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Greene SJ, Choi S, Lippmann SJ, Mentz RJ, Greiner MA, Hardy NC, Hammill BG, Luo N, Samsky MD, Heidenreich PA, Laskey WK, Yancy CW, Peterson PN, Curtis LH, Hernandez AF, Fonarow GC, O'Brien EC. Clinical Effectiveness of Sacubitril/Valsartan Among Patients Hospitalized for Heart Failure With Reduced Ejection Fraction. J Am Heart Assoc 2021; 10:e021459. [PMID: 34350772 PMCID: PMC8475054 DOI: 10.1161/jaha.121.021459] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Sacubitril/Valsartan has been highly efficacious in randomized trials of heart failure with reduced ejection fraction (HFrEF). However, the effectiveness of sacubitril/valsartan in older patients hospitalized for HFrEF in real‐world US practice is unclear. Methods and Results This study included Medicare beneficiaries age ≥65 years who were hospitalized for HFrEF ≤40% in the Get With The Guidelines–Heart Failure registry between October 2015 and December 2018, and eligible for sacubitril/valsartan. Associations between discharge prescription of sacubitril/valsartan and clinical outcomes were assessed after inverse probability of treatment weighting and adjustment for other HFrEF medications. Overall, 1551 (10.9%) patients were discharged on sacubitril/valsartan. Of those not prescribed sacubitril/valsartan, 7857 (62.0%) were prescribed an angiotensin‐converting enzyme inhibitor/angiotensin II receptor blocker. Over 12‐month follow‐up, compared with a discharge prescription of angiotensin‐converting enzyme inhibitor/angiotensin II receptor blocker, sacubitril/valsartan was independently associated with lower all‐cause mortality (adjusted hazard ratio [HR], 0.82; 95% CI, 0.72–0.94; P=0.004) but not all‐cause hospitalization (adjusted HR, 0.97; 95% CI, 0.89–1.07; P=0.55) or heart failure hospitalization (adjusted HR, 1.04; 95% CI, 0.91–1.18; P=0.59). Patients prescribed sacubitril/valsartan versus those without a prescription had lower risk of all‐cause mortality (adjusted HR, 0.69; 95% CI, 0.60–0.79; P<0.001), all‐cause hospitalization (adjusted HR, 0.90; 95% CI, 0.82–0.98; P=0.02), but not heart failure hospitalization (adjusted HR, 0.94; 95% CI, 0.82–1.08; P=0.40). Conclusions Among patients hospitalized for HFrEF, prescription of sacubitril/valsartan at discharge was independently associated with reduced postdischarge mortality compared with angiotensin‐converting enzyme inhibitor/angiotensin II receptor blocker, and reduced mortality and all‐cause hospitalization compared with no sacubitril/valsartan. These findings support the use of sacubitril/valsartan to improve postdischarge outcomes among older patients hospitalized for HFrEF in routine US clinical practice.
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Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute Durham NC.,Division of Cardiology Duke University School of Medicine Durham NC
| | - Sujung Choi
- Department of Population Health Sciences Duke University School of Medicine Durham NC
| | - Steven J Lippmann
- Department of Population Health Sciences Duke University School of Medicine Durham NC
| | - Robert J Mentz
- Duke Clinical Research Institute Durham NC.,Division of Cardiology Duke University School of Medicine Durham NC
| | - Melissa A Greiner
- Department of Population Health Sciences Duke University School of Medicine Durham NC
| | - N Chantelle Hardy
- Department of Population Health Sciences Duke University School of Medicine Durham NC
| | - Bradley G Hammill
- Department of Population Health Sciences Duke University School of Medicine Durham NC
| | - Nancy Luo
- Dignity Health Heart and Vascular Institute Sacramento CA
| | - Marc D Samsky
- Duke Clinical Research Institute Durham NC.,Division of Cardiology Duke University School of Medicine Durham NC
| | - Paul A Heidenreich
- Department of Medicine Veterans Affairs Palo Alto Health Care System Palo Alto CA
| | - Warren K Laskey
- Division of Cardiology University of New Mexico School of Medicine Albuquerque NM
| | - Clyde W Yancy
- Division of Cardiology Northwestern University Feinberg School of Medicine Chicago IL
| | - Pamela N Peterson
- Division of Cardiology University of Colorado, Anschutz Medical Campus Aurora CO.,Division of Cardiology Denver Health Medical Center Denver CO
| | - Lesley H Curtis
- Duke Clinical Research Institute Durham NC.,Department of Population Health Sciences Duke University School of Medicine Durham NC
| | - Adrian F Hernandez
- Duke Clinical Research Institute Durham NC.,Division of Cardiology Duke University School of Medicine Durham NC
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center University of California Los Angeles Los Angeles CA
| | - Emily C O'Brien
- Duke Clinical Research Institute Durham NC.,Department of Population Health Sciences Duke University School of Medicine Durham NC
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Herrmann HC, Laskey WK. Pressure loss recovery in aortic valve stenosis: Contemporary relevance. Catheter Cardiovasc Interv 2021; 99:195-197. [PMID: 33886155 DOI: 10.1002/ccd.29729] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 04/07/2021] [Accepted: 04/13/2021] [Indexed: 11/12/2022]
Abstract
Pressure loss recovery (PLR) is a hydrodynamic phenomenon that occurs when blood flow encounters a narrowing typified by aortic valve stenosis (AS). Multiple factors contribute to the magnitude of PLR including the volumetric rate of flow, the geometry of the entrance to the vena contracta (VC) or point of minimum dimension, including that of the left ventricular outflow tract and valve orifice, and the geometry of the proximal aorta. In the majority of clinical circumstances, PLR results in echocardiographic Doppler gradient estimates that are modestly, but generally not clinically important, greater than those derived from rigorously performed catheter measurements. The contribution of PLR to the echocardiographically-measured gradient may not differ significantly between currently available valve prostheses and is likely to be small in patients with mild AS following TAVR.
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Affiliation(s)
- Howard C Herrmann
- Cardiovascular Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania School, Philadelphia, Pennsylvania, USA
| | - Warren K Laskey
- Cardiovascular Division, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, Mexico
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Samsky MD, Lin L, Greene SJ, Lippmann SJ, Peterson PN, Heidenreich PA, Laskey WK, Yancy CW, Greiner MA, Hardy NC, Kavati A, Park S, Mentz RJ, Fonarow GC, O'Brien EC. Patient Perceptions and Familiarity With Medical Therapy for Heart Failure. JAMA Cardiol 2021; 5:292-299. [PMID: 31734700 DOI: 10.1001/jamacardio.2019.4987] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance There are major gaps in use of guideline-directed medical therapy (GDMT) for patients with heart failure (HF). Patient-reported data outlining patient goals and preferences associated with GDMT are not available. Objective To survey patients with chronic HF to better understand their experiences and perceptions of living with HF, including their familiarity and concerns with important GDMT therapies. Design, Setting, and Participants Study participants were recruited from the GfK KnowledgePanel, a probability-sampled online panel representative of the US adult population. English-speaking adults who met the following criteria were eligible if they were (1) previously told by a physician that they had HF; (2) currently taking medications for HF; and (3) had no history of left ventricular assist device or cardiac transplant. Data were collected between October and November 2018. Analysis began in December 2018. Main Outcomes and Measures The survey included 4 primary domains: (1) relative importance of disease-related goals, (2) challenges associated with living with HF, (3) decision-making process associated with HF medication use, and (4) awareness and concerns about available HF medications. Results Of 30 707 KnowledgePanel members who received the initial survey, 15 091 (49.1%) completed the screening questions, 440 were eligible and began the survey, and 429 completed the survey. The median (interquartile range) age was 68 (60-75) years and most were white (320 [74.6%]), male (304 [70.9%]), and had at least a high school education (409 [95.3%]). Most survey responders reported familiarity with β-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and diuretics. Overall, 107 (24.9%) reported familiarity with angiotensin receptor-neprilysin inhibitors or mineralocorticoid receptor antagonists. Overall, 136 patients (42.5%) reported have safety concerns regarding angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and 133 (38.5%) regarding β-blockers, 35 (37.9%) regarding mineralocorticoid receptor antagonists, 38 (36.5%) regarding angiotensin receptor-neprilysin inhibitors, and 123 (37.2%) regarding diuretics. Between 27.7% (n = 26) and 38.5% (n = 136) reported concerns regarding the effectiveness of β-blockers, angiotensin receptor-neprilysin inhibitors, mineralocorticoid receptor antagonists, or diuretics, while 41% (n = 132) were concerned with the effectiveness of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers. Conclusions and Relevance In this survey study, many patients were not familiar with GDMT for HF, with familiarity lowest for angiotensin receptor-neprilysin inhibitors and mineralocorticoid receptor antagonists. Among patients not familiar with these therapies, significant proportions questioned their effectiveness and/or safety. Enhanced patient education and shared decision-making support may be effective strategies to improve the uptake of GDMT for HF in US clinical practice.
