcomes overall, although numerically reduced the risk of ED visits in women but not men (HR 0.79, 95% CI 0.63-1.00 vs. HR 0.98, 95% CI 0.80-1.19; sex-treatment interaction p = 0.23). The uptake of guideline-directed medical therapy was no different with the intervention than with usual care, with the exception of sacubitril/valsartan, which increased with the intervention (3.3% vs 1.5%; relative risk 6.2, 95% CI 1.92-20.06). CONCLUSIONS More than 9 of 10 patients hospitalized for HF experienced all-cause death, readmission, or ED visit at 3 years. A transitional care model with services titrated to risk did not improve the composite of these endpoints, likely because there were no major differences in uptake of medical therapies between the groups. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT02112227.
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Affiliation(s)
- Tauben Averbuch
- Department of Cardiology, University of Calgary, Calgary, AB, Canada
| | - Shun Fu Lee
- Population Health Research Institute, Hamilton, ON, Canada
| | - Brandon Zagorski
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Alexandre Mebazaa
- Department of Anesthesia and Critical Care-APHP, AM: Université Paris Cité; MASCOT Inserm, Paris, France
| | - Gregg C Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles Medical Center, Los Angeles, CA, USA
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- The Research Institute of St. Joe's, Hamilton, ON, Canada
| | - Harriette G C Van Spall
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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Bhatt AS, Fonarow GC, Greene SJ, Holmes DN, Alhanti B, Devore AD, Butler J, Heidenreich PA, Huang JC, Kittleson MM, Linganathan K, Joyntmaddox KE, McDermott JJ, Owens AT, Peterson PN, Solomon SD, Vardeny O, Yancy CW, Vaduganathan M. Medical Therapy Before, During and After Hospitalization in Medicare Beneficiaries With Heart Failure and Diabetes: Get With The Guidelines - Heart Failure Registry. J Card Fail 2024; 30:319-328. [PMID: 37757995 DOI: 10.1016/j.cardfail.2023.09.005] [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] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 08/23/2023] [Accepted: 09/03/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Patients hospitalized with heart failure (HF) and diabetes mellitus (DM) are at risk for worsening clinical status. Little is known about the frequency of therapeutic changes during hospitalization. We characterized the use of medical therapies before, during and after hospitalization in patients with HF and DM. METHODS We identified Medicare beneficiaries in Get With The Guidelines-Heart Failure (GWTG-HF) hospitalized between July 2014 and September 2019 with Part D prescription coverage. We evaluated trends in the use of 7 classes of antihyperglycemic therapies (metformin, sulfonylureas, GLP-1RA, SGLT2-inhibitors, DPP-4 inhibitors, thiazolidinediones, and insulins) and 4 classes of HF therapies (evidence-based β-blockers, ACEi or ARB, MRA, and ARNI). Medication fills were assessed at 6 and 3 months before hospitalization, at hospital discharge and at 3 months post-discharge. RESULTS Among 35,165 Medicare beneficiaries, the median age was 77 years, 54% were women, and 76% were white; 11,660 (33%) had HFrEF (LVEF ≤ 40%), 3700 (11%) had HFmrEF (LVEF 41%-49%), and 19,805 (56%) had HFpEF (LVEF ≥ 50%). Overall, insulin was the most commonly prescribed antihyperglycemic after HF hospitalization (n = 12,919, 37%), followed by metformin (n = 7460, 21%) and sulfonylureas (n = 7030, 20%). GLP-1RA (n = 700, 2.0%) and SGLT2i (n = 287, 1.0%) use was low and did not improve over time. In patients with HFrEF, evidence-based beta-blocker, RASi, MRA, and ARNI fills during the 6 months preceding HF hospitalization were 63%, 62%, 19%, and 4%, respectively. Fills initially declined prior to hospitalization, but then rose from 3 months before hospitalization to discharge (beta-blocker: 56%-82%; RASi: 51%-57%, MRA: 15%-28%, ARNI: 3%-6%, triple therapy: 8%-20%; P < 0.01 for all). Prescription rates 3 months after hospitalization were similar to those at hospital discharge. CONCLUSIONS In-hospital optimization of medical therapy in patients with HF and DM is common in participating hospitals of a large US quality improvement registry.
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Affiliation(s)
- Ankeet S Bhatt
- Kaiser Permanente San Francisco Medical Center and Division of Research, Oakland, CA; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles, Los Angeles, CA
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | | | | | - Adam D Devore
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA
| | | | | | | | - Karen E Joyntmaddox
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO
| | | | - Anjali Tiku Owens
- Heart and Vascular Center, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, PA
| | - Pamela N Peterson
- Department of Medicine, Denver Health Medical Center, Denver, CO; Department of Medicine, University of Colorado Anschutz Medical Center, Aurora, CO
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Orly Vardeny
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, University of Minnesota, Minneapolis, MN
| | - Clyde W Yancy
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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Diamond JE, Kaltenbach LA, Granger BB, Fonarow GC, Al-Khalidi HR, Albert NM, Butler J, Allen LA, Lanfear DE, Thibodeau JT, Granger CB, Hernandez AF, Ariely D, DeVore AD. Access to Mobile Health Interventions Among Patients Hospitalized With Heart Failure: Insights Into the Digital Divide From the CONNECT-HF mHealth Substudy. Circ Heart Fail 2024; 17:e011140. [PMID: 38205653 DOI: 10.1161/circheartfailure.123.011140] [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] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Affiliation(s)
| | - Lisa A Kaltenbach
- Duke Clinical Research Institute, Durham, NC (L.A.K., A.F.H., A.D.D.)
| | | | - Gregg C Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles (G.C.F.)
| | - Hussein R Al-Khalidi
- Department of Biostatistics and Bioinformatics (H.R.A.-K.), Duke University, Durham, NC
| | - Nancy M Albert
- Office of Nursing Research and Innovation, Cleveland Clinic Health System, Clinical Nurse Specialist-Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular & Thoracic Institute, Clinic Main Campus, OH (N.M.A.)
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX (J.B.)
- University of Mississippi, Jackson (J.B.)
| | - Larry A Allen
- Division of Cardiology, University of Colorado School of Medicine, Aurora (L.A.A.)
| | - David E Lanfear
- Division of Cardiology, Department of Medicine, Henry Ford Hospital, Detroit, MI (D.E.L.)
| | - Jennifer T Thibodeau
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas (J.T.T.)
| | - Christopher B Granger
- Division of Cardiology and Department of Medicine, Duke University School of Medicine, Durham, NC (C.B.G., A.F.H., A.D.D.)
| | - Adrian F Hernandez
- Division of Cardiology and Department of Medicine, Duke University School of Medicine, Durham, NC (C.B.G., A.F.H., A.D.D.)
- Duke Clinical Research Institute, Durham, NC (L.A.K., A.F.H., A.D.D.)
| | - Dan Ariely
- Center for Advanced Hindsight (D.A.), Duke University, Durham, NC
| | - Adam D DeVore
- Division of Cardiology and Department of Medicine, Duke University School of Medicine, Durham, NC (C.B.G., A.F.H., A.D.D.)
- Duke Clinical Research Institute, Durham, NC (L.A.K., A.F.H., A.D.D.)