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Affiliation(s)
- Marc D Samsky
- Duke Clinical Research Institute, Durham, North Carolina.,Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Li Lin
- Duke Clinical Research Institute, Durham, North Carolina
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina.,Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Steven J Lippmann
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Pamela N Peterson
- Division of Cardiology, University of Colorado, Anschutz Medical Campus, Aurora.,Division of Cardiology, Denver Health Medical Center, Denver, Colorado
| | - Paul A Heidenreich
- Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Warren K Laskey
- Division of Cardiology, University of New Mexico School of Medicine, Albuquerque
| | - Clyde W Yancy
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Deputy Editor
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - N Chantelle Hardy
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Abhishek Kavati
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Siyeon Park
- Department of Pharmaceutical Health Services Research, University of Maryland, Baltimore, Baltimore
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina.,Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Gregg C Fonarow
- Ahmanson-University of California, Los Angeles, Cardiomyopathy Center, University of California, Los Angeles.,Section Editor
| | - Emily C O'Brien
- Duke Clinical Research Institute, Durham, North Carolina.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
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Luo N, Lippmann SJ, Mentz RJ, Greiner MA, Hammill BG, Hardy NC, Laskey WK, Heidenreich PA, Chang CL, Hernandez AF, Curtis LH, Peterson PN, Fonarow GC, O'Brien EC. Relationship Between Hospital Characteristics and Early Adoption of Angiotensin-Receptor/Neprilysin Inhibitor Among Eligible Patients Hospitalized for Heart Failure. J Am Heart Assoc 2020; 8:e010484. [PMID: 30712431 PMCID: PMC6405590 DOI: 10.1161/jaha.118.010484] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background The angiotensin‐receptor/neprilysin inhibitor (ARNI) sacubitril/valsartan reduces hospitalization and mortality for patients with heart failure with reduced ejection fraction. However, adoption of ARNI into clinical practice has been slow. Factors influencing use of ARNI have not been fully elucidated. Using data from the Get With The Guidelines‐Heart Failure registry, Hospital Compare, Dartmouth Atlas, and the American Hospital Association Survey, we sought to identify hospital characteristics associated with patient‐level receipt of an ARNI prescription. Methods and Results We analyzed patients with heart failure with reduced ejection fraction who were eligible for ARNI prescription (ejection fraction≤40%, no contraindications) and hospitalized from October 1, 2015 through December 31, 2016. We used logistic regression to estimate the associations between hospital characteristics and patient ARNI prescription at hospital discharge, accounting for clustering of patients within hospitals using generalized estimating equation methods and adjusting for patient‐level covariates. Of 16 674 eligible hospitalizations from 210 hospitals, 1020 patients (6.1%) were prescribed ARNI at discharge. The median hospital‐level proportion of patients prescribed ARNI was 3.3% (Q1, Q3: 0%, 12.6%). After adjustment for patient‐level covariates, for‐profit hospitals had significantly higher odds of ARNI prescription compared with not‐for‐profit hospitals (odds ratio, 2.53; 95% CI, 1.05–6.10; P=0.04), and hospitals located in the Western United States had lower odds of ARNI prescription compared with those in the Northeast (odds ratio, 0.33; 95% CI, 0.13–0.84; P=0.02). Conclusions Relatively few hospital characteristics were associated with ARNI prescription at hospital discharge, in contrast to what has been observed in early adoption in other disease areas. Additional evaluation of barriers to implementing new evidence into heart failure practice is needed. See Editorial by Bergethon and Wasfy
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Affiliation(s)
- Nancy Luo
- 1 Division of Cardiovascular Medicine University of California-Davis Medical Center Sacramento CA
| | - Steven J Lippmann
- 2 Department of Population Health Sciences Duke University School of Medicine Durham NC
| | - Robert J Mentz
- 3 Department of Medicine Duke University School of Medicine Durham NC.,4 Duke Clinical Research Institute Duke University School of Medicine Durham NC
| | - Melissa A Greiner
- 2 Department of Population Health Sciences Duke University School of Medicine Durham NC
| | - Bradley G Hammill
- 2 Department of Population Health Sciences Duke University School of Medicine Durham NC
| | - N Chantelle Hardy
- 2 Department of Population Health Sciences Duke University School of Medicine Durham NC
| | - Warren K Laskey
- 5 Division of Cardiology University of New Mexico School of Medicine Albuquerque NM
| | - Paul A Heidenreich
- 6 Department of Medicine Veterans Affairs Palo Alto Health Care System Palo Alto CA
| | - Chun-Lan Chang
- 7 US Health Economics & Outcomes Research Novartis Pharmaceuticals Corporation East Hanover NJ
| | - Adrian F Hernandez
- 3 Department of Medicine Duke University School of Medicine Durham NC.,4 Duke Clinical Research Institute Duke University School of Medicine Durham NC
| | - Lesley H Curtis
- 2 Department of Population Health Sciences Duke University School of Medicine Durham NC.,4 Duke Clinical Research Institute Duke University School of Medicine Durham NC
| | - Pamela N Peterson
- 8 Department of Medicine Denver Health Medical Center Denver CO.,9 Anschutz Medical Center University of Colorado Aurora CO
| | - Gregg C Fonarow
- 10 Ahmanson-UCLA Cardiomyopathy Center University of California Los Angeles CA
| | - Emily C O'Brien
- 2 Department of Population Health Sciences Duke University School of Medicine Durham NC.,4 Duke Clinical Research Institute Duke University School of Medicine Durham NC
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Greene SJ, Lippmann SJ, Mentz RJ, Greiner MA, Hardy NC, Chang CL, Hammill BG, Luo N, Samsky MD, Heidenreich PA, Laskey WK, Yancy CW, Peterson PN, Curtis LH, Hernandez AF, Fonarow GC, O'Brien EC. Clinical Effectiveness of Sacubitril/valsartan among Patients Hospitalized for Heart Failure with Reduced Ejection Fraction. J Card Fail 2019. [DOI: 10.1016/j.cardfail.2019.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Cooper LB, Lippmann SJ, DiBello JR, Gorsh B, Curtis LH, Sikirica V, Hernandez AF, Sprecher DL, Laskey WK, Saini R, Fonarow GC, Hammill BG. The Burden of Congestion in Patients Hospitalized With Acute Decompensated Heart Failure. Am J Cardiol 2019; 124:545-553. [PMID: 31208702 DOI: 10.1016/j.amjcard.2019.05.030] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/03/2019] [Accepted: 05/13/2019] [Indexed: 12/19/2022]
Abstract
Congestion is associated with adverse outcomes in heart failure (HF) patients. We characterized congestion in patients hospitalized for HF and examined the association between congestion severity at admission and postdischarge outcomes. Using the OPTIMIZE-HF registry linked to Medicare claims, we analyzed patients ≥65 years old hospitalized for HF from 2003 to 2004. Congestion severity was measured using a 15-point scale that scores dyspnea, orthopnea, fatigue, jugular venous pressure, rales, and edema. Patient characteristics and outcomes were described by congestion strata. Proportional hazards models were fit to examine associations between congestion and 1-year outcomes. Congestion scores for the 24,724 patients ranged from 0 to 14, with a median of 5 (Q1, Q3: 3, 7). At baseline, patients with the highest scores (≥7) had the highest rates of recent HF hospitalizations, EF ≤40%, and co-morbidities, including arrhythmias, diabetes mellitus, and renal insufficiency. Adjusting for patient characteristics, a 3-point congestion score increase was positively associated with mortality (hazard ratio [HR] 1.06, 95% confidence interval [CI] 1.03, 1.09), all-cause rehospitalization (HR 1.02, 95% CI 1.00, 1.04), and HF rehospitalization (HR 1.09, 95% CI 1.06, 1.12), but not emergency department visits (HR 0.99, 95% CI 0.97, 1.01). In conclusion, for patients hospitalized with HF, congestion was associated with rehospitalization and mortality.
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Greene SJ, O'Brien EC, Mentz RJ, Luo N, Hardy NC, Laskey WK, Heidenreich PA, Chang CL, Turner SJ, Yancy CW, Hernandez AF, Curtis LH, Peterson PN, Fonarow GC, Hammill BG. Home-Time After Discharge Among Patients Hospitalized With Heart Failure. J Am Coll Cardiol 2019; 71:2643-2652. [PMID: 29880124 DOI: 10.1016/j.jacc.2018.03.517] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 03/05/2018] [Accepted: 03/07/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Surveys of patients with cardiovascular disease have suggested that "home-time"-being alive and out of any health care institution-is a prioritized outcome. This novel measure has not been studied among patients with heart failure (HF). OBJECTIVES This study sought to characterize home-time following hospitalization for HF and assess its relationship with patient characteristics and traditionally reported clinical outcomes. METHODS Using GWTG-HF (Get With The Guidelines-Heart Failure) registry data, patients discharged alive from an HF hospitalization between 2011 and 2014 and ≥65 years of age were identified. Using Medicare claims, post-discharge home-time over 30-day and 1-year follow-up was calculated for each patient as the number of days alive and spent outside of a hospital, skilled nursing facility (SNF), or rehabilitation facility. RESULTS Among 59,736 patients, 57,992 (97.1%) and 42,153 (70.6%) had complete follow-up for home-time calculation through 30 days and 1 year, respectively. The mean home-time was 21.6 ± 11.7 days at 30 days and 243.9 ± 137.6 days at 1 year. Contributions to reduced home-time varied by follow-up period, with days spent in SNF being the largest contributor though 30 days and death being the largest contributor through 1 year. Over 1 year, 2,044 (4.8%) patients had no home-time following index hospitalization discharge, whereas 8,194 (19.4%) had 365 days of home-time. In regression models, several conditions were associated with substantially reduced home-time, including chronic obstructive pulmonary disease, renal insufficiency, and dementia. Through 1 year, home-time was highly correlated with time-to-event endpoints of death (tau = 0.72) and the composite of death or HF readmission (tau = 0.59). CONCLUSIONS Home-time, which can be readily calculated from administrative claims data, is substantially reduced for many patients following hospitalization for HF and is highly correlated with traditional time-to-event mortality and hospitalization outcomes. Home-time represents a novel, easily measured, patient-centered endpoint that may reflect effectiveness of interventions in future HF studies.
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Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Emily C O'Brien
- Duke Clinical Research Institute, Durham, North Carolina; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Nancy Luo
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - N Chantelle Hardy
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Warren K Laskey
- Division of Cardiology, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Paul A Heidenreich
- Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Chun-Lan Chang
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Stuart J Turner
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Clyde W Yancy
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Lesley H Curtis
- Duke Clinical Research Institute, Durham, North Carolina; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Pamela N Peterson
- Division of Cardiology, Anschutz Medical Campus, University of Colorado Denver, Aurora, Colorado; Division of Cardiology, Denver Health Medical Center, Denver, Colorado
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, California
| | - Bradley G Hammill
- Duke Clinical Research Institute, Durham, North Carolina; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina.
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Frizzell JD, Liang L, Schulte PJ, Yancy CW, Heidenreich PA, Hernandez AF, Bhatt DL, Fonarow GC, Laskey WK. Prediction of 30-Day All-Cause Readmissions in Patients Hospitalized for Heart Failure: Comparison of Machine Learning and Other Statistical Approaches. JAMA Cardiol 2019; 2:204-209. [PMID: 27784047 DOI: 10.1001/jamacardio.2016.3956] [Citation(s) in RCA: 203] [Impact Index Per Article: 40.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Several attempts have been made at developing models to predict 30-day readmissions in patients with heart failure, but none have sufficient discriminatory capacity for clinical use. Machine-learning (ML) algorithms represent a novel approach and may have potential advantages over traditional statistical modeling. Objective To develop models using a ML approach to predict all-cause readmissions 30 days after discharge from a heart failure hospitalization and to compare ML model performance with models developed using "conventional" statistically based methods. Design, Setting, and Participants Models were developed using ML algorithms, specifically, a tree-augmented naive Bayesian network, a random forest algorithm, and a gradient-boosted model and compared with traditional statistical methods using 2 independently derived logistic regression models (a de novo model and an a priori model developed using electronic health records) and a least absolute shrinkage and selection operator method. The study sample was randomly divided into training (70%) and validation (30%) sets to develop and test model performance. This was a registry-based study, and the study sample was obtained by linking patients from the Get With the Guidelines Heart Failure registry with Medicare data. After applying appropriate inclusion and exclusion criteria, 56 477 patients were included in our analysis. The study was conducted between January 4, 2005, and December 1, 2010, and analysis of the data was conducted between November 25, 2014, and June 30, 2016. Main Outcomes and Measures C statistics were used for comparison of discriminatory capacity across models in the validation sample. Results The overall 30-day rehospitalization rate was 21.2% (11 959 of 56 477 patients). For the tree-augmented naive Bayesian network, random forest, gradient-boosted, logistic regression, and least absolute shrinkage and selection operator models, C statistics for the validation sets were similar: 0.618, 0.607, 0.614, 0.624, and 0.618, respectively. Applying the previously validated electronic health records model to our study sample yielded a C statistic of 0.589 for the validation set. Conclusions and Relevance Use of a number of ML algorithms did not improve prediction of 30-day heart failure readmissions compared with more traditional prediction models. Although there will likely be further applications of ML approaches in prognostic modeling, our study fits within the literature of limited predictive ability for heart failure readmissions.