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25
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Khan MS, Fonarow GC, Greene SJ. Guideline-directed medical therapy for heart failure: The key ingredient for successful in-hospital and post-discharge care. Eur J Heart Fail 2024; 26:355-358. [PMID: 38291014 DOI: 10.1002/ejhf.3152] [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: 01/05/2024] [Accepted: 01/09/2024] [Indexed: 02/01/2024] Open
Affiliation(s)
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles, CA, USA
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
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26
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Lin J, Long D, Jiang C, Sang C, Tang R, Li S, Wang W, Guo X, Ning M, Sun Z, Yang N, Hao Y, Liu J, Liu J, Du X, Morgan L, Fonarow GC, Smith SC, Lip GY, Zhao D, Dong J, Ma C. Oral anti-coagulants use in Chinese hospitalized patients with atrial fibrillation. Chin Med J (Engl) 2024; 137:172-180. [PMID: 38146256 PMCID: PMC10798766 DOI: 10.1097/cm9.0000000000002915] [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] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Indexed: 12/27/2023] Open
Abstract
BACKGROUND Oral anti-coagulants (OAC) are the intervention for the prevention of stroke, which consistently improve clinical outcomes and survival among patients with atrial fibrillation (AF). The main purpose of this study is to identify problems in OAC utilization among hospitalized patients with AF in China. METHODS Using data from the Improving Care for Cardiovascular Disease in China-Atrial Fibrillation (CCC-AF) registry, guideline-recommended OAC use in eligible patients was assessed. RESULTS A total of 52,530 patients with non-valvular AF were enrolled from February 2015 to December 2019, of whom 38,203 were at a high risk of stroke, 9717 were at a moderate risk, and 4610 were at a low risk. On admission, only 20.0% (6075/30,420) of patients with a diagnosed AF and a high risk of stroke were taking OAC. The use of pre-hospital OAC on admission was associated with a lower risk of new-onset ischemic stroke/transient ischemic attack among the diagnosed AF population (adjusted odds ratio: 0.54, 95% confidence interval: 0.43-0.68; P <0.001). At discharge, the prescription rate of OAC was 45.2% (16,757/37,087) in eligible patients with high stroke risk and 60.7% (2778/4578) in eligible patients with low stroke risk. OAC utilization in patients with high stroke risk on admission or at discharge both increased largely over time (all P <0.001). Multivariate analysis showed that OAC utilization at discharge was positively associated with in-hospital rhythm control strategies, including catheter ablation (adjusted odds ratio [OR] 11.63, 95% confidence interval [CI] 10.04-13.47; P <0.001), electronic cardioversion (adjusted OR 2.41, 95% CI 1.65-3.51; P <0.001), and anti-arrhythmic drug use (adjusted OR 1.45, 95% CI 1.38-1.53; P <0.001). CONCLUSIONS In hospitals participated in the CCC-AF project, >70% of AF patients were at a high risk of stroke. Although poor performance on guideline-recommended OAC use was found in this study, over time the CCC-AF project has made progress in stroke prevention in the Chinese AF population.Registration:ClinicalTrials.gov, NCT02309398.
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Affiliation(s)
- Jing Lin
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing 100029 China
| | - Deyong Long
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing 100029 China
| | - Chenxi Jiang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing 100029 China
| | - Caihua Sang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing 100029 China
| | - Ribo Tang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing 100029 China
| | - Songnan Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing 100029 China
| | - Wei Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing 100029 China
| | - Xueyuan Guo
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing 100029 China
| | - Man Ning
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing 100029 China
| | - Zhaoqing Sun
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Na Yang
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Yongchen Hao
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Jun Liu
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Jing Liu
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Xin Du
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing 100029 China
| | - Louise Morgan
- International Quality Improvement Department, American Heart Association, Dallas, TX 07076, USA
| | - Gregg C. Fonarow
- Division of Cardiology, Geffen School of Medicine at University of California, Los Angeles CA 90024, USA
| | - Sidney C. Smith
- Division of Cardiology, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Gregory Y.H. Lip
- Department of Cardiology, Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L143PE, UK
- Department of Clinical Medicine, Aalborg University, Aalborg 9000, Denmark
| | - Dong Zhao
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Jianzeng Dong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing 100029 China
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing 100029 China
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27
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Ye Y, Hao Y, Zhao X, Liu J, Yang N, Smith SC, Huo Y, Fonarow GC, Ge J, Morgan L, Sun Z, Hu D, Yang Y, Ma CS, Zhao D, Han Y, Liu J, Zeng Y. Percutaneous Coronary Intervention in Acute Coronary Syndrome with Mild-to-Moderate Thrombocytopenia. Thromb Haemost 2024. [PMID: 38081311 DOI: 10.1055/a-2225-5263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
BACKGROUND Baseline thrombocytopenia is commonly observed in patients with acute coronary syndrome (ACS) requiring percutaneous coronary intervention (PCI). AIM The purpose of this analysis was to investigate safety and effectiveness of PCI in ACS patients with baseline mild-to-moderate thrombocytopenia. METHODS The data were collected from the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome project. A total of 50,009 ACS patients were recruited between July 2017 and December 2019. Among them, there were 6,413 patients with mild-to-moderate thrombocytopenia, defined as a platelet count of ≥50 × 109/L and <150 × 109/L on admission. The primary outcome was in-hospital net adverse clinical events (NACE), consisting of major adverse cardiac events (MACE) and major bleeding events. The associations between PCI and in-hospital outcomes were analyzed by inverse probability treatment weighting (IPTW) method. RESULTS PCI was performed in 4,023 of 6,413 patients (62.7%). The IPTW analysis showed that PCI was significantly associated with a reduced risk of in-hospital MACE (odd ratio [OR]: 0.45; 95% confidence interval [CI]: 0.31-0.67; p < 0.01) and NACE (OR: 0.59; 95% CI: 0.42-0.83; p < 0.01). PCI was also associated with an increased risk of any bleeding (OR: 1.56; 95% CI: 1.09-2.22; p = 0.01) and minor bleeding (OR: 1.52; 95% CI: 1.00-2.30; p = 0.05), but not major bleeding (OR: 1.51; 95% CI: 0.76-2.98; p = 0.24). CONCLUSION Compared with medical therapy alone, PCI is associated with better in-hospital outcomes in ACS patients with mild-to-moderate thrombocytopenia. Further studies with long-term prognosis are needed.
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Affiliation(s)
- Yicong Ye
- Department of Cardiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing Anzhen Hospital, Beijing, China
| | - Yongchen Hao
- Department of Epidemiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing Anzhen Hospital, Beijing, China
| | - Xiliang Zhao
- Department of Cardiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing Anzhen Hospital, Beijing, China
| | - Jun Liu
- Department of Epidemiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing Anzhen Hospital, Beijing, China
| | - Na Yang
- Department of Epidemiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing Anzhen Hospital, Beijing, China
| | - Sidney C Smith
- Division of Cardiology, University of North Carolina, Chapel Hill, North Carolina, United States
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Gregg C Fonarow
- Division of Cardiology, Geffen School of Medicine at University of California, Los Angeles, California, United States
| | - Junbo Ge
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Fudan University, Zhongshan Hospital, Shanghai, China
| | - Louise Morgan
- International Quality Improvement Department, American Heart Association, Dallas, Texas, United States
| | - Zhaoqing Sun
- Department of Epidemiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing Anzhen Hospital, Beijing, China
| | - Danqing Hu
- Department of Epidemiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing Anzhen Hospital, Beijing, China
| | - Yiqian Yang
- Department of Epidemiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing Anzhen Hospital, Beijing, China
| | - Chang-Sheng Ma
- Department of Cardiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing Anzhen Hospital, Beijing, China
| | - Dong Zhao
- Department of Epidemiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing Anzhen Hospital, Beijing, China
| | - Yaling Han
- Department of Cardiology, Cardiovascular Research Institute, General Hospital of Northern Theater Command, Shenyang, Liaoning, China
| | - Jing Liu
- Department of Epidemiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing Anzhen Hospital, Beijing, China
| | - Yong Zeng
- Department of Cardiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing Anzhen Hospital, Beijing, China
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28
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Shahid I, Khan MS, Fonarow GC, Butler J, Greene SJ. Bridging gaps and optimizing implementation of guideline-directed medical therapy for heart failure. Prog Cardiovasc Dis 2024; 82:61-69. [PMID: 38244825 DOI: 10.1016/j.pcad.2024.01.008] [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: 01/13/2024] [Accepted: 01/13/2024] [Indexed: 01/22/2024]
Abstract
Despite robust scientific evidence and strong guideline recommendations, there remain significant gaps in initiation and dose titration of guideline-directed medical therapy (GDMT) for heart failure (HF) among eligible patients. Reasons surrounding these gaps are multifactorial, and largely attributed to patient, healthcare professionals, and institutional challenges. Concurrently, HF remains a predominant cause of mortality and hospitalization, emphasizing the critical need for improved delivery of therapy to patients in routine clinical practice. To optimize GDMT, various implementation strategies have emerged in the recent decade such as in-hospital rapid initiation of GDMT, improving patient adherence, addressing clinical inertia, improving affordability, engagement in quality improvement registries, multidisciplinary clinics, and EHR-integrated interventions. This review highlights the current use and barriers to optimal utilization of GDMT, and proposes novel strategies aimed at improving GDMT in HF.
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Affiliation(s)
- Izza Shahid
- Division of Preventive Cardiology, Houston Methodist Academic Institute, Houston, TX, USA
| | | | - Gregg C Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles Medical Center, Los Angeles, CA, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA; Department of Medicine, University of Mississippi, Jackson, MS, USA
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA.
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29
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Greene SJ, Fonarow GC, Butler J. SGLT2 Inhibitors for Heart Failure with Preserved Ejection Fraction: What Hospitalists Need to Know. Am J Cardiovasc Drugs 2024; 24:1-4. [PMID: 38157160 DOI: 10.1007/s40256-023-00624-2] [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] [Accepted: 12/11/2023] [Indexed: 01/03/2024]
Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute, 300 West Morgan Street, Durham, NC, 27701, USA.