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Affiliation(s)
| | - Li Liang
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | | | - Clyde W Yancy
- Northwestern University Feinberg School of Medicine, Chicago, Illinois5Deputy Editor, JAMA Cardiology
| | - Paul A Heidenreich
- Veterans Affairs Palo Alto Health Care System and Stanford University, Palo Alto, California
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University, Durham, North Carolina7Associate Editor, JAMA Cardiology
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Gregg C Fonarow
- Ahmanson University of California at Los Angeles Cardiomyopathy Center10Associate Editor for Health Care Quality and Guidelines, JAMA Cardiology
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Hirshfeld JW, Ferrari VA, Bengel FM, Bergersen L, Chambers CE, Einstein AJ, Eisenberg MJ, Fogel MA, Gerber TC, Haines DE, Laskey WK, Limacher MC, Nichols KJ, Pryma DA, Raff GL, Rubin GD, Smith D, Stillman AE, Thomas SA, Tsai TT, Wagner LK, Samuel Wann L, Januzzi JL, Afonso LC, Everett B, Hernandez AF, Hucker W, Jneid H, Kumbhani D, Edward Marine J, Morris PB, Piana RN, Watson KE, Wiggins BS. 2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging-Best Practices for Safety and Effectiveness, Part 1: Radiation Physics and Radiation Biology: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways Developed in Collaboration With Mended Hearts. Catheter Cardiovasc Interv 2018; 92:203-221. [PMID: 30160013 DOI: 10.1002/ccd.27660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The stimulus to create this document was the recognition that ionizing radiation-guided cardiovascular procedures are being performed with increasing frequency, leading to greater patient radiation exposure and, potentially, to greater exposure for clinical personnel. Although the clinical benefit of these procedures is substantial, there is concern about the implications of medical radiation exposure. The American College of Cardiology leadership concluded that it is important to provide practitioners with an educational resource that assembles and interprets the current radiation knowledge base relevant to cardiovascular procedures. By applying this knowledge base, cardiovascular practitioners will be able to select procedures optimally, and minimize radiation exposure to patients and to clinical personnel. Optimal Use of Ionizing Radiation in Cardiovascular Imaging: Best Practices for Safety and Effectiveness is a comprehensive overview of ionizing radiation use in cardiovascular procedures and is published online. To provide the most value to our members, we divided the print version of this document into 2 focused parts. Part I: Radiation Physics and Radiation Biology addresses the issue of medical radiation exposure, the basics of radiation physics and dosimetry, and the basics of radiation biology and radiation-induced adverse effects. Part II: Radiological Equipment Operation, Dose-Sparing Methodologies, Patient and Medical Personnel Protection covers the basics of operation and radiation delivery for the 3 cardiovascular imaging modalities (x-ray fluoroscopy, x-ray computed tomography, and nuclear scintigraphy) and will be published in the next issue of the Journal.
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Hirshfeld JW, Ferrari VA, Bengel FM, Bergersen L, Chambers CE, Einstein AJ, Eisenberg MJ, Fogel MA, Gerber TC, Haines DE, Laskey WK, Limacher MC, Nichols KJ, Pryma DA, Raff GL, Rubin GD, Smith D, Stillman AE, Thomas SA, Tsai TT, Wagner LK, Samuel Wann L, Januzzi JL, Afonso LC, Everett B, Hernandez AF, Hucker W, Jneid H, Kumbhani D, Edward Marine J, Morris PB, Piana RN, Watson KE, Wiggins BS. 2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging-Best Practices for Safety and Effectiveness, Part 2: Radiological Equipment Operation, Dose-Sparing Methodologies, Patient and Medical Pe. Catheter Cardiovasc Interv 2018; 92:222-246. [DOI: 10.1002/ccd.27661] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Hirshfeld JW, Ferrari VA, Bengel FM, Bergersen L, Chambers CE, Einstein AJ, Eisenberg MJ, Fogel MA, Gerber TC, Haines DE, Laskey WK, Limacher MC, Nichols KJ, Pryma DA, Raff GL, Rubin GD, Smith D, Stillman AE, Thomas SA, Tsai TT, Wagner LK, Samuel Wann L, Januzzi JL, Afonso LC, Everett B, Hernandez AF, Hucker W, Jneid H, Kumbhani D, Edward Marine J, Morris PB, Piana RN, Watson KE, Wiggins BS. 2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging: Best Practices for Safety and Effectiveness. Catheter Cardiovasc Interv 2018; 92:E35-E97. [DOI: 10.1002/ccd.27659] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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12
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Luo N, Ballew NG, O'Brien EC, Greiner MA, Peterson PN, Hammill BG, Hardy NC, Laskey WK, Heidenreich PA, Chang CL, Hernandez AF, Curtis LH, Mentz RJ, Fonarow GC. Early impact of guideline publication on angiotensin-receptor neprilysin inhibitor use among patients hospitalized for heart failure. Am Heart J 2018; 200:134-140. [PMID: 29898842 DOI: 10.1016/j.ahj.2018.01.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 01/24/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND On May 20, 2016, US professional organizations in cardiology published joint treatment guidelines recommending the use of angiotensin-receptor neprilysin inhibitor (ARNI) for eligible patients with heart failure with reduced ejection fraction (HFrEF). Using data from the Get With The Guidelines-Heart Failure registry, we evaluated the early impact of this update on temporal trends in ARNI prescription. METHODS We analyzed patients with HFrEF who were eligible for ARNI prescription (EF ≤40%, no contraindications) and hospitalized from February 20, 2016, through August 19, 2016-allowing for 13weeks before and after guideline publication. We quantified trends in ARNI use associated with guidelines publication with an interrupted time-series design using logistic regression and accounting for correlations within hospitals using general estimating equation methods. RESULTS Of 7,200 eligible patient hospitalizations, 51.9% were discharged in the period directly preceding publication of the guidelines, and 48.1% were discharged after. Odds ratios of ARNI prescription at discharge were significantly higher in the postguideline period compared with the preguideline period in adjusted models (adjusted odds ratio 1.29, 95% CI 1.06-1.57, P=.01). However, there was no significant interaction between observed and expected ARNI use after guideline publication (Pinteraction=.14). Results were consistent using a 6-month before and after time frame. CONCLUSIONS The model suggested a small increase in ARNI use in HF patients being discharged from the hospital immediately after guideline release. However, the publication of national guidelines recommending ARNI use seemed to have little influence on the adoption of this evidence-based medication in the first 3 to 6months.
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13
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Hirshfeld JW, Ferrari VA, Bengel FM, Bergersen L, Chambers CE, Einstein AJ, Eisenberg MJ, Fogel MA, Gerber TC, Haines DE, Laskey WK, Limacher MC, Nichols KJ, Pryma DA, Raff GL, Rubin GD, Smith D, Stillman AE, Thomas SA, Tsai TT, Wagner LK, Wann LS. 2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging—Best Practices for Safety and Effectiveness, Part 2: Radiological Equipment Operation, Dose-Sparing Methodologies, Patient and Medical Personnel Protection. J Am Coll Cardiol 2018; 71:2829-2855. [DOI: 10.1016/j.jacc.2018.02.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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14
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Udell JA, Fonarow GC, Maddox TM, Cannon CP, Frank Peacock W, Laskey WK, Grau-Sepulveda MV, Smith EE, Hernandez AF, Peterson ED, Bhatt DL. Sustained sex-based treatment differences in acute coronary syndrome care: Insights from the American Heart Association Get With The Guidelines Coronary Artery Disease Registry. Clin Cardiol 2018. [PMID: 29521450 DOI: 10.1002/clc.22938] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Sex-based differences in acute coronary syndrome (ACS) mortality may attenuate with age due to better symptom recognition and prompt care. HYPOTHESIS Age is a modifier of temporal trends in sex-based differences in ACS care. METHODS Among 104 817 eligible patients with ACS enrolled in the AHA Get With the Guidelines-Coronary Artery Disease registry between 2003 and 2008, care and in-hospital mortality were evaluated stratified by sex and age. Temporal trends within sex and age groups were assessed for 2 care processes: percentage of STEMI patients presenting to PCI-capable hospitals with a DTB time ≤ 90 minutes (DTB90) and proportion of eligible ACS patients receiving aspirin within 24 hours. RESULTS After adjustment for clinical risk factors and sociodemographic and hospital characteristics, 2276 (51.7%) women and 6276 (56.9%) men with STEMI were treated with DTB90 (adjusted OR: 0.85, 95% CI: 0.80-0.91, P < 0.0001 for women vs men). Time trend analysis showed an absolute increase ranging from 24% to 35% in DTB90 rates among both men and women (P for trend <0.0001 for each group), with consistent differences over time across the 4 age/sex groups (3-way P-interaction = 0.93). Despite high rate of baseline aspirin use (87%-91%), there was a 9% to 11% absolute increase in aspirin use over time, also with consistent differences across the 4 age/sex groups (all 3-way P-interaction ≥0.15). CONCLUSIONS Substantial gains of generally similar magnitude existed in ACS performance measures over 6 years of study across sex and age groups; areas for improvement remain, particularly among younger women.