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA.
| | - Gregg C Fonarow
- Division of Cardiology, Department of Medicine, Ronald Reagan-UCLA Medical Center, Los Angeles, CA, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA
- Department of Medicine, University of Mississippi, Jackson, MS, USA
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30
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Zile MR, Kahwash R, Sarkar S, Koehler J, Zielinski T, Mehra MR, Fonarow GC, Gulati S, Butler J. A Novel Heart Failure Diagnostic Risk Score Using a Minimally Invasive Subcutaneous Insertable Cardiac Monitor. JACC Heart Fail 2024; 12:182-196. [PMID: 37943225 DOI: 10.1016/j.jchf.2023.09.014] [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] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 09/08/2023] [Accepted: 09/13/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND The authors tested the hypothesis that physiological information from sensors within a minimally invasive, subcutaneous, insertable cardiac monitor (ICM) could be used to develop an ambulatory heart failure risk score (HFRS) to accurately identify heart failure (HF) patients, across the ejection fraction spectrum, at high risk of an impending worsening heart failure event (HFE). OBJECTIVES The purpose of this study was to examine performance of ICM-based, multiparameter, dynamic HFRS to predict HFEs in patients with NYHA functional class II/III HF. METHODS In 2 observational cohorts, HF patients were implanted with an ICM; subcutaneous impedance, respiratory rate, heart rate and variability, atrial fibrillation burden, ventricular rate during atrial fibrillation, and activity duration were combined into an HFRS to identify the probability of HFE within 30 days. Patients and providers were blinded to the data. HFRS sensitivity and unexplained detection rate were defined in 2 independent patient population data sets. HFEs were defined as hospitalization, observation unit, or emergency department visit with a primary diagnosis of HF, and intravenous diuretic treatment. RESULTS First data set (development): 42 patients had 19 HFE; second data set (validation): 94 patients had 19 HFE (mean age 66 ± 11 years, 63% men, 50% with LVEF ≥40%, 80% NYHA functional class III). Using a high-risk threshold = 7.5%, development and validation data sets: sensitivity was 73.7% and 68.4%; unexplained detection rate of 1.4 and 1.5 per patient-year; median 47 and 64 days early warning before HFE. CONCLUSIONS ICM-HFRS provides a multiparameter, integrated diagnostic method with the ability to identify when HF patients are at increased risk of heart failure events. (Reveal LINQ Evaluation of Fluid [REEF]; NCT02275923, Reveal LINQ Heart Failure [LINQ HF]; NCT02758301, Algorithm Using LINQ Sensors for Evaluation and Treatment of Heart Failure [ALLEVIATE-HF]; NCT04452149).
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Affiliation(s)
- Michael R Zile
- Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Health Care System, Charleston, South Carolina, USA.
| | | | | | | | | | - Mandeep R Mehra
- Center for Advanced Heart Disease, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Gregg C Fonarow
- University of California, Division of Cardiology, Los Angeles, California, USA
| | - Sanjeev Gulati
- Sanger Heart and Vascular Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Javed Butler
- Baylor Scott and White Research Institute Dallas Texas, University of Mississippi, Jackson, Mississippi, USA
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31
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Ahmad Cheema H, Azeem S, Ejaz A, Khan F, Muhammad A, Shahid A, Nashwan AJ, Maqsood MH, Dani SS, Mentz RJ, Fudim M, Fonarow GC. Efficacy and safety of torsemide versus furosemide in heart failure patients: A systematic review of randomized controlled trials. Clin Cardiol 2024; 47:e24088. [PMID: 37608566 PMCID: PMC10765996 DOI: 10.1002/clc.24088] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/31/2023] [Accepted: 06/29/2023] [Indexed: 08/24/2023] Open
Affiliation(s)
- Huzaifa Ahmad Cheema
- Department of CardiologyKing Edward Medical UniversityLahorePakistan
- Department of MedicineKing Edward Medical UniversityLahorePakistan
| | - Saleha Azeem
- Department of MedicineKing Edward Medical UniversityLahorePakistan
| | - Abdullah Ejaz
- Department of MedicineKing Edward Medical UniversityLahorePakistan
| | - Faiza Khan
- Department of MedicineKing Edward Medical UniversityLahorePakistan
| | - Anza Muhammad
- Department of MedicineKing Edward Medical UniversityLahorePakistan
| | - Abia Shahid
- Department of MedicineKing Edward Medical UniversityLahorePakistan
| | | | | | - Sourbha S. Dani
- Division of Cardiovascular Medicine, Beth Israel Lahey HealthLahey Hospital and Medical CenterBurlingtonMassachusettsUSA
| | - Robert J. Mentz
- Division of Cardiology, Department of MedicineDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Marat Fudim
- Department of MedicineDuke University Medical CenterDurhamNCUSA
- Duke Clinical Research InstituteDurhamNorth CarolinaUSA
| | - Gregg C. Fonarow
- Ahmanson‐UCLA Cardiomyopathy Center, Division of CardiologyUniversity of California Los AngelesLos AngelesCaliforniaUSA
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32
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Xia J, Brownell NK, Fonarow GC, Ziaeian B. New models for heart failure care delivery. Prog Cardiovasc Dis 2024; 82:70-89. [PMID: 38311306 DOI: 10.1016/j.pcad.2024.01.009] [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: 01/13/2024] [Accepted: 01/13/2024] [Indexed: 02/10/2024]
Abstract
Heart failure (HF) is a common disease with increasing prevalence around the world. There is high morbidity and mortality associated with poorly controlled HF along with increasing costs and strain on healthcare systems due to a high rate of rehospitalization and resource utilization. Despite the establishment of clear evidence-based guideline directed medical therapies (GDMT) proven to improve HF morbidity and mortality, there remains significant clinical inertia to optimizing HF patients on GDMT. Only a minority of HF patients are prescribed on all four classes of GDMT. To bridge the gap between the vulnerable population of HF patients and lifesaving GDMT, HF implementation is of increasing importance. HF implementation involves strategies and techniques to improve GDMT optimization along with other modalities to improve HF management. HF implementation meets patients where they are, including at the time of acute decompensation in the inpatient setting, at the vulnerable discharge stage, and at the chronic management stage in the outpatient setting. Inpatient HF implementation strategies include protocolized rapid titration of GDMT, site-level audit-and-feedback, virtual GDMT optimization teams, and electronic health record notifications and alerts. Discharge HF implementation strategies include education at patient and provider levels, discharge summaries, and HF transitional programs. Outpatient HF implementation strategies include digital innovations such as electronic health record utilization and mobile applications, population level strategies such as registries and clinical dashboards), changes in HF team structure and member roles, remote monitoring with implanted devices and telemonitoring, and hospital at home care model. With a growing population of HF patients, there is an increasing need for novel and creative HF implementation and monitoring methods.
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Affiliation(s)
- Jeffrey Xia
- Department of Medicine David Geffen School of Medicine at UCLA, Los Angeles, United States of America.
| | - Nicholas K Brownell
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, United States of America.
| | - Gregg C Fonarow
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, United States of America.
| | - Boback Ziaeian
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, United States of America.
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Affiliation(s)
- Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles, 10,833 LeConte Ave, Room 47-123 CHS, Los Angeles, CA 90095, USA.
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Raychev R, Sun JL, Schwamm L, Smith EE, Fonarow GC, Messé SR, Xian Y, Chiswell K, Blanco R, Mac Grory B, Saver JL. Performance of Thrombectomy-Capable, Comprehensive, and Primary Stroke Centers in Reperfusion Therapies for Acute Ischemic Stroke: Report From the Get With The Guidelines-Stroke Registry. Circulation 2023; 148:2019-2028. [PMID: 37855118 DOI: 10.1161/circulationaha.123.066114] [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: 07/04/2023] [Accepted: 09/18/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND The thrombectomy-capable stroke center (TSC) is a recently introduced intermediate tier of accreditation for hospitals at which patients with acute ischemic stroke receive care. The comparative quality and clinical outcomes of reperfusion therapies at TSCs, primary stroke centers (PSCs), and comprehensive stroke centers (CSCs) have not been well delineated. METHODS We conducted a retrospective, observational, cohort study from 2018 to 2020 that included patients with acute ischemic stroke who received endovascular thrombectomy (EVT) and intravenous thrombolysis reperfusion therapies at CSCs, TSCs, or PSCs. Participants were recruited from Get With The Guidelines-Stroke registry. Study end points included timeliness of intravenous thrombolysis and EVT, successful reperfusion, discharge destination, discharge mortality, and functional independence at discharge. RESULTS Among 84 903 patients, 48 682 received EVT, of whom 73% were treated at CSCs, 22% at PSCs, and 4% at TSCs. The median annual EVT volume was 76 for CSCs, 55 for TSCs, and 32 for PSCs. Patient differences by center status included higher National Institutes of Health Stroke Scale score, longer onset-to-arrival time, and higher transfer-in rates for CSCs, TSCs, and PSCs, respectively. In adjusted analyses, the likelihood of achieving the goal door-to-needle time was higher in CSCs compared with PSCs (odds ratio [OR], 1.39 [95% CI, 1.17-1.66]) and in TSCs compared with PSCs (OR, 1.45 [95% CI, 1.08-1.96]). Likewise, the odds of achieving the goal door-to-puncture time were higher in CSCs compared with PSCs (OR, 1.58 [95% CI, 1.13-2.21]). CSCs and TSCs also demonstrated better clinical efficacy outcomes compared with PSCs. The odds of discharge to home or rehabilitation were higher in CSCs compared with PSCs (OR, 1.18 [95% CI, 1.06-1.31]), whereas the odds of in-hospital mortality or discharge to hospice were lower in both CSCs compared with PSCs (OR, 0.87 [95% CI, 0.81-0.94]) and TSCs compared with PSCs (OR, 0.86 [95% CI, 0.75-0.98]). There were no significant differences in any of the quality-of-care metrics and clinical outcomes between TSCs and CSCs. CONCLUSIONS In this study representing national US practice, CSCs and TSCs exceeded PSCs in key quality-of-care reperfusion metrics and outcomes, whereas TSCs and CSCs demonstrated a similar performance. With more than one-fifth of all EVT procedures during the study period conducted at PSCs, it may be desirable to explore national initiatives aimed at facilitating the elevation of eligible PSCs to a higher certification status.
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Affiliation(s)
- Radoslav Raychev
- Duke Clinical Research Institute, Durham, NC (J.-L.S., K.C., R.R.)
- Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA (R.R., J.S., G.C.F.)
| | - Jie-Lena Sun
- Duke Clinical Research Institute, Durham, NC (J.-L.S., K.C., R.R.)
- Duke University School of Medicine, Durham, NC (J.-L.S.)
| | - Lee Schwamm
- Yale School of Medicine, New Haven, CT (L.S.)
| | | | - Gregg C Fonarow
- Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA (R.R., J.S., G.C.F.)
| | | | - Ying Xian
- University of Texas, Southwestern Medical Center, Dallas (Y.X.)
| | - Karen Chiswell
- Duke Clinical Research Institute, Durham, NC (J.-L.S., K.C., R.R.)
| | | | | | - Jeffrey L Saver
- Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA (R.R., J.S., G.C.F.)
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Mullen MT, Gurol ME, Prabhakaran S, Messé SR, Kleindorfer DO, Smith EE, Fonarow GC, Xu H, Zhao X, Cigarroa JE, Schwamm LH. Hospital-Level Variability in Reporting of Ischemic Stroke Subtypes and Supporting Diagnostic Evaluation in GWTG-Stroke Registry. J Am Heart Assoc 2023; 12:e031303. [PMID: 38108258 PMCID: PMC10863791 DOI: 10.1161/jaha.123.031303] [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: 06/06/2023] [Accepted: 10/18/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Secondary prevention of ischemic stroke (IS) requires adequate diagnostic evaluation to identify the likely etiologic subtype. We describe hospital-level variability in diagnostic testing and IS subtyping in a large nationwide registry. METHODS AND RESULTS We used the GWTG-Stroke (Get With The Guidelines-Stroke) registry to identify patients hospitalized with a diagnosis of acute IS at 1906 hospitals between January 1, 2016, and September 30, 2017. We compared the documentation rates and presence of risk factors, diagnostic testing, achievement/quality measures, and outcomes between patients with and without reported IS subtype. Recording of diagnostic evaluation was optional in all IS subtypes except cryptogenic, where it was required. Of 607 563 patients with IS, etiologic IS subtype was documented in 57.4% and missing in 42.6%. Both the rate of missing stroke pathogenesis and the proportion of cryptogenic strokes were highly variable across hospitals. Patients missing stroke pathogenesis less frequently had documentation of risk factors, evidence-based interventions, or discharge to home. The reported rates of major diagnostic testing, including echocardiography, carotid and intracranial vascular imaging, and short-term cardiac monitoring were <50% in patients with documented IS pathogenesis, although these variables were missing in >40% of patients. Long-term cardiac rhythm monitoring was rarely reported, even in cryptogenic stroke. CONCLUSIONS Reporting of IS etiologic subtype and supporting diagnostic testing was low overall, with high rates of missing optional data. Improvement in the capture of these data elements is needed to identify opportunities for quality improvement in the diagnostic evaluation and secondary prevention of stroke.
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Affiliation(s)
| | - M. Edip Gurol
- Massachusetts General HospitalHarvard UniversityBostonMA
| | | | - Steven R. Messé
- Hospital of the University of PennsylvaniaThe University of PennsylvaniaPhiladelphiaPA
| | | | - Eric E. Smith
- Hotchkiss Brain InstituteUniversity of CalgaryCalgaryAlbertaCanada
| | | | - Haolin Xu
- Duke Clinical Research InstituteDurhamNC
| | - Xin Zhao
- Duke Clinical Research InstituteDurhamNC
| | | | - Lee H. Schwamm
- Massachusetts General HospitalHarvard UniversityBostonMA
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Pierce JB, Fonarow GC, Greene SJ. Identifying Barriers to Initiation of Sodium-Glucose Cotransporter-2 Inhibitor Therapy in Patients Hospitalized With Heart Failure With Reduced Ejection Fraction-Reply. JAMA Cardiol 2023; 8:1188-1189. [PMID: 37878275 DOI: 10.1001/jamacardio.2023.3784] [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] [Indexed: 10/26/2023]
Affiliation(s)
- Jacob B Pierce
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles
- Associate Editor for Health Care Quality and Guidelines, JAMA Cardiology
| | - Stephen J Greene
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
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Matasic DS, Blumenthal RS, Fonarow GC, Gulati M. Taking the next step in cardiovascular risk reduction: Integrating heart failure and peripheral arterial disease prevention. Am Heart J 2023; 266:176-178. [PMID: 37480974 DOI: 10.1016/j.ahj.2023.07.004] [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: 05/22/2023] [Revised: 07/04/2023] [Accepted: 07/07/2023] [Indexed: 07/24/2023]
Affiliation(s)
- Daniel S Matasic
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University, Baltimore, MD
| | - Roger S Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Johns Hopkins University, Baltimore, MD
| | - Gregg C Fonarow
- Division of Cardiology, University of California, Los Angeles, CA
| | - Martha Gulati
- Department of Cardiology, Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA.
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Sandhu A, Kaltenbach LA, Chiswell K, Shimoga V, Ashur C, Pribish A, Fonarow GC, Piccini JP, Ho PM, Varosy PD, Hess PL. Off-Label Dosing of Direct Oral Anticoagulants Among Inpatients With Atrial Fibrillation in the United States. Circ Cardiovasc Qual Outcomes 2023; 16:e010062. [PMID: 37929603 PMCID: PMC10842588 DOI: 10.1161/circoutcomes.123.010062] [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: 03/16/2023] [Accepted: 10/06/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Among patients hospitalized for atrial fibrillation, the frequency of off-label direct oral anticoagulant (DOAC) dosing, associated factors, hospital-level variation, and temporal trends in contemporary practice are unknown. METHODS Using the Get With The Guidelines-Atrial Fibrillation registry, patients admitted from January 1, 2014, to March 31, 2020, and discharged on DOACs were stratified according to receipt of underdosing, overdosing, or recommended dosing. Factors associated with off-label dosing (defined as underdosing or overdosing) were identified using logistic regression. Median odds ratio (OR) and time-series analyses were used to assess hospital-level variation and temporal trends, respectively. RESULTS Of 22 470 patients (70.1±12.1 years, 48.1% female, 82.5% White) prescribed a DOAC at discharge from hospitalization for atrial fibrillation (66% apixaban, 29% rivaroxaban, and 5% dabigatran), underdosing occurred among 2006 (8.9%), overdosing among 511 (2.3%), and recommended dosing among 19 953 (88.8%). The overall rate of off-label dosing was 11.2%. Patient-related factors associated with off-label dose included age (underdosing: OR, 1.06 per 1-year increase [95% CI, 1.06-1.07]; overdosing: OR, 1.07 per 1-year increase [95% CI, 1.06-1.09]), dialysis dependence (underdosing: OR, 5.50 [95% CI, 3.76-8.05]; overdosing: OR, 5.47 [95% CI, 2.74-10.88]), female sex (overdosing: OR, 0.79 [95% CI, 0.63-0.99]), and weight (overdosing: OR, 0.96 per 1-kg increase [95% CI, 0.95-1.00]). Across hospitals, the adjusted median OR for off-label DOAC dose was 1.45 (95% CI, 1.34-1.65; underdosing: OR, 1.52 [95% CI, 1.39-1.76]; overdosing: OR, 1.32 [95% CI, 1.20-1.84]), indicating significant hospital-level variation. Over the study period, recommended dosing significantly increased over time (81.9%-90.9%; P<0.0001 for trend) with a corresponding decline in underdosing (14.4%-6.6%; P<0.0001 for trend) and overdosing (3.8%-2.5%; P=0.001 for trend). CONCLUSIONS Over 1 in 10 patients hospitalized for atrial fibrillation are discharged on an off-label DOAC dose with significant variation across hospitals. While the proportion of patients receiving recommended dosing has significantly improved over time, opportunities to improve DOAC dosing persist.