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Affiliation(s)
- Jacob A Udell
- Cardiovascular Division, Department of Medicine Women's College Hospital and Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Gregg C Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles
| | - Thomas M Maddox
- Division of Cardiology, Washington University School of Medicine, St. Louis, Missouri
| | - Christopher P Cannon
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | - Warren K Laskey
- Division of Cardiology, Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque
| | | | - Eric E Smith
- Department of Clinical Neurosciences, Radiology, and Community Health Sciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke Medical Center, Durham, North Carolina.,Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke Medical Center, Durham, North Carolina.,Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
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15
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Hirshfeld JW, Ferrari VA, Bengel FM, Bergersen L, Chambers CE, Einstein AJ, Eisenberg MJ, Fogel MA, Gerber TC, Haines DE, Laskey WK, Limacher MC, Nichols KJ, Pryma DA, Raff GL, Rubin GD, Smith D, Stillman AE, Thomas SA, Tsai TT, Wagner LK, Wann LS. 2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging-Best Practices for Safety and Effectiveness, Part 1: Radiation Physics and Radiation Biology: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol 2018; 71:2811-2828. [PMID: 29729876 DOI: 10.1016/j.jacc.2018.02.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [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: 01/13/2023]
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16
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Hirshfeld JW, Ferrari VA, Bengel FM, Bergersen L, Chambers CE, Einstein AJ, Eisenberg MJ, Fogel MA, Gerber TC, Haines DE, Laskey WK, Limacher MC, Nichols KJ, Pryma DA, Raff GL, Rubin GD, Smith D, Stillman AE, Thomas SA, Tsai TT, Wagner LK, Wann LS. 2018 ACC/HRS/NASCI/SCAI/SCCT Expert Consensus Document on Optimal Use of Ionizing Radiation in Cardiovascular Imaging: Best Practices for Safety and Effectiveness: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol 2018; 71:e283-e351. [PMID: 29729877 DOI: 10.1016/j.jacc.2018.02.016] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [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: 12/13/2022]
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17
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Anabtawi A, Mondragon J, Dodendorf D, Laskey WK. Late-stage left ventricular dysfunction in adult survivors of tetralogy of Fallot repair in childhood. Open Heart 2017; 4:e000690. [PMID: 29225904 PMCID: PMC5708319 DOI: 10.1136/openhrt-2017-000690] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 08/24/2017] [Accepted: 11/07/2017] [Indexed: 11/20/2022] Open
Abstract
Objective Left ventricular systolic dysfunction (LVSD) in adult survivors of tetralogy of Fallot (TOF) repair in childhood has been observed, although the relationship with long-term outcome remains inadequately described. Methods A cohort of 44 consecutive adult patients with TOF repair in childhood were followed prospectively from January 2001 through June 2016. LVSD was defined as an echocardiographically derived left ventricular (LV) ejection fraction <0.55. Clinical and demographic characteristics in patients with and without LVSD were compared. Event-free survival (all-cause death or hospitalisation) was estimated using the product limit method. Results The average time from childhood surgical repair to cohort inception was similar between groups (LVSD, 33.7±12.7 years; normal LV function, 36.1±14.9 years; P=0.62) as were their mean ages (LVSD, 36.5±14.5 years; normal LV function, 40.7±15.2 years; P=0.73). Patients with LVSD (n=13) had more prior surgeries, more frequent history of significant pulmonic regurgitation, right ventricular systolic dysfunction and more implantable cardiac devices. Over a total observation time of 15.5 years, patients with LVSD were at significantly higher risk of all-cause death or hospitalisation (P=0.006). Onset of LVSD frequently preceded an adverse outcome. Conclusions In this cohort of adult patients with TOF repair in childhood followed for a total of 550 patient-years, the frequency of LVSD was 30%. LVSD was associated with lower event-free survival. The appearance of LVSD many years after TOF repair may herald the onset of an adverse outcome.
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Affiliation(s)
- Abdel Anabtawi
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Judith Mondragon
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Diane Dodendorf
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Warren K Laskey
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
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18
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Win TT, Davis HT, Laskey WK. Mortality Among Patients Hospitalized With Heart Failure and Diabetes Mellitus: Results From the National Inpatient Sample 2000 to 2010. Circ Heart Fail 2017; 9:e003023. [PMID: 27146551 DOI: 10.1161/circheartfailure.115.003023] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [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: 10/22/2015] [Accepted: 04/08/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND Case fatality and hospitalization rates for US patients with heart failure (HF) have steadily decreased during the past several decades. Diabetes mellitus (DM), a risk factor for, and frequent coexisting condition with, HF continues to increase in the general population. METHODS AND RESULTS We used the National Inpatient Sample to estimate overall as well as age-, sex-, and race/ethnicity-specific trends in HF hospitalizations, DM prevalence, and in-hospital mortality among 2.5 million discharge records from 2000 to 2010 with HF as primary discharge diagnosis. Multivariable logistic and Poisson regression were used to assess the impact of the above demographic characteristics on in-hospital mortality. Age-standardized hospitalizations decreased significantly in HF overall and in HF with DM. Age-standardized in-hospital mortality with HF declined from 2000 to 2010 (4.57% to 3.09%, Ptrend<0.0001), whereas DM prevalence in HF increased (38.9% to 41.9%, Ptrend<0.0001) as did comorbidity burden. Age-standardized in-hospital mortality in HF with DM also decreased significantly (3.53% to 2.27%, Ptrend<0.0001). After adjusting for year, age, and comorbid burden, males remained at 17% increased risk versus females, non-Hispanics remained at 12% increased risk versus Hispanics, and whites had a 30% higher mortality versus non-white minorities. Absolute mortality rates were lower in younger versus older patients, although the rate of decline was attenuated in younger patients. CONCLUSIONS In-hospital mortality in HF patients with DM significantly decreased during the past decade, despite increases in DM prevalence and comorbid conditions. Mortality rate decreases among younger patients were significantly attenuated, and mortality disparities remain among important demographic subgroups.
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Affiliation(s)
- Theingi Tiffany Win
- From the Divisions of Cardiology (T.T.W., W.K.L.) and Epidemiology, Biostatistics, and Preventive Medicine (H.T.D., W.K.L.), Department of Medicine, University of New Mexico School of Medicine, Albuquerque
| | - Herbert T Davis
- From the Divisions of Cardiology (T.T.W., W.K.L.) and Epidemiology, Biostatistics, and Preventive Medicine (H.T.D., W.K.L.), Department of Medicine, University of New Mexico School of Medicine, Albuquerque
| | - Warren K Laskey
- From the Divisions of Cardiology (T.T.W., W.K.L.) and Epidemiology, Biostatistics, and Preventive Medicine (H.T.D., W.K.L.), Department of Medicine, University of New Mexico School of Medicine, Albuquerque.
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19
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Deedwania P, Acharya T, Kotak K, Fonarow GC, Cannon CP, Laskey WK, Peacock WF, Pan W, Bhatt DL. Compliance with guideline-directed therapy in diabetic patients admitted with acute coronary syndrome: Findings from the American Heart Association's Get With The Guidelines-Coronary Artery Disease (GWTG-CAD) program. Am Heart J 2017; 187:78-87. [PMID: 28454811 DOI: 10.1016/j.ahj.2017.02.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [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: 12/20/2016] [Accepted: 02/18/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND To evaluate and compare baseline characteristics, outcomes and compliance with guideline based therapy at discharge among diabetic and non-diabetic patients admitted with acute coronary syndromes (ACS). METHODS AND RESULTS Study population consisted of 151,270 patients admitted with ACS from 2002 through 2008 at 411 sites participating in the American Heart Association's Get with the Guidelines (GWTG) program. Demographic variables, physical exam findings, laboratory data, left ventricular ejection fraction, length of stay, in-hospital mortality and discharge medications were compared between diabetic and non-diabetic patients. Temporal trends in compliance with guidelines directed therapy were evaluated. Of 151,270 patients, 48,938 (32%) had diabetes. Overall, diabetic patients were significantly older and more likely non-white. They had significantly more hypertension, atherosclerotic disease, CKD, and LV dysfunction and were more likely to present as NSTEMI. They had longer hospital stay and higher hospital mortality than non-diabetic patients. Diabetic patients were less likely to get LDL checks (65% vs 70%) and less frequently prescribed statins (85% vs 89%), RAAS blockers for LV dysfunction (80% vs 84%) and dual-antiplatelet therapy (69% vs 74%). Diabetic patients were less likely to achieve BP goals before discharge (75% vs 82%). Fewer diabetic patients met first medical contact to PCI time for STEMI (44% vs 52%). Temporal trends, however, showed continued progressive improvement in most performance measures from 2002 to 2008 (all P<.001). CONCLUSIONS These data from a large cohort of ACS patients demonstrate gaps in compliance with guidelines directed therapy in diabetic patients but also indicate significant and continued improvement in most performance measures over time. Concerted efforts are needed to continue this positive trend.
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Affiliation(s)
- Prakash Deedwania
- Division of Cardiology, University of California, San Francisco, Fresno, California.
| | - Tushar Acharya
- Division of Cardiology, University of California, San Francisco, Fresno, California
| | - Kamal Kotak
- Division of Cardiology, University of California, San Francisco, Fresno, California
| | - Gregg C Fonarow
- Division of Cardiology, University of California, Los Angeles and Ahmanson-UCLA Cardiomyopathy Center, Los Angeles, California
| | - Christopher P Cannon
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA
| | - Warren K Laskey
- Division of Cardiology, University of New Mexico, Albuquerque, New Mexico
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor Medical Center, Houston, TX
| | - Wenqin Pan
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA
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20
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Kolte D, Spence N, Puthawala M, Hyder O, Tuohy CP, Davidson CB, Sheldon MW, Laskey WK, Abbott JD. Association of radial versus femoral access with contrast-induced acute kidney injury in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction. Cardiovascular Revascularization Medicine 2016; 17:546-551. [DOI: 10.1016/j.carrev.2016.07.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 07/18/2016] [Indexed: 02/04/2023]
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21
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Abstract
Purpose: Increased levels of markers of systemic inflammation have been noted in patients following coronary angiographic procedures. The purpose of the present study was to examine the influence of the type of the angiographic procedure as well as the type of radiographic contrast media (RCM) on markers of inflammation. Material and Methods: Thirty-seven patients undergoing diagnostic or interventional coronary angiographic procedures were randomly assigned to receive one of three RCM − an ionic low osmolar agent; a non-ionic, iso-osmotic agent; or a non-ionic, low osmolar agent. Sera were analyzed at baseline (prior to receiving RCM), and at 2, 6 and 24 h thereafter for interleukin (IL)-6 and soluble receptors for tumor necrosis factor alpha (TNFα)-1 and TNFα- 2. Results: Statistically significant increases over time in each RCM group were noted for IL-6 and both TNFα receptors. Comparable increases in inflammatory markers were observed in patients undergoing diagnostic angiography and in patients undergoing an associated coronary intervention. While these markers increased following exposure to both ionic and non-ionic RCM, there was a consistent trend towards lessened marker release with non-ionic RCM. Conclusion: Both diagnostic and interventional coronary angiographic procedures are associated with an increase in serum inflammatory markers. While both ionic and non-ionic RCM are associated with increases in serum inflammatory markers, this increase may be attenuated with non-ionic RCM.
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Affiliation(s)
- W K Laskey
- Cardiac Catheterization Laboratory, Division of Cardiology, University of Maryland Medical System, Baltimore, MD, USA.
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22
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Laskey WK, Wu J, Schulte PJ, Hernandez AF, Yancy CW, Heidenreich PA, Bhatt DL, Fonarow GC. Association of Arterial Pulse Pressure With Long-Term Clinical Outcomes in Patients With Heart Failure. JACC: Heart Failure 2016; 4:42-9. [DOI: 10.1016/j.jchf.2015.09.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 09/04/2015] [Accepted: 09/05/2015] [Indexed: 01/23/2023]
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23
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Schwartz BG, Qualls C, Kloner RA, Laskey WK. Relation of Total and Cardiovascular Death Rates to Climate System, Temperature, Barometric Pressure, and Respiratory Infection. Am J Cardiol 2015; 116:1290-7. [PMID: 26297511 DOI: 10.1016/j.amjcard.2015.07.050] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 07/03/2015] [Accepted: 07/03/2015] [Indexed: 11/28/2022]
Abstract
A distinct seasonal pattern in total and cardiovascular death rates has been reported. The factors contributing to this pattern have not been fully explored. Seven locations (average total population 71,354,000) were selected where data were available including relatively warm, cold, and moderate temperatures. Over the period 2004 to 2009, there were 2,526,123 all-cause deaths, 838,264 circulatory deaths, 255,273 coronary heart disease deaths, and 135,801 ST-elevation myocardial infarction (STEMI) deaths. We used time series and multivariate regression modeling to explore the association between death rates and climatic factors (temperature, dew point, precipitation, barometric pressure), influenza levels, air pollution levels, hours of daylight, and day of week. Average seasonal patterns for all-cause and cardiovascular deaths were very similar across the 7 locations despite differences in climate. After adjusting for multiple covariates and potential confounders, there was a 0.49% increase in all-cause death rate for every 1°C decrease. In general, all-cause, circulatory, coronary heart disease and STEMI death rates increased linearly with decreasing temperatures. The temperature effect varied by location, including temperature's linear slope, cubic fit, positional shift on the temperature axis, and the presence of circulatory death increases in locally hot temperatures. The variable effect of temperature by location suggests that people acclimatize to local temperature cycles. All-cause and circulatory death rates also demonstrated sizable associations with influenza levels, dew point temperature, and barometric pressure. A greater understanding of how climate, temperature, and barometric pressure influence cardiovascular responses would enhance our understanding of circulatory and STEMI deaths.
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Affiliation(s)
- Bryan G Schwartz
- Division of Cardiology, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico; Heart Institute, Good Samaritan Hospital, Los Angeles, California.
| | - Clifford Qualls
- Department of Mathematics and Statistics, University of New Mexico, Albuquerque, New Mexico; Clinical Translational Sciences Center, University of New Mexico, Albuquerque, New Mexico
| | - Robert A Kloner
- Heart Institute, Good Samaritan Hospital, Los Angeles, California; Huntington Medical Research Institute, Pasadena, California; Division of Cardiovascular Medicine, Department of Internal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Warren K Laskey
- Division of Cardiology, Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico
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Laskey WK, Alomari I, Cox M, Schulte PJ, Zhao X, Hernandez AF, Heidenreich PA, Eapen ZJ, Yancy C, Bhatt DL, Fonarow GC. Heart rate at hospital discharge in patients with heart failure is associated with mortality and rehospitalization. J Am Heart Assoc 2015; 4:jah3907. [PMID: 25904590 PMCID: PMC4579947 DOI: 10.1161/jaha.114.001626] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background Whether heart rate upon discharge following hospitalization for heart failure is associated with long‐term adverse outcomes and whether this association differs between patients with sinus rhythm (SR) and atrial fibrillation (AF) have not been well studied. Methods and Results We conducted a retrospective cohort study from clinical registry data linked to Medicare claims for 46 217 patients participating in Get With The Guidelines®–Heart Failure. Cox proportional‐hazards models were used to estimate the association between discharge heart rate and all‐cause mortality, all‐cause readmission, and the composite outcome of mortality/readmission through 1 year. For SR and AF patients with heart rate ≥75, the association between heart rate and mortality (expressed as hazard ratio [HR] per 10 beats‐per‐minute increment) was significant at 0 to 30 days (SR: HR 1.30, 95% CI 1.22 to 1.39; AF: HR 1.23, 95% CI 1.16 to 1.29) and 31 to 365 days (SR: HR 1.15, 95% CI 1.12 to 1.20; AF: HR 1.05, 95% CI 1.01 to 1.08). Similar associations between heart rate and all‐cause readmission and the composite outcome were obtained for SR and AF patients from 0 to 30 days but only in the composite outcome for SR patients over the longer term. The HR from 0 to 30 days exceeded that from 31 to 365 days for both SR and AF patients. At heart rates <75, an association was significant for mortality only for both SR and AF patients. Conclusions Among older patients hospitalized with heart failure, higher discharge heart rate was associated with increased risks of death and rehospitalization, with higher risk in the first 30 days and for SR compared with AF.
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Affiliation(s)
- Warren K Laskey
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM (W.K.L.)
| | - Ihab Alomari
- Division of Cardiology, University of California at Irvine, CA (I.A.)
| | - Margueritte Cox
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.C., P.J.S., X.Z., A.F.H., Z.J.E.)
| | - Phillip J Schulte
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.C., P.J.S., X.Z., A.F.H., Z.J.E.)
| | - Xin Zhao
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.C., P.J.S., X.Z., A.F.H., Z.J.E.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.C., P.J.S., X.Z., A.F.H., Z.J.E.)
| | | | - Zubin J Eapen
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (M.C., P.J.S., X.Z., A.F.H., Z.J.E.)
| | - Clyde Yancy
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (C.Y.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.)
| | - Gregg C Fonarow
- David-Geffen School of Medicine, University of California at Los Angeles, CA (G.C.F.)
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25
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Kumbhani DJ, Fonarow GC, Cannon CP, Hernandez AF, Peterson ED, Peacock WF, Laskey WK, Deedwania P, Grau-Sepulveda M, Schwamm LH, Bhatt DL. Temporal trends for secondary prevention measures among patients hospitalized with coronary artery disease. Am J Med 2015; 128:426.e1-9. [PMID: 25433302 DOI: 10.1016/j.amjmed.2014.11.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [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: 04/28/2014] [Revised: 08/06/2014] [Accepted: 11/04/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Prior studies have noted that in-hospital adherence to secondary prevention measures varied among patients undergoing coronary artery bypass graft surgery, percutaneous coronary revascularization, or no intervention. We sought to study contemporary temporal trends in the in-hospital management of patients with coronary artery disease. METHODS By using data from the Get With The Guidelines-Coronary Artery Disease registry, we compared adherence to 6 performance measures (aspirin within 24 hours, discharge on aspirin, discharge on beta-blockers, patients with low ejection fraction discharged on angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, smoking cessation counseling, and use of lipid-lowering medications) in eligible patients with coronary artery disease who underwent coronary artery bypass graft surgery, percutaneous coronary intervention, or no intervention between 2003 and 2008. RESULTS A total of 113,971 patients with coronary artery disease were treated at 193 hospitals. Overall adherence to all 6 quality of care measures improved over time in all 3 treatment groups, but was highest at all time periods in the percutaneous coronary intervention group compared with the coronary artery bypass graft surgery group, whereas the no intervention group had the lowest use of prevention measures at all time points (P < .0001). Likewise, 100% adherence to all 6 measures was superior in the percutaneous coronary intervention group at all time points (P < .0001). On multivariable adjustment for case-mix of patients, the majority of these differences persisted. CONCLUSIONS Over the last decade, overall adherence with secondary prevention measures improved significantly in patients hospitalized with coronary artery disease regardless of revascularization strategy. However, there still exist select opportunities for improving adherence, particularly among patients undergoing coronary artery bypass graft surgery or no intervention.
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Affiliation(s)
- Dharam J Kumbhani
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas.
| | - Gregg C Fonarow
- UCLA Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, Los Angeles, Calif
| | - Christopher P Cannon
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Mass
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - W Frank Peacock
- Emergency Medicine, Baylor College of Medicine, Houston, Tex
| | - Warren K Laskey
- Division of Cardiology, University of New Mexico, Albuquerque
| | | | | | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Mass
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Laskey WK. Drug-eluting stents: boom or bust? Ann Intern Med 2014; 161:740-1. [PMID: 25402515 DOI: 10.7326/m14-0874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Ahmed B, Davis HT, Laskey WK. In-hospital mortality among patients with type 2 diabetes mellitus and acute myocardial infarction: results from the national inpatient sample, 2000-2010. J Am Heart Assoc 2014; 3:jah3668. [PMID: 25158866 PMCID: PMC4310403 DOI: 10.1161/jaha.114.001090] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Case‐fatality rates in acute myocardial infarction (AMI) have significantly decreased; however, the prevalence of diabetes mellitus (DM), a risk factor for AMI, has increased. The purposes of the present study were to assess the prevalence and clinical impact of DM among patients hospitalized with AMI and to estimate the impact of important clinical characteristics associated with in‐hospital mortality in patients with AMI and DM. Methods and Results We used the National Inpatient Sample to estimate trends in DM prevalence and in‐hospital mortality among 1.5 million patients with AMI from 2000 to 2010, using survey data‐analysis methods. Clinical characteristics associated with in‐hospital mortality were identified using multivariable logistic regression. There was a significant increase in DM prevalence among AMI patients (year 2000, 22.2%; year 2010, 29.6%, Ptrend<0.0001). AMI patients with DM tended to be older and female and to have more cardiovascular risk factors. However, age‐standardized mortality decreased significantly from 2000 (8.48%) to 2010 (4.95%) (Ptrend<0.0001). DM remained independently associated with mortality (adjusted odds ratio 1.069, 95% CI 1.051 to 1.087; P<0.0001). The adverse impact of DM on in‐hospital mortality was unchanged over time. Decreased death risk over time was greatest among women and elderly patients. Among younger patients of both sexes, there was a leveling off of this decrease in more recent years. Conclusions Despite increasing DM prevalence and disease burden among AMI patients, in‐hospital mortality declined significantly from 2000 to 2010. The adverse impact of DM on mortality remained unchanged overall over time but was age and sex dependent.
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Affiliation(s)
- Bina Ahmed
- Division of Cardiology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM (B.A., W.K.L.)
| | - Herbert T Davis
- Division of Epidemiology, Biostatistics and Prevention, University of New Mexico School of Medicine, Albuquerque, NM (H.T.D., W.K.L.)
| | - Warren K Laskey
- Division of Epidemiology, Biostatistics and Prevention, University of New Mexico School of Medicine, Albuquerque, NM (H.T.D., W.K.L.) Division of Cardiology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM (B.A., W.K.L.)