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Affiliation(s)
- Amneet Sandhu
- Denver VA Medical Center, Section of Cardiology
- University of Colorado, Division of Cardiology
| | | | | | | | | | | | | | | | - P. Michael Ho
- Denver VA Medical Center, Section of Cardiology
- University of Colorado, Division of Cardiology
| | - Paul D. Varosy
- Denver VA Medical Center, Section of Cardiology
- University of Colorado, Division of Cardiology
| | - Paul L. Hess
- Denver VA Medical Center, Section of Cardiology
- University of Colorado, Division of Cardiology
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Udelson JE, Fonarow GC, Bonow RO. Realigning Priorities in the Evaluation and Management of Patients With Heart Failure. JAMA Cardiol 2023; 8:1163-1164. [PMID: 37878287 DOI: 10.1001/jamacardio.2023.3900] [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] [Indexed: 10/26/2023]
Affiliation(s)
- James E Udelson
- Division of Cardiology and the Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts
- Associate Editor, JAMA Cardiology
| | - Gregg C Fonarow
- Division of Cardiology, Ronald Reagan-UCLA Medical Center, Los Angeles, California
- Associate Section Editor, JAMA Cardiology
| | - Robert O Bonow
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Editor, JAMA Cardiology
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Murthy SB, Zhang C, Shah S, Schwamm LH, Fonarow GC, Smith EE, Bhatt DL, Ziai WC, Kamel H, Sheth KN. Antithrombotic and Statin Prescription After Intracerebral Hemorrhage in the Get With The Guidelines-Stroke Registry. Stroke 2023; 54:2972-2980. [PMID: 37942641 PMCID: PMC10842167 DOI: 10.1161/strokeaha.123.043194] [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: 05/09/2023] [Accepted: 10/17/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Survivors of intracerebral hemorrhage (ICH) face an increased risk of ischemic cardiovascular events. Current ICH guidelines do not provide definitive recommendations regarding the use of antithrombotic and statin therapies. We, therefore, sought to study practice patterns and factors associated with the use of such medications after ICH. METHODS This was a cross-sectional study of patients with ICH in the Get With The Guidelines-Stroke registry, between 2011 and 2021. Patients transferred to another hospital, those who died during hospitalization, and those with missing information on discharge medications were excluded. The study exposure was the proportion of patients who were prescribed antithrombotic or statin medications. We first ascertained the proportion of patients prescribed antithrombotic and lipid-lowering medications at discharge overall and across strata defined by pre-ICH use and history of previous ischemic vascular disease or atrial fibrillation. We then studied factors associated with the discharge prescription of these medications after ICH, using multiple logistic regressions. RESULTS In the final cohort, 50 416 (10.4%) of 486 586 patients with ICH were prescribed antiplatelet medications, 173 322 (35.1%) of 493 491 patients with ICH were prescribed statins, and 27 085 (5.4%) of 486 585 patients with ICH were prescribed anticoagulation therapy at discharge. The proportion of patients with antiplatelet therapy was 16.6% with pre-ICH use and 15.6% in those with previous ischemic vascular disease. Statins were prescribed to 41.1% and 43.7% of patients on previous lipid-lowering therapy and ischemic vascular disease, respectively. Anticoagulation therapy was restarted in 11.1% of patients. In logistic regression analysis, factors associated with higher use of antithrombotic or statin therapies after ICH were younger age, male sex, pre-ICH medication use, previous ischemic vascular disease, atrial fibrillation, lower admission National Institutes of Health Stroke Scale, longer length of stay, and favorable discharge outcome. CONCLUSIONS Few patients with ICH are prescribed antithrombotic or statin therapies at hospital discharge. Given the emerging association between ICH and future major cardiovascular events, trials examining the net benefit of antiplatelet and lipid-lowering therapy after ICH are warranted.
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Affiliation(s)
- Santosh B Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M., C.Z., H.K.), Weill Cornell Medicine, New York, NY
- Department of Neurology (S.B.M., C.Z., H.K.), Weill Cornell Medicine, New York, NY
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M., C.Z., H.K.), Weill Cornell Medicine, New York, NY
- Department of Neurology (S.B.M., C.Z., H.K.), Weill Cornell Medicine, New York, NY
| | - Shreyansh Shah
- Department of Neurology, Duke University Hospital, Durham, NC (S.S.)
| | - Lee H Schwamm
- Department of Biomedical Informatics and Data Sciences (L.H.S.), Yale School of Medicine, New Haven, CT
| | - Gregg C Fonarow
- Division of Cardiology, Ronald Reagan University of California, Los Angeles Medical Center (G.C.F.)
| | - Eric E Smith
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, AB, Canada (E.E.S.)
| | - Deepak L Bhatt
- Department of Cardiovascular Medicine, Icahn School of Medicine at Mount Sinai Health System, New York, NY (D.L.B.)
| | - Wendy C Ziai
- Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (W.C.Z.)
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M., C.Z., H.K.), Weill Cornell Medicine, New York, NY
- Department of Neurology (S.B.M., C.Z., H.K.), Weill Cornell Medicine, New York, NY
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Departments of Neurology and Neurosurgery, The Yale Center for Brain and Mind Health (K.N.S.), Yale School of Medicine, New Haven, CT
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Ahmed A, Anker SD, Butler J, Bakris GL, Bhatt DL, Fonarow GC, Packer M. Comparing the effectiveness of glucose-lowering agents: real-world data to emulate a four-arm target trial. Lancet Diabetes Endocrinol 2023; 11:892-894. [PMID: 37996192 DOI: 10.1016/s2213-8587(23)00291-7] [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: 08/11/2023] [Accepted: 09/28/2023] [Indexed: 11/25/2023]
Affiliation(s)
- Ali Ahmed
- Center for Data Science and Outcomes Research, Veterans Affairs Medical Center, Washington, DC 20422, USA; Department of Medicine, George Washington University, Washington, DC, USA; Department of Medicine, Georgetown University, Washington, DC, USA.
| | - Stefan D Anker
- Department of Cardiology of German Heart Center Charité (Campus Virchow-Klinikum), Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA; University of Mississippi, Jackson, MS, USA
| | - George L Bakris
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Gregg C Fonarow
- Department of Medicine, University of California, Los Angeles, CA, USA
| | - Milton Packer
- Baylor University Medical Center, Dallas, TX, USA; Imperial College London, London, UK
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Dixit NM, Parikh NU, Ziaeian B, Fonarow GC. Economic Modeling Analysis of an Intensive GDMT Optimization Program in Hospitalized Heart Failure Patients. Circ Heart Fail 2023; 16:e011218. [PMID: 37929591 PMCID: PMC10872946 DOI: 10.1161/circheartfailure.123.011218] [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: 09/11/2023] [Accepted: 10/23/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND The STRONG-HF trial (Safety, Tolerability and Efficacy of Up-Titration of Guideline-Directed Medical Therapies for Acute Heart Failure) demonstrated substantial reductions in the composite of mortality and morbidity over 6 months among hospitalized patients with heart failure (HF) who were randomized to intensive guideline-directed medical therapy (GDMT) optimization compared with usual care. Whether an intensive GDMT optimization program would be cost-effective for patients with HF with reduced ejection fraction is unknown. METHODS Using a 2-state Markov model, we evaluated the effect of an intensive GDMT optimization program on hospitalized patients with HF with reduced ejection fraction. Two population models were created to simulate this intervention, a clinical trial model, based on the participants in the STRONG-HF trial, and a real-world model, based on the Get With The Guidelines-HF registry of patients admitted with worsening HF. We then modeled the effect of a 6-month intensive triple therapy GDMT optimization program comprised of cardiologists, clinical pharmacists, and registered nurses. Hazard ratios from the intervention arm of the STRONG-HF trial were applied to both population models to simulate clinical and financial outcomes of an intensive GDMT optimization program from a US health care sector perspective with a lifetime time horizon. Optimal quadruple GDMT use was also modeled. RESULTS An intensive GDMT optimization program was extremely cost-effective with incremental cost-effectiveness ratios <$10 000 per quality-adjusted life-year in both models. Optimal quadruple GDMT implementation resulted in the most gains in life-years with incremental cost-effectiveness ratios of $60 000 and $54 000 in the clinical trial and real-world models, respectively. CONCLUSIONS An intensive GDMT optimization program for patients hospitalized with HF with reduced ejection fraction would be cost-effective and result in substantial gains in clinical outcomes, especially with the use of optimal quadruple GDMT. Clinicians, payers, and policymakers should prioritize the creation of such programs.