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Shah B, Bangalore S, Gianos E, Liang L, Peacock WF, Fonarow GC, Laskey WK, Hernandez AF, Bhatt DL. Temporal trends in clinical characteristics of patients without known cardiovascular disease with a first episode of myocardial infarction. Am Heart J 2014; 167:480-488.e1. [PMID: 24655696 PMCID: PMC3964370 DOI: 10.1016/j.ahj.2013.12.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 12/25/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Recent initiatives have focused on primary prevention to delay time to first myocardial infarction (MI). The aim of this study was to evaluate the change in risk factor profile over time in patients without known cardiovascular disease presenting with first MI. METHODS In the American Heart Association's Get With The Guidelines-Coronary Artery Disease national registry, 100,884 patients without known cardiovascular disease presenting with acute MI from 408 hospitals were evaluated between 2002 and 2008. The time trends of the proportion of patients with cardiovascular risk factors (nonmodifiable: age >45 years for men or >55 years for women, male sex, modifiable: diabetes mellitus, hypertension, hyperlipidemia, tobacco use) were analyzed. Analyses were stratified by non-ST-segment elevation MI (NSTEMI) versus ST-segment elevation MI (STEMI). RESULTS The proportion of patients with ≥3 of 6 traditional risk factors slightly decreased over time in the NSTEMI (69.5%-66.8%, P < .0001) and STEMI (68.9%-66.4%, P < .0001) cohorts. The proportion of patients with ≥2 of 4 modifiable risk factors increased from 52% to 59% and then declined to 52.1% (P < .0001) in the NSTEMI cohort but declined slightly in the STEMI cohort (50.9%-47.3%, P < .0001). After adjusting for age and gender, the time trend of proportion with diabetes mellitus, hypertension, and tobacco use declined in both cohorts. However, the proportion of patients with hyperlipidemia remained similar. CONCLUSIONS Although risk factor profiles in patients presenting with first MI have shown improvements over time, the changes are modest.
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Affiliation(s)
- Binita Shah
- New York University School of Medicine, New York, NY.
| | | | | | - Li Liang
- Duke Clinical Research Institute, Durham, NC
| | | | - Gregg C Fonarow
- University of California, Los Angeles Medical Center, Los Angeles, CA
| | | | | | - Deepak L Bhatt
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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Cavender MA, Rassi AN, Schwamm LH, Fonarow GC, Cannon CP, Peacock WF, Laskey WK, Hernandez AF, Peterson ED, Cox M, Grau-Sepulveda M, Bhatt DL. Response to Relationship of race/ethnicity with door-to-balloon time and mortality in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction: Findings from Get With the Guidelines-Coronary Artery Diseases. Authors' reply. Clin Cardiol 2014; 37:323. [PMID: 24596074 DOI: 10.1002/clc.22265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 01/24/2014] [Indexed: 11/05/2022] Open
Affiliation(s)
- Matthew A Cavender
- TIMI Study Group, Heart and Vascular Center Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Bainey KR, Armstrong PW, Fonarow GC, Cannon CP, Hernandez AF, Peterson ED, Peacock WF, Laskey WK, Zhao X, Schwamm LH, Bhatt DL. Use of Renin–Angiotensin System Blockers in Acute Coronary Syndromes. Circ Cardiovasc Qual Outcomes 2014; 7:227-35. [DOI: 10.1161/circoutcomes.113.000422] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Kevin R. Bainey
- From the Canadian VIGOUR Centre, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (K.R.B., P.W.A.); Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles Medical Center (G.C.F.); Cardiovascular Division, TIMI Study Group, Brigham and Women’s Hospital, Boston, MA (C.P.C.); Duke Clinical Research Institute, Duke University, Durham, NC (A.F.H., E.D.P., X.Z.); Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W
| | - Paul W. Armstrong
- From the Canadian VIGOUR Centre, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (K.R.B., P.W.A.); Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles Medical Center (G.C.F.); Cardiovascular Division, TIMI Study Group, Brigham and Women’s Hospital, Boston, MA (C.P.C.); Duke Clinical Research Institute, Duke University, Durham, NC (A.F.H., E.D.P., X.Z.); Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W
| | - Gregg C. Fonarow
- From the Canadian VIGOUR Centre, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (K.R.B., P.W.A.); Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles Medical Center (G.C.F.); Cardiovascular Division, TIMI Study Group, Brigham and Women’s Hospital, Boston, MA (C.P.C.); Duke Clinical Research Institute, Duke University, Durham, NC (A.F.H., E.D.P., X.Z.); Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W
| | - Christopher P. Cannon
- From the Canadian VIGOUR Centre, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (K.R.B., P.W.A.); Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles Medical Center (G.C.F.); Cardiovascular Division, TIMI Study Group, Brigham and Women’s Hospital, Boston, MA (C.P.C.); Duke Clinical Research Institute, Duke University, Durham, NC (A.F.H., E.D.P., X.Z.); Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W
| | - Adrian F. Hernandez
- From the Canadian VIGOUR Centre, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (K.R.B., P.W.A.); Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles Medical Center (G.C.F.); Cardiovascular Division, TIMI Study Group, Brigham and Women’s Hospital, Boston, MA (C.P.C.); Duke Clinical Research Institute, Duke University, Durham, NC (A.F.H., E.D.P., X.Z.); Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W
| | - Eric D. Peterson
- From the Canadian VIGOUR Centre, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (K.R.B., P.W.A.); Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles Medical Center (G.C.F.); Cardiovascular Division, TIMI Study Group, Brigham and Women’s Hospital, Boston, MA (C.P.C.); Duke Clinical Research Institute, Duke University, Durham, NC (A.F.H., E.D.P., X.Z.); Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W
| | - W. Frank Peacock
- From the Canadian VIGOUR Centre, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (K.R.B., P.W.A.); Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles Medical Center (G.C.F.); Cardiovascular Division, TIMI Study Group, Brigham and Women’s Hospital, Boston, MA (C.P.C.); Duke Clinical Research Institute, Duke University, Durham, NC (A.F.H., E.D.P., X.Z.); Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W
| | - Warren K. Laskey
- From the Canadian VIGOUR Centre, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (K.R.B., P.W.A.); Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles Medical Center (G.C.F.); Cardiovascular Division, TIMI Study Group, Brigham and Women’s Hospital, Boston, MA (C.P.C.); Duke Clinical Research Institute, Duke University, Durham, NC (A.F.H., E.D.P., X.Z.); Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W
| | - Xin Zhao
- From the Canadian VIGOUR Centre, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (K.R.B., P.W.A.); Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles Medical Center (G.C.F.); Cardiovascular Division, TIMI Study Group, Brigham and Women’s Hospital, Boston, MA (C.P.C.); Duke Clinical Research Institute, Duke University, Durham, NC (A.F.H., E.D.P., X.Z.); Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W
| | - Lee H. Schwamm
- From the Canadian VIGOUR Centre, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (K.R.B., P.W.A.); Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles Medical Center (G.C.F.); Cardiovascular Division, TIMI Study Group, Brigham and Women’s Hospital, Boston, MA (C.P.C.); Duke Clinical Research Institute, Duke University, Durham, NC (A.F.H., E.D.P., X.Z.); Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W
| | - Deepak L. Bhatt
- From the Canadian VIGOUR Centre, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (K.R.B., P.W.A.); Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles Medical Center (G.C.F.); Cardiovascular Division, TIMI Study Group, Brigham and Women’s Hospital, Boston, MA (C.P.C.); Duke Clinical Research Institute, Duke University, Durham, NC (A.F.H., E.D.P., X.Z.); Department of Emergency Medicine, Baylor College of Medicine, Houston, TX (W
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Thukkani AK, Fonarow GC, Cannon CP, Cox M, Hernandez AF, Peterson ED, Peacock WF, Laskey WK, Schwamm LH, Bhatt DL. Quality of care for patients with acute coronary syndromes as a function of hospital revascularization capability: Insights from get with the guidelines-CAD. Clin Cardiol 2014; 37:285-92. [PMID: 24452828 DOI: 10.1002/clc.22246] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 12/10/2013] [Accepted: 12/10/2013] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Revascularization availability at US hospitals varies and may impact care quality for acute coronary syndrome patients. HYPOTHESIS The hypothesis of this study was that there would be differences in care quality at Get With The Guidelines-Coronary Artery Disease (GWTG-CAD) hospitals based on revascularization capability. METHODS For acute coronary syndrome patients admitted to GWTG-CAD hospitals between 2000 and 2010, care quality at hospitals with or without revascularization capability was examined by assessing conformity with performance and quality measures. RESULTS This study included 95 999 acute coronary syndrome patients admitted to 310 GWTG-CAD hospitals. There were 89 000 patients admitted to 226 revascularization-capable hospitals and 6999 patients admitted to 84 hospitals without revascularization capability included. Adjusted multivariate analysis demonstrated that 8 of the 19 measures were more frequently performed in the revascularization cohort: aspirin (odds ratio [OR]: 1.41, 95% confidence interval [CI]: 1.04-1.92), clopidogrel (OR: 2.31, 95% CI: 1.78-3.00), lipid-lowering therapies at discharge (OR: 1.39, 95% CI: 1.04-1.87), lipid-lowering therapies for low-density lipoprotein >100 mg/dL (OR: 1.85, 95% CI: 1.23-2.77), achievement of blood pressure <140/90 mm Hg (OR: 1.20, 95% CI: 1.03-1.40), LDL recorded (OR: 1.47, 95% CI: 1.05-2.06), and recommendations offered for physical activity (OR: 3.82, 95% CI: 2.23-6.55) or weight management (OR: 1.74, 95% CI: 1.12-2.69). CONCLUSIONS The GWTG-CAD revascularization hospitals were associated with better performance in some, but not all, measures assessed. Although the difference in conformity between hospital types was modest for performance measures but more variable for quality measures, room for improvement exists in key aspects of care.
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Affiliation(s)
- Arun K Thukkani
- Heart and Vascular Center, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Cavender MA, Rassi AN, Fonarow GC, Cannon CP, Peacock WF, Laskey WK, Hernandez AF, Peterson ED, Cox M, Grau-Sepulveda M, Schwamm LH, Bhatt DL. Relationship of race/ethnicity with door-to-balloon time and mortality in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction: findings from Get With the Guidelines-Coronary Artery Disease. Clin Cardiol 2013; 36:749-56. [PMID: 24085713 DOI: 10.1002/clc.22213] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [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: 07/25/2013] [Revised: 08/26/2013] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Prior studies have described racial/ethnic disparities in door-to-balloon (DTB) time for patients undergoing primary percutaneous coronary intervention (PCI). We sought to compare DTB time between different racial/ethnic groups undergoing primary PCI for ST-elevation myocardial infarction in Get With the Guidelines (GWTG). HYPOTHESIS There may be differences in D2B time associated with race/ethnicity. METHODS We identified 7445 white (n = 6365), African American (n = 568), and Hispanic (n = 512) patients undergoing primary PCI. RESULTS There were no differences in the median DTB time between white (74 minutes; intraquartile range [IQR], 54-99), African American (77 minutes; IQR, 57-100), and Hispanic (75 minutes; IQR, 56-100) (P = 0.13) patients. There were no crude differences in DTB time ≤90 minutes; however, after adjusting for confounders, African American race was associated with lower odds of DTB time ≤90 minutes (odds ratio [OR]: 0.84; 95% confidence interval [CI]: 0.70-0.99; P = 0.04). This association was seen in African American males (OR: 0.66; 95% CI: 0.55-0.80) but not African American females (OR: 1.27; 95% CI: 0.96-1.68). Overall, Hispanic ethnicity was not associated with a difference in DTB time ≤90 minutes (OR: 0.98; 95% CI: 0.77-1.25; P = 0.88); although Hispanic males did have a slightly longer median DTB time compared with whites. During the study, the proportion of patients with DTB times ≤90 minutes increased for all groups, and mortality was similar between groups (white 3.8%, African American 3.0%, Hispanic 4.1%, P = 0.62). CONCLUSIONS In GWTG-Coronary Artery Disease, small differences in DTB times persist among different races/ethnicities. However, the proportion achieving DTB times ≤90 minutes has increased substantially for all patients over time, and there was no association between race/ethnicity and in-hospital mortality.
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Affiliation(s)
- Matthew A Cavender
- Department of Medicine, TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School Boston, Massachusetts
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Laskey WK, Ricciardi MJ. 30-day readmission rate following percutaneous coronary intervention: much more than a binary variable. JACC Cardiovasc Interv 2013; 6:245-6. [PMID: 23517835 DOI: 10.1016/j.jcin.2012.12.119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Accepted: 12/07/2012] [Indexed: 11/18/2022]
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Affiliation(s)
- Alex Schevchuck
- From the Division of Cardiology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM
| | - Warren K. Laskey
- From the Division of Cardiology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM
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Rassi AN, Cavender MA, Fonarow GC, Cannon CP, Hernandez AF, Peterson ED, Peacock WF, Laskey WK, Rosas SE, Zhao X, Schwamm LH, Bhatt DL. Temporal Trends and Predictors in the Use of Aldosterone Antagonists Post-Acute Myocardial Infarction. J Am Coll Cardiol 2013; 61:35-40. [DOI: 10.1016/j.jacc.2012.08.1019] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Revised: 08/22/2012] [Accepted: 08/30/2012] [Indexed: 01/11/2023]
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Kumbhani DJ, Fonarow GC, Cannon CP, Hernandez AF, Peterson ED, Peacock WF, Laskey WK, Pan W, Schwamm LH, Bhatt DL. Predictors of adherence to performance measures in patients with acute myocardial infarction. Am J Med 2013; 126:74.e1-9. [PMID: 22925314 DOI: 10.1016/j.amjmed.2012.02.025] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [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: 12/27/2011] [Revised: 01/22/2012] [Accepted: 02/23/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND There have been substantial improvements in the use of evidence-based, guideline-recommended therapies for patients with acute myocardial infarction. Nevertheless, some gaps, disparities, and variations in use remain. To understand how such gaps in recommended care may be narrowed further, it may be useful to determine those factors associated with lessened adherence to guideline-based care. METHODS The Get with the Guidelines-Coronary Artery Disease registry measured adherence with 6 performance measures (aspirin within 24 hours, discharge on aspirin and beta-blockers, patients with low ejection fraction discharged on angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, smoking cessation counseling, use of lipid-lowering medications) in 148,654 patients with acute myocardial infarction between 2002 and 2009. Logistic multivariable regression models using generalized estimating equations were utilized to identify patient and hospital characteristics associated with adherence to each of 6 measures, and to a summary score of performance for all measures, in eligible patients. RESULTS We identified 10 variables that were associated significantly with either greater adherence (hypertension, hyperlipidemia, hospital with full interventional capabilities, calendar year) or worse adherence (age, female sex, congestive heart failure, chronic renal insufficiency, atrial fibrillation, chronic dialysis) in at least 4 of the 6 treatment adherence models, as well as the summary score adherence model. Age, sex, and calendar year were significant in all models. CONCLUSIONS Use of evidence-based acute myocardial infarction treatments remains less than ideal for certain high-risk populations. The close correlations among factors associated with underperformance highlights the potential for specifically targeting and tailoring quality improvement interventions.
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Affiliation(s)
- Dharam J Kumbhani
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
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Ricciardi MJ, Selzer F, Marroquin OC, Holper EM, Venkitachalam L, Williams DO, Kelsey SF, Laskey WK. Incidence and predictors of 30-day hospital readmission rate following percutaneous coronary intervention (from the National Heart, Lung, and Blood Institute Dynamic Registry). Am J Cardiol 2012; 110:1389-96. [PMID: 22853982 PMCID: PMC3483468 DOI: 10.1016/j.amjcard.2012.07.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [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: 05/08/2012] [Revised: 07/06/2012] [Accepted: 07/06/2012] [Indexed: 01/08/2023]
Abstract
Postdischarge outcomes after percutaneous coronary intervention (PCI) are important measurements of quality of care and complement in-hospital measurements. We sought to assess in-hospital and postdischarge PCI outcomes to (1) better understand the relation between acute and 30-day outcomes, (2) identify predictors of 30-day hospital readmission, and (3) determine the prognostic significance of 30-day hospital readmission. We analyzed in-hospital death and length of stay (LOS) and nonelective cardiac-related rehospitalization after discharge in 10,965 patients after PCI in the Dynamic Registry. From 1999 to 2006 in-hospital death rate and LOS decreased. Thirty-day cardiac readmission rate was 4.6%, with considerable variability over time and among hospitals. Risk of rehospitalization was greater in women and those with congestive heart failure, unstable angina, multiple lesions, and emergency PCI. Conversely, a lower risk of rehospitalization was associated with a larger number of treated lesions. Patients readmitted within 30 days had higher 1-year mortality than those free from hospital readmission. In conclusion, although in-hospital mortality and LOS after PCI have decreased over time, the observed 30-day cardiac readmission rate was highly variable and risk of readmission was more closely associated with underlying patient characteristics than procedural characteristics.
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Affiliation(s)
- Mark J Ricciardi
- Division of Cardiology, University of New Mexico School of Medicine, Albuquerque, New Mexico.
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Boyer NM, Laskey WK, Cox M, Hernandez AF, Peterson ED, Bhatt DL, Cannon CP, Fonarow GC. Trends in clinical, demographic, and biochemical characteristics of patients with acute myocardial infarction from 2003 to 2008: a report from the american heart association get with the guidelines coronary artery disease program. J Am Heart Assoc 2012; 1:e001206. [PMID: 23130159 PMCID: PMC3487339 DOI: 10.1161/jaha.112.001206] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Accepted: 07/05/2012] [Indexed: 11/30/2022]
Abstract
Background An analysis of the changes in the clinical and demographic characteristics of patients with acute myocardial infarction could identify successes and failures of risk factor identification and treatment of patients at increased risk for cardiovascular events. Methods and Results We reviewed data collected from 138 122 patients with acute myocardial infarction admitted from 2003 to 2008 to hospitals participating in the American Heart Association Get With The Guidelines Coronary Artery Disease program. Clinical, demographic, and laboratory characteristics were analyzed for each year stratified on the electrocardiogram at presentation. Patients with non–ST-segment–elevation myocardial infarction were older, more likely to be women, and more likely to have hypertension, diabetes mellitus, and a history of past cardiovascular disease than were patients with ST-elevation myocardial infarction. In the overall patient sample, significant trends were observed of an increase over time in the proportions of non–ST-segment–elevation myocardial infarction, patient age of 45 to 65 years, obesity, and female sex. The prevalence of diabetes mellitus decreased over time, whereas the prevalences of hypertension and smoking were substantial and unchanging. The prevalence of “low” high-density lipoprotein increased over time, whereas that of “high” low-density lipoprotein decreased. Stratum-specific univariate analysis revealed quantitative and qualitative differences between strata in time trends for numerous demographic, clinical, and biochemical measures. On multivariable analysis, there was concordance between strata with regard to the increase in prevalence of patients 45 to 65 years of age, obesity, and “low” high-density lipoprotein and the decrease in prevalence of “high” low-density lipoprotein. However, changes in trends in age distribution, sex ratio, and prevalence of smokers and the magnitude of change in diabetes mellitus prevalence differed between strata. Conclusions There were notable differences in risk factors and patient characteristics among patients with ST-elevation myocardial infarction and those with non–ST-segment–elevation myocardial infarction. The increasing prevalence of dysmetabolic markers in a growing proportion of patients with acute myocardial infarction suggests further opportunities for risk factor modification. (J Am Heart Assoc. 2012;1:e001206 doi: 10.1161/JAHA.112.001206.)
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Affiliation(s)
- Nathan M Boyer
- University of New Mexico, Albuquerque, NM (N.M.B., W.K.L.)
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Bashore TM, Balter S, Barac A, Byrne JG, Cavendish JJ, Chambers CE, Hermiller JB, Kinlay S, Landzberg JS, Laskey WK, McKay CR, Miller JM, Moliterno DJ, Moore JWM, Oliver-McNeil SM, Popma JJ, Tommaso CL. 2012 American College of Cardiology Foundation/Society for Cardiovascular Angiography and Interventions expert consensus document on cardiac catheterization laboratory standards update: A report of the American College of Cardiology Foundation Task Force on Expert Consensus documents developed in collaboration with the Society of Thoracic Surgeons and Society for Vascular Medicine. J Am Coll Cardiol 2012; 59:2221-305. [PMID: 22575325 DOI: 10.1016/j.jacc.2012.02.010] [Citation(s) in RCA: 151] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Bashore TM, Balter S, Barac A, Byrne JG, Cavendish JJ, Chambers CE, Hermiller JB, Kinlay S, Landzberg JS, Laskey WK, McKay CR, Miller JM, Moliterno DJ, Moore JW, Oliver-McNeil SM, Popma JJ, Tommaso ACL, Harrington RA, Bates ER, Bhatt DL, Bridges CR, Eisenberg MJ, Ferrari VA, Fisher JD, Gardner T, Gentile F, Gilson MF, Hlatky MA, Jacobs AK, Kaul S, Moliterno DJ, Mukherjee D, Rosenson RS, Weitz HH, Wesley DJ. 2012 American college of cardiology foundation/society for cardiovascular angiography and interventions expert consensus document on cardiac catheterization laboratory standards update: American college of cardiology foundation task force on expert consen. Catheter Cardiovasc Interv 2012; 80:E37-49. [DOI: 10.1002/ccd.24466] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Rassi AN, Cavender MA, Fonarow GC, Cannon CPCP, Hernandez AF, Peterson ED, Peacock WF, Laskey WK, Zhao X, Schwamm LH, Bhatt DL. Abstract 227: Aldosterone Antagonists in Post-Acute Myocardial Infarction Use, Predictors, and Temporal Trends of a Class I Recommendation. Circ Cardiovasc Qual Outcomes 2012. [DOI: 10.1161/circoutcomes.5.suppl_1.a227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives:
To measure the use of guideline-recommended aldosterone antagonist therapy in eligible patients with post-MI and reduced ejection fraction (EF), temporal trends, and characteristics associated with use.
Background:
Current guidelines recommend the initiation of aldosterone antagonist therapy post-AMI for those with an EF ≤ 40% with heart failure or diabetes prior to hospital discharge, in the absence of contraindications. We explored the relationship between this Class IA recommendation issued in 2004 (STEMI)/2007 (NSTEMI) and its implementation into practice.
Methods:
Data from the AHA’s Get with the Guidelines-CAD national database were analyzed for 81,570 post-AMI patients from 219 hospitals between January 1, 2006 and December 29, 2009 of whom 11,255 (13.8%) were eligible for aldosterone antagonist therapy.