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Affiliation(s)
- Neal M. Dixit
- Division of Cardiovascular Medicine, Department of Medicine, University of California, Davis, Sacramento, California
| | - Neil U. Parikh
- School of Medicine, Keck School of Medicine of USC, Los Angeles, CA
| | - Boback Ziaeian
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Division of Cardiology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Gregg C. Fonarow
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
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Fonarow GC, Mohebi R. Sotagliflozin Efficacy Irrespective of Hemoglobin A1c Level. J Am Coll Cardiol 2023; 82:1852-1853. [PMID: 37914515 DOI: 10.1016/j.jacc.2023.09.004] [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: 09/08/2023] [Accepted: 09/11/2023] [Indexed: 11/03/2023]
Affiliation(s)
- Gregg C Fonarow
- Division of Cardiology, Department of Medicine, Ronald Reagan-UCLA Medical Center, Los Angeles, California, USA.
| | - Reza Mohebi
- Division of Cardiology, Department of Medicine, Ronald Reagan-UCLA Medical Center, Los Angeles, California, USA
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Ostrominski JW, Arnold SV, Butler J, Fonarow GC, Hirsch JS, Palli SR, Donato BMK, Parrinello CM, O’Connell T, Collins EB, Woolley JJ, Kosiborod MN, Vaduganathan M. Prevalence and Overlap of Cardiac, Renal, and Metabolic Conditions in US Adults, 1999-2020. JAMA Cardiol 2023; 8:1050-1060. [PMID: 37755728 PMCID: PMC10535010 DOI: 10.1001/jamacardio.2023.3241] [Citation(s) in RCA: 4] [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: 11/30/2022] [Accepted: 08/04/2023] [Indexed: 09/28/2023]
Abstract
Importance Individually, cardiac, renal, and metabolic (CRM) conditions are common and leading causes of death, disability, and health care-associated costs. However, the frequency with which CRM conditions coexist has not been comprehensively characterized to date. Objective To examine the prevalence and overlap of CRM conditions among US adults currently and over time. Design, Setting, and Participants To establish prevalence of CRM conditions, nationally representative, serial cross-sectional data included in the January 2015 through March 2020 National Health and Nutrition Examination Survey (NHANES) were evaluated in this cohort study. To assess temporal trends in CRM overlap, NHANES data between 1999-2002 and 2015-2020 were compared. Data on 11 607 nonpregnant US adults (≥20 years) were included. Data analysis occurred between November 10, 2020, and November 23, 2022. Main Outcomes and Measures Proportion of participants with CRM conditions, overall and stratified by age, defined as cardiovascular disease (CVD), chronic kidney disease (CKD), type 2 diabetes (T2D), or all 3. Results From 2015 through March 2020, of 11 607 US adults included in the analysis (mean [SE] age, 48.5 [0.4] years; 51.0% women), 26.3% had at least 1 CRM condition, 8.0% had at least 2 CRM conditions, and 1.5% had 3 CRM conditions. Overall, CKD plus T2D was the most common CRM dyad (3.2%), followed by CVD plus T2D (1.7%) and CVD plus CKD (1.6%). Participants with higher CRM comorbidity burden were more likely to be older and male. Among participants aged 65 years or older, 33.6% had 1 CRM condition, 17.1% had 2 CRM conditions, and 5.0% had 3 CRM conditions. Within this subset, CKD plus T2D (7.3%) was most common, followed by CVD plus CKD (6.0%) and CVD plus T2D (3.8%). The CRM comorbidity burden was disproportionately high among participants reporting non-Hispanic Black race or ethnicity, unemployment, low socioeconomic status, and no high school degree. Among participants with 3 CRM conditions, nearly one-third (30.5%) did not report statin use, and only 4.8% and 3.0% used glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter 2 inhibitors, respectively. Between 1999 and 2020, the proportion of US adults with multiple CRM conditions increased significantly (from 5.3% to 8.0%; P < .001 for trend), as did the proportion having all 3 CRM conditions (0.7% to 1.5%; P < .001 for trend). Conclusions and Relevance This cohort study found that CRM multimorbidity is increasingly common and undertreated among US adults, highlighting the importance of collaborative and comprehensive management strategies.
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Affiliation(s)
- John W. Ostrominski
- Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Suzanne V. Arnold
- Saint Luke’s Mid America Heart Institute and University of Missouri–Kansas City, Kansas City
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas
- Department of Medicine, University of Mississippi, Jackson
| | - Gregg C. Fonarow
- Division of Cardiology, University of California, Los Angeles Medical Center, David Geffen School of Medicine, Los Angeles
| | - Jamie S. Hirsch
- Division of Kidney Diseases and Hypertension, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York
| | - Swetha R. Palli
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, Connecticut
| | | | | | | | | | | | - Mikhail N. Kosiborod
- Saint Luke’s Mid America Heart Institute and University of Missouri–Kansas City, Kansas City
| | - Muthiah Vaduganathan
- Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
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Minhas AMK, Fudim M, Garan AR, Davis JD, Fonarow GC, Antoine SM, Fedson S, Nambi V, Abramov D. Socioeconomic status and in-hospital outcomes for patients undergoing heart transplantation or ventricular assist device implantation. Clin Transplant 2023; 37:e15093. [PMID: 37548056 DOI: 10.1111/ctr.15093] [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] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/19/2023] [Accepted: 07/25/2023] [Indexed: 08/08/2023]
Abstract
INTRODUCTION Although lower socioeconomic status (SES) has been associated with worse in-hospital outcomes among patients with heart failure, the in-hospital outcomes for patients undergoing durable Left Ventricular Assist Device (LVAD) implantation or Heart Transplantation (HT) based on SES have not been well characterized. METHODS We analyzed data from the National Inpatient Sample of hospitalizations between January 2016 and December 2020 of patients aged 18 and over who underwent a HT or newly implanted LVAD. Quartile classification of the median household income of the patient's residential zip code was used to estimate SES. Multivariable analyses with logistic and linear regression were used to evaluate the effects of SES on inpatient outcomes including inpatient mortality, length of stay, and key inpatient complications. RESULTS A total of 16,265 weighted hospitalizations for new LVAD implantation and 14,320 weighted hospitalizations for HT were identified. In multivariable analysis, among patients undergoing HT or LVAD implantation respectively, there were no significant differences between the lowest and highest SES quartiles among important in-hospital outcomes including length of stay (adj B-coeff .56, (-3.59)-(4.71), p = .79 and adj B-coeff 2.40, (-.21)-(5.02), p = .07) and mortality (aOR 1.02, .61-1.70, p = .94 and aOR 1.08, .72-1.62, p = .73). There were also no differences based on SES quartile in important inpatient complications including stroke and cardiac arrest. CONCLUSION In this analysis from the National Inpatient Sample, we demonstrate that SES, evaluated by median zip code income, was not associated with important in-hospital metrics including mortality and length of stay among patients undergoing LVAD or HT.