Results:
Among eligible patients, 1023 (9.1%) were prescribed an aldosterone antagonist at discharge. There was wide variation in use among hospitals (0% to 40.0) with no hospital treating even half their eligible patients. Patient and hospital characteristics independently associated with prescription of aldosterone antagonists were history of diabetes, heart failure, or coronary revascularization. Conversely, patients less likely to have an aldosterone antagonist prescribed had a history of renal insufficiency, were smokers, and had higher EF. Larger hospital size was associated with higher aldosterone antagonist use. Prescription of an aldosterone antagonist increased in the study population from 6.0% to 13.4% from January 2006 to December 2009 (p<0.001).
Conclusions:
Fewer than one in ten post-MI patients eligible for an aldosterone antagonist, were discharged with this Class IA recommended therapy. Although rates of utilization are rising modestly over time, compliance continues to be extremely low. This discrepancy between evidence based therapy and actual prescribing patterns suggests the need for specific targeted performance improvement efforts.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Xin Zhao
- Duke Clinical Rsch Institute, Durham, NC,
| | | | - Deepak L Bhatt
- VA Boston Healthcare System and Brigham and Women's Hosp, Boston, MA
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Qian F, Ling FS, Deedwania P, Hernandez AF, Fonarow GC, Cannon CP, Peterson ED, Peacock WF, Kaltenbach LA, Laskey WK, Schwamm LH, Bhatt DL. Care and outcomes of Asian-American acute myocardial infarction patients: findings from the American Heart Association Get With The Guidelines-Coronary Artery Disease program. Circ Cardiovasc Qual Outcomes 2012; 5:126-33. [PMID: 22235068 DOI: 10.1161/circoutcomes.111.961987] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Asian-Americans represent an important United States minority population, yet there are limited data regarding the clinical care and outcomes of Asian-Americans following acute myocardial infarction (AMI). Using data from the American Heart Association Get With The Guidelines-Coronary Artery Disease (GWTG-CAD) program, we compared use of and trends in evidence-based care AMI processes and outcome in Asian-American versus white patients. METHODS AND RESULTS We analyzed 107,403 AMI patients (4412 Asian-Americans, 4.1%) from 382 United States centers participating in the Get With The Guidelines-Coronary Artery Disease program between 2003 and 2008. Use of 6 AMI performance measures, composite "defect-free" care (proportion receiving all eligible performance measures), door-to-balloon time, and in-hospital mortality were examined. Trends in care over this time period were explored. Compared with whites, Asian-American AMI patients were significantly older, more likely to be covered by Medicaid and recruited in the west region, and had a higher prevalence of diabetes, hypertension, heart failure, and smoking. In-hospital unadjusted mortality was higher among Asian-American patients. Overall, Asian-Americans were comparable with whites regarding the baseline quality of care, except that Asian-Americans were less likely to get smoking cessation counseling (65.6% versus 81.5%). Asian-American AMI patients experienced improvement in the 6 individual measures (P≤0.048), defect-free care (P<0.001), and door-to-balloon time (P<0.001). The improvement rates were similar for both Asian-Americans and whites. Compared with whites, the adjusted in-hospital mortality rate was higher for Asian-Americans (adjusted relative risk: 1.16; 95% confidence interval: 1.00-1.35; P=0.04). CONCLUSIONS Evidence-based care for AMI processes improved significantly over the period of 2003 to 2008 for Asian-American and white patients in the Get With The Guidelines-Coronary Artery Disease program. Differences in care between Asian-Americans and whites, when present, were reduced over time.
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Affiliation(s)
- Feng Qian
- University of Rochester, Rochester, NY 14642, USA.
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Medina H, Cannon CC, Fonarow GC, Peacock FW, Laskey WK, Grau-Sepulveda MV, Fernandez AF, Peterson ED, Schwamm LH, Bhatt DL. QUALITY OF CARE AND OUTCOMES IN 5,339 PATIENTS AGED 80 OR ABOVE PRESENTING WITH ST-ELEVATION MYOCARDIAL INFARCTION: ANALYSIS FROM AMERICAN HEART ASSOCIATION GET WITH THE GUIDELINES: CORONARY ARTERY DISEASE. J Am Coll Cardiol 2011. [DOI: 10.1016/s0735-1097(11)61285-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Qian F, Ling FS, Deedwania P, Hernandez AF, Fonarow GC, Cannon CP, Peterson ED, Peacock WF, Kaltenbach LA, Laskey WK, Schwamm LH, Bhatt DL. CARE AND OUTCOMES OF ASIAN ACUTE MYOCARDIAL INFARCTION PATIENTS: RESULTS FROM THE AMERICAN HEART ASSOCIATION GET WITH THE GUIDELINES-CORONARY ARTERY DISEASE PROGRAM. J Am Coll Cardiol 2011. [DOI: 10.1016/s0735-1097(11)61163-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Kumbhani DJ, Fonarow GC, Cannon CC, Hernandez AF, Peterson ED, Peacock WF, Laskey WK, Pan W, Schwamm LH, Bhatt DL. PREDICTORS OF DEFECT-FREE COMPLIANCE WITH PROCESS MEASURES IN PATIENTS PRESENTING WITH ACUTE MYOCARDIAL INFARCTION: INSIGHTS FROM GET WITH THE GUIDELINES CAD. J Am Coll Cardiol 2011. [DOI: 10.1016/s0735-1097(11)61276-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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E. Chambers C, A. Fetterly K, Holzer R, Paul Lin PJ, C. Blankenship J, Balter S, K. Laskey W. Radiation safety program for the cardiac catheterization laboratory. Catheter Cardiovasc Interv 2011; 77:546-56. [DOI: 10.1002/ccd.22867] [Citation(s) in RCA: 224] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Revised: 09/28/2010] [Accepted: 10/06/2010] [Indexed: 11/11/2022]
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Rana JS, Venkitachalam L, Selzer F, Mulukutla SR, Marroquin OC, Laskey WK, Holper EM, Srinivas VS, Kip KE, Kelsey SF, Nesto RW. Evolution of percutaneous coronary intervention in patients with diabetes: a report from the National Heart, Lung, and Blood Institute-sponsored PTCA (1985-1986) and Dynamic (1997-2006) Registries. Diabetes Care 2010; 33:1976-82. [PMID: 20519661 PMCID: PMC2928347 DOI: 10.2337/dc10-0247] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate the association of successive percutaneous coronary intervention (PCI) modalities with balloon angioplasty (BA), bare-metal stent (BMS), drug-eluting stents (DES), and pharmacotherapy over the last 3 decades with outcomes among patients with diabetes in routine clinical practice. RESEARCH DESIGN AND METHODS We examined outcomes in 1,846 patients with diabetes undergoing de novo PCI in the multicenter, National Heart, Lung, and Blood Institute-sponsored 1985-1986 Percutaneous Transluminal Coronary Angioplasty (PTCA) Registry and 1997-2006 Dynamic Registry. Multivariable Cox regression models were used to estimate the adjusted risk of events (death/myocardial infarction [MI], repeat revascularization) over 1 year. RESULTS Cumulative event rates for postdischarge (31-365 days) death/MI were 8% by BA, 7% by BMS, and 7% by DES use (P = 0.76) and for repeat revascularization were 19, 13, and 9% (P < 0.001), respectively. Multivariable analysis showed a significantly lower risk of repeat revascularization with DES use when compared with the use of BA (hazard ratio [HR] 0.41 [95% CI 0.29-0.58]) and BMS (HR 0.55 [95% CI 0.39-0.76]). After further adjustment for discharge medications, the lower risk for death/MI was not statistically significant for DES when compared with BA. CONCLUSIONS In patients with diabetes undergoing PCI, the use of DES is associated with a reduced need for repeat revascularization when compared with BA or BMS use. The associated death/MI benefit observed with the DES versus the BA group may well be due to greater use of pharmacotherapy.
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Affiliation(s)
- Jamal S Rana
- Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
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Laskey WK, Feinendegen LE, Neumann RD, Dilsizian V. Low-level ionizing radiation from noninvasive cardiac imaging: can we extrapolate estimated risks from epidemiologic data to the clinical setting? JACC Cardiovasc Imaging 2010; 3:517-24. [PMID: 20466348 DOI: 10.1016/j.jcmg.2009.11.017] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [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: 08/11/2009] [Revised: 11/03/2009] [Accepted: 11/06/2009] [Indexed: 11/17/2022]
Abstract
Clinical decision-making regarding the use of low-level ionizing radiation for diagnostic and/or therapeutic purposes in patients with cardiovascular disease must, as in all other clinical scenarios, encompass the broad range of the risk-benefit ratio. Concerns regarding the late carcinogenic effects of exposure to low levels, i.e., <100 mSv, of ionizing radiation stem from extrapolation of exposure-outcome data in survivors of World War II atomic bomb explosions. However, ongoing debate regarding the true incremental risk to subjects exposed to doses currently administered in cardiovascular procedures fails to take into account the uncertainty of the dose-response relationship in this lower range, as well as tissue-specific reparative responses, also manifest at lower levels of exposure. The present discussion draws attention to both of these aspects as they relate to clinical decision-making.
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Affiliation(s)
- Warren K Laskey
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico 87131, USA.
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Martinez J, Laskey WK, Wells C, Foghi A, Rohde S, Ricciardi M, Mobarak C. Proteomic Analysis of the Systemic Response to Radiographic Contrast Media. Clin Proteomics 2010. [DOI: 10.1007/s12014-010-9048-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Abstract
Introduction
Radiographic contrast media (RCM) have numerous effects on the hemostatic system, inflammatory pathways, and vascular endothelium. Given the increasing number of high-risk patients undergoing radiographic procedures, more information regarding the systemic effects of RCM is needed.
Methods
Blood samples prior to baseline, 4 and 24 h following elective coronary angiography in 10 patients, were subjected to matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. Data are presented as the ratio of the protein mass at 4 (iTRAQ4) and 24 h (iTRAQ24) compared to baseline. A ratio >1.0 and a ratio <1.0 indicate production and consumption, respectively, relative to baseline.
Results
In this sample, we identified 102 proteins with a confidence interval of ≥90%. Six proteins were identified at each time point in all patients. Of the proteins identified, apolipoprotein A-I, apolipoprotein A-II, complement C3, fibrinogen beta chain, immunoglobulin α, and prothrombin revealed an iTRAQ ratio <1.0 at 4 h when compared to baseline (all with p value <0.05) and a trend toward baseline levels at 24 h.
Conclusions
Systemic administration of RCM results in a variety of alterations to the proteome. Of interest, there is activation of the thrombotic and inflammatory pathways as well as an interaction with lipoprotein metabolism. These changes are most pronounced at 4 h but may persist through 24 h and may be of clinical relevance in patients at risk for thrombotic- and inflammatory-mediated consequences of atherosclerosis.
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