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Affiliation(s)
| | - Marat Fudim
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - A Reshad Garan
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jonathan D Davis
- Department of Medicine, Division of Cardiology, University of San Francisco, San Francisco, California, USA
| | - Gregg C Fonarow
- Department of Medicine, Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Steve M Antoine
- Michael E DeBakey Veterans Affairs Hospital and Baylor College of Medicine, Center for Cardiovascular Disease Prevention, Houston, Texas, USA
| | - Savitri Fedson
- Michael E DeBakey Veterans Affairs Hospital and Baylor College of Medicine, Center for Cardiovascular Disease Prevention, Houston, Texas, USA
| | - Vijay Nambi
- Michael E DeBakey Veterans Affairs Hospital and Baylor College of Medicine, Center for Cardiovascular Disease Prevention, Houston, Texas, USA
| | - Dmitry Abramov
- Department of Medicine, Division of Cardiology, Loma Linda Medical Center, Loma Linda, California, USA
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Peters AE, Solomon N, Chiswell K, Fonarow GC, Khouri MG, Baylor L, Alvir J, Bruno M, Huda A, Allen LA, Sharma K, DeVore AD, Greene SJ. Transthyretin amyloid cardiomyopathy among patients hospitalized for heart failure and performance of an adapted wild-type ATTR-CM machine learning model: Findings from GWTG-HF. Am Heart J 2023; 265:22-30. [PMID: 37400049 DOI: 10.1016/j.ahj.2023.06.013] [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: 06/27/2023] [Accepted: 06/27/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND An 11-factor random forest model has been developed among ambulatory heart failure (HF) patients for identifying potential wild-type amyloidogenic TTR cardiomyopathy (wtATTR-CM). The model has not been evaluated in a large sample of patients hospitalized for HF. METHODS This study included Medicare beneficiaries aged ≥65 years hospitalized for HF in the Get With The Guidelines-HF® Registry from 2008-2019. Patients with and without a diagnosis of ATTR-CM were compared, as defined by inpatient and outpatient claims data within 6 months pre- or post-index hospitalization. Within a cohort matched 1:1 by age and sex, univariable logistic regression was used to evaluate relationships between ATTR-CM and each of the 11 factors of the established model. Discrimination and calibration of the 11-factor model were assessed. RESULTS Among 205,545 patients (median age 81 years) hospitalized for HF across 608 hospitals, 627 patients (0.31%) had a diagnosis code for ATTR-CM. Univariable analysis within the 1:1 matched cohort of each of the 11-factors in the ATTR-CM model found pericardial effusion, carpal tunnel syndrome, lumbar spinal stenosis, and elevated serum enzymes (e.g., troponin elevation) to be strongly associated with ATTR-CM. The 11-factor model showed modest discrimination (c-statistic 0.65) and good calibration within the matched cohort. CONCLUSIONS Among US patients hospitalized for HF, the number of patients with ATTR-CM defined by diagnosis codes on an inpatient/outpatient claim within 6 months of admission was low. Most factors within the prior 11-factor model were associated with greater odds of ATTR-CM diagnosis. In this population, the ATTR-CM model demonstrated modest discrimination.
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Affiliation(s)
- Anthony E Peters
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | | | | | - Gregg C Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles Medical Center, Los Angeles, CA
| | - Michel G Khouri
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | | | | | | | | | - Larry A Allen
- Division of Cardiology & Colorado Cardiovascular Outcomes Research Consortium, University of Colorado School of Medicine, Aurora, CO
| | - Kavita Sharma
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Adam D DeVore
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC.
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Khan MS, Singh S, Segar MW, Usman MS, Keshvani N, Ambrosy AP, Fiuzat M, Van Spall HGC, Fonarow GC, Zannad F, Felker GM, Januzzi JL, O'Connor C, Butler J, Pandey A. Polypharmacy and Optimization of Guideline-Directed Medical Therapy in Heart Failure: The GUIDE-IT Trial. JACC Heart Fail 2023; 11:1507-1517. [PMID: 37115133 DOI: 10.1016/j.jchf.2023.03.007] [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] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 03/03/2023] [Accepted: 03/16/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Polypharmacy is common among patients with heart failure with reduced ejection fraction (HFrEF). However, its impact on the use of optimal guideline-directed medical therapy (GDMT) is not well established. OBJECTIVES This study sought to evaluate the association between polypharmacy and odds of receiving optimal GDMT over time among patients with HFrEF. METHODS The authors conducted a post hoc analysis of the GUIDE-IT (Guiding Evidence-Based Therapy Using Biomarker Intensified Treatment) trial. Polypharmacy was defined as receiving ≥5 medications (excluding HFrEF GDMT) at baseline. The outcome of interest was optimal triple therapy GDMT (concurrent administration of a renin-angiotensin-aldosterone blocker and beta-blocker at 50% of the target dose and a mineralocorticoid receptor antagonist at any dose) achieved over the 12-month follow-up. Multivariable adjusted mixed-effect logistic regression models with multiplicative interaction terms (time × polypharmacy) were constructed to evaluate how polypharmacy at baseline modified the odds of achieving optimal GDMT on follow-up. RESULTS The study included 891 participants with HFrEF. The median number of non-GDMT medications at baseline was 4 (IQR: 3-6), with 414 (46.5%) prescribed ≥5 and identified as being on polypharmacy. The proportion of participants who achieved optimal GDMT at the end of the 12-month follow-up was lower with vs without polypharmacy at baseline (15% vs 19%, respectively). In adjusted mixed models, the odds of achieving optimal GDMT over time were modified by baseline polypharmacy status (P for interaction < 0.001). Patients without polypharmacy at baseline had increased odds of achieving GDMT (OR: 1.16 [95% CI: 1.12-1.21] per 1-month increase; P < 0.001) but not patients with polypharmacy (OR: 1.01 [95% CI: 0.96-1.06)] per 1-month increase). CONCLUSIONS Patients with HFrEF who are on non-GDMT polypharmacy have lower odds of achieving optimal GDMT on follow-up.
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Affiliation(s)
- Muhammad Shahzeb Khan
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sumitabh Singh
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Matthew W Segar
- Department of Cardiology, Texas Heart Institute, Houston, Texas, USA
| | - Muhammad Shariq Usman
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Neil Keshvani
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Andrew P Ambrosy
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA; Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Mona Fiuzat
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Harriette G C Van Spall
- Department of Medicine, Population Health Research Institute, Research Institute of St. Joseph's, McMaster University, Hamilton, Ontario, Canada
| | - Gregg C Fonarow
- Division of Cardiology, Ronald Reagan-UCLA Medical Center, Los Angeles, California, USA
| | - Faiez Zannad
- Université de Lorraine, Inserm Centre d'Investigation, Centre Hospitalier Régional Universitaire, Université de Lorraine, Nancy, France
| | - G Michael Felker
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - James L Januzzi
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | | | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA; Baylor Scott and White Research Institute, Dallas, Texas, USA
| | - Ambarish Pandey
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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Lim TW, Camm AJ, Virdone S, Singer DE, Bassand JP, Fonarow GC, Fox KAA, Ezekowitz M, Gersh BJ, Kayani G, Hylek EM, Kakkar AK, Mahaffey KW, Pieper KS, Peterson ED, Piccini JP. Predictors of intracranial hemorrhage in patients with atrial fibrillation treated with oral anticoagulants: Insights from the GARFIELD-AF and ORBIT-AF registries. Clin Cardiol 2023; 46:1398-1407. [PMID: 37596725 PMCID: PMC10642328 DOI: 10.1002/clc.24109] [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: 06/19/2023] [Revised: 07/14/2023] [Accepted: 07/24/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND An unmet need exists to reliably predict the risk of intracranial hemorrhage (ICH) in patients with atrial fibrillation (AF) treated with oral anticoagulants (OACs). HYPOTHESIS An externally validated model improves ICH risk stratification. METHODS Independent factors associated with ICH were identified by Cox proportional hazard modeling, using pooled data from the GARFIELD-AF (Global Anticoagulant Registry in the FIELD-Atrial Fibrillation) and ORBIT-AF (Outcomes Registry for Better Informed Treatment of Atrial Fibrillation) registries. A predictive model was developed and validated by bootstrap sampling and by independent data from the Danish National Patient Register. RESULTS In the combined training data set, 284 of 53 878 anticoagulated patients had ICH over a 2-year period (0.31 per 100 person-years; 95% confidence interval [CI]: 0.28-0.35). Independent predictors of ICH included: older age, prior stroke or transient ischemic attack, concomitant antiplatelet (AP) use, and moderate-to-severe chronic kidney disease (CKD). Vitamin K antagonists (VKAs) were associated with a significantly higher risk of ICH compared with non-VKA oral anticoagulants (NOACs) (adjusted hazard ratio: 1.61; 95% CI: 1.25-2.08; p = .0002). The ability of the model to discriminate individuals in the training set with and without ICH was fair (optimism-corrected C-statistic: 0.68; 95% CI: 0.65-0.71) and outperformed three previously published methods. Calibration between predicted and observed ICH probabilities was good in both training and validation data sets. CONCLUSIONS Age, prior ischemic events, concomitant AP therapy, and CKD were important risk factors for ICH in anticoagulated AF patients. Moreover, ICH was more frequent in patients receiving VKA compared to NOAC. The new validated model is a step toward mitigating this potentially lethal complication.
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Affiliation(s)
- Toon Wei Lim
- National Heart CentreSingaporeSingapore
- National University HospitalSingaporeSingapore
| | - Alan John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences InstituteSt. George's University of LondonLondonUK
| | | | - Daniel E. Singer
- Massachusetts General Hospital and Harvard Medical SchoolBostonMassachusettsUSA
| | - Jean P. Bassand
- Thrombosis Research InstituteLondonUK
- Department of CardiologyUniversity of BesançonBesançonFrance
| | | | - Keith A. A. Fox
- Department of Cardiovascular ScienceCentre for Cardiovascular Science, University of EdinburghEdinburghUK
| | - Michael Ezekowitz
- Sidney Kimmel Medical SchoolThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Bernard J. Gersh
- Mayo Clinic College of Medicine and ScienceRochesterMinnesotaUSA
| | | | - Elaine M. Hylek
- Department of MedicineBoston University School of MedicineBostonMassachusettsUSA
| | - Ajay K. Kakkar
- Thrombosis Research InstituteLondonUK
- Department of SurgeryUniversity College LondonLondonUK
| | - Kenneth W. Mahaffey
- Stanford Center for Clinical ResearchStanford School of MedicineStanfordCaliforniaUSA
| | - Karen S. Pieper
- Thrombosis Research InstituteLondonUK
- Department of Cardiac ElectrophysiologyDuke Clinical Research InstituteDurhamNorth CarolinaUSA
| | - Eric D. Peterson
- Department of Cardiac ElectrophysiologyDuke Clinical Research InstituteDurhamNorth CarolinaUSA
- Duke University School of MedicineDurhamNorth CarolinaUSA
| | - Jonathan P. Piccini
- Department of Cardiac ElectrophysiologyDuke Clinical Research InstituteDurhamNorth CarolinaUSA
- Duke University School of MedicineDurhamNorth CarolinaUSA
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Bhatt AS, Vaduganathan M, Claggett BL, Fonarow GC, Packer M, Pfeffer MA, Shah SJ, Shen X, Cristino J, McMurray JJV, Solomon SD, Gaziano TA. Health and Economic Evaluation of Sacubitril-Valsartan for Heart Failure Management. JAMA Cardiol 2023; 8:1041-1048. [PMID: 37755814 PMCID: PMC10534998 DOI: 10.1001/jamacardio.2023.3216] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 12/23/2022] [Accepted: 07/11/2023] [Indexed: 09/28/2023]
Abstract
Importance The US Food and Drug Administration expanded labeling of sacubitril-valsartan from the treatment of patients with chronic heart failure (HF) with reduced ejection fraction (EF) to all patients with HF, noting the greatest benefits in those with below-normal EF. However, the upper bound of below normal is not clearly defined, and value determinations across a broader EF range are unknown. Objective To estimate the cost-effectiveness of sacubitril-valsartan vs renin-angiotensin system inhibitors (RASis) across various upper-level cutoffs of EF. Design, Setting, and Participants This economic evaluation included participant-level data from the PARADIGM-HF (Prospective Comparison of ARNI With ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure) and the PARAGON-HF (Prospective Comparison of ARNi with ARB Global Outcomes in HF With Preserved Ejection Fraction) trials. PARADIGM-HF was conducted between 2009 and 2014, PARAGON-HF was conducted between 2014 and 2019, and this analysis was conducted between 2021 and 2023. Main Outcomes and Measures A 5-state Markov model used risk reductions for all-cause mortality and HF hospitalization from PARADIGM-HF and PARAGON-HF. Quality-of-life differences were estimated from EuroQol-5D scores. Hospitalization and medication costs were obtained from published national sources; the wholesale acquisition cost of sacubitril-valsartan was $7092 per year. Risk estimates and treatment effects were generated in consecutive 5% EF increments up to 60% and applied to an EF distribution of US patients with HF from the Get With the Guidelines-Heart Failure registry. The base case included a lifetime horizon from a health care sector perspective. Incremental cost-effectiveness ratios (ICERs) were estimated at EFs of 60% or less (base case) and at various upper-level EF cutoffs. Results Among 13 264 total patients whose data were analyzed, for those with EFs of 60% or less, sacubitril-valsartan was projected to add 0.53 quality-adjusted life-years (QALYs) at an incremental lifetime cost of $40 892 compared with RASi, yielding an ICER of $76 852 per QALY. In a probabilistic sensitivity analysis, 95% of the values of the ICER occurred between $71 516 and $82 970 per QALY. Among patients with chronic HF and an EF of 60% or less, treatment with sacubitril-valsartan vs RASis would be at least of economic intermediate value (ICER <$180 000 per QALY) at a sacubitril-valsartan cost of $10 242 or less per year, of high economic value (ICER <$60 000 per QALY) at a cost of $3673 or less per year, and cost-saving at a cost of $338 or less per year. The ICERs were $67 331 per QALY, $59 614 per QALY, and $56 786 per QALY at EFs of 55% or less, 50% or less, and 45% or less, respectively. Treatment with sacubitril-valsartan in only those with EFs of 45% or greater (up to ≤60%) yielded an ICER of $127 172 per QALY gained; treatment was more cost-effective in those at the lower end of this range (ICER of $100 388 per QALY gained for those with EFs of 45%-55%; ICER of $84 291 per QALY gained for those with EFs of 45%-50%). Conclusions and Relevance Cost-effectiveness modeling provided an ICER for treatment with sacubitril-valsartan vs RASis consistent with high economic value for patients with reduced and mildly reduced EFs (≤50%) and at least intermediate value at the current undiscounted wholesale acquisition cost price at an EF of 60% or less. Treatment was more cost-effective at lower EF ranges. These findings may have implications for coverage decisions and value assessments in contemporary clinical practice guidelines.
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Affiliation(s)
- Ankeet S. Bhatt
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Kaiser Permanente San Francisco Medical Center and Division of Research, San Francisco, California
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Brian L. Claggett
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gregg C. Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles
- Associate Section Editor, JAMA Cardiology
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas
| | - Marc A. Pfeffer
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sanjiv J. Shah
- Department of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Xian Shen
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | | | - John J. V. McMurray
- BHF Glasgow Cardiovascular Research Center, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland
| | - Scott D. Solomon
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Thomas A. Gaziano
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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50
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Kosaraju RS, Fonarow GC, Ong MK, Heidenreich PA, Washington DL, Wang X, Ziaeian B. Geographic Variation in the Quality of Heart Failure Care Among U.S. Veterans. JACC Heart Fail 2023; 11:1534-1545. [PMID: 37542510 PMCID: PMC10792103 DOI: 10.1016/j.jchf.2023.06.010] [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] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 05/09/2023] [Accepted: 06/05/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND The burden of heart failure is growing. Guideline-directed medical therapies (GDMT) reduce adverse outcomes in heart failure with reduced ejection fraction (HFrEF). Whether there is geographic variation in HFrEF quality of care is not well described. OBJECTIVES This study evaluated variation nationally for prescription of GDMT within the Veterans Health Administration. METHODS A cohort of Veterans with HFrEF had their address linked to hospital referral regions (HRRs). GDMT prescription was defined using pharmacy data between July 1, 2020, and July 1, 2021. Within HRRs, we calculated the percentage of Veterans prescribed GDMT and a composite GDMT z-score. National choropleth maps were created to evaluate prescription variation. Associations between GDMT performance and demographic characteristics were evaluated using linear regression. RESULTS Maps demonstrated significant variation in the HRR composite score and GDMT prescriptions. Within HRRs, the prescription of beta-blockers to Veterans was highest with a median of 80% (IQR: 77.3%-82.2%) followed by angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitors (69.3%; IQR: 66.4%-72.1%), sodium-glucose cotransporter-2 inhibitors (10.3%; IQR: 7.7%-12.8%), mineralocorticoid receptor antagonists (29.2%; IQR: 25.8%-33.9%), and angiotensin receptor-neprilysin inhibitors (12.2%; IQR: 8.6%-15.3%). HRR composite GDMT z-scores were inversely associated with the HRR median Gini coefficient (R = -0.13; P = 0.0218) and the percentage of low-income residents (R = -0.117; P = 0.0413). CONCLUSIONS Wide geographic differences exist for HFrEF care. Targeted strategies may be required to increase GDMT prescription for Veterans in lower-performing regions, including those affected by income inequality and poverty.
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Affiliation(s)
- Revanth S Kosaraju
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA. https://twitter.com/revanthsk12
| | - Gregg C Fonarow
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA. https://twitter.com/gcfmd
| | - Michael K Ong
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA; Veterans Affairs Health Services Research and Development, Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA; Department of Health Policy and Management, UCLA Jonathan and Karin Fielding School of Public Health, Los Angeles, California, USA. https://twitter.com/michael_ong
| | - Paul A Heidenreich
- Department of Medicine, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California, USA. https://twitter.com/paheidenreich
| | - Donna L Washington
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA; Veterans Affairs Health Services Research and Development, Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Xiaoyan Wang
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Boback Ziaeian
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA; Veterans Affairs Health Services Research and Development, Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA.
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