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Lalani C, Yeh RW. Residual Chest Pain After PCI - A Failure In Diagnosis Rather Than Treatment. J Am Coll Cardiol 2024:S0735-1097(24)07131-6. [PMID: 38759903 DOI: 10.1016/j.jacc.2024.04.042] [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: 04/29/2024] [Accepted: 04/30/2024] [Indexed: 05/19/2024]
Affiliation(s)
- Christina Lalani
- Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA
| | - Robert W Yeh
- Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston MA; Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Aggarwal R, Ruff CT, Virdone S, Perreault S, Kakkar AK, Palazzolo MG, Dorais M, Kayani G, Yeh RW. Response by Aggarwal et al to Letter Regarding Article, "Development and Validation of the DOAC Score: A Novel Bleeding Risk Prediction Tool for Patients With Atrial Fibrillation on Direct-Acting Oral Anticoagulants". Circulation 2024; 149:e1111-e1112. [PMID: 38620083 DOI: 10.1161/circulationaha.123.068239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Affiliation(s)
- Rahul Aggarwal
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center (R.A., R.W.Y.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Heart and Vascular Center (R.A.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Christian T Ruff
- Thrombolysis in Myocardial Infarction Study Group, Division of Cardiovascular Medicine (C.T.R., M.G.P.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Saverio Virdone
- Thrombosis Research Institute, London, United Kingdom (S.V., A.K.K., G.K.)
| | | | - Ajay K Kakkar
- Thrombosis Research Institute, London, United Kingdom (S.V., A.K.K., G.K.)
- Division of Surgery, University College London, United Kingdom (A.K.K.)
| | - Michael G Palazzolo
- Thrombolysis in Myocardial Infarction Study Group, Division of Cardiovascular Medicine (C.T.R., M.G.P.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Marc Dorais
- StatSciences Inc, Notre-Dame-de-l'Île-Perrot, Canada (M.D.)
| | - Gloria Kayani
- Thrombosis Research Institute, London, United Kingdom (S.V., A.K.K., G.K.)
| | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center (R.A., R.W.Y.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Anderson TS, Herzig SJ, Marcantonio ER, Yeh RW, Souza J, Landon BE. Medicare Transitional Care Management Program and Changes in Timely Postdischarge Follow-Up. JAMA Health Forum 2024; 5:e240417. [PMID: 38607641 PMCID: PMC11065163 DOI: 10.1001/jamahealthforum.2024.0417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 02/13/2024] [Indexed: 04/13/2024] Open
Abstract
Importance In 2013, Medicare implemented payments for transitional care management (TCM) services, which provide increased reimbursement to clinicians providing ambulatory care to patients after discharge from medical facilities to the community. Objective To determine whether the introduction of TCM payments was associated with an increase in timely postdischarge follow-up. Design, Setting, and Participants This cross-sectional interrupted time-series study assessed quarterly postdischarge visit rates before (2010-2012) and after (2013-2019) TCM implementation 100% sample of Medicare fee-for-service beneficiaries discharged to the community after a hospital or skilled nursing facility stay. Data analyses were performed February 1 to December 15, 2023. Exposure Implementation of payments for TCM. Main Outcomes and Measures Timely postdischarge primary care follow-up, defined as receipt of a primary care ambulatory visit within 14 days of discharge. Secondary outcomes included receipt of a TCM visit and specialty care follow-up. Results The study sample comprised 79 125 965 eligible discharges. Of these, 55.4% were female; 1.5% were Asian, 12.1% Black, 5.6% Hispanic, and 79.0% were White individuals; and 79.6% were beneficiaries aged 65 years and older. Timely primary care follow-up increased from 31.5% in 2010 to 38.8% in 2019 (absolute increase 7.3%), whereas specialist follow-up increased from 27.6% to 30.8% (absolute increase 3.2%). By 2019, 11.3% of eligible patients received TCM services. Interrupted time-series analyses demonstrated an increased slope of timely primary care follow-up after the introduction of TCM services (pre-TCM slope, 0.12% per quarter vs post-TCM slope, 0.29% per quarter; difference, 0.13%; 95% CI, 0.02% to 0.22%). Receipt of timely follow-up increased for all demographic groups; however, Black, Hispanic, and Medicaid dual-eligible patients and patients residing in urban areas and counties with high-level social deprivation were less likely to receive follow-up during the study period. These disparities widened for Black patients (difference-in-differences in pre-TCM vs post-TCM slope, -0.14%; 95% CI, -0.25% to -0.2%) and patients who were Medicaid dual-eligible (difference-in-differences pre-TCM vs post-TCM slope, -0.21%; 95% CI, -0.35% to -0.07%). Conclusions These findings indicate that Medicare's introduction of payments for TCM services was associated with a persistent increase in the rate of timely postdischarge primary care but did not narrow demographic or socioeconomic disparities. Most beneficiaries did not receive timely primary care follow-up.
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Affiliation(s)
- Timothy S. Anderson
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Shoshana J. Herzig
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Edward R. Marcantonio
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Robert W. Yeh
- Harvard Medical School, Boston, Massachusetts
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jeffrey Souza
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Bruce E. Landon
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Secemsky EA, Yeh RW, Schneider PA, Gray W, Parikh S. The End of a Controversy: The Rise, Fall, and Redemption of Paclitaxel-Coated Devices. Am J Cardiol 2024; 216:43-45. [PMID: 38369174 DOI: 10.1016/j.amjcard.2024.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/12/2024] [Accepted: 01/22/2024] [Indexed: 02/20/2024]
Affiliation(s)
- Eric A Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California San Francisco, San Francisco, California
| | - William Gray
- Division of Cardiology, Lankenau Heart Institute, Main Line Health, Wynnewood, Pennsylvania; Department of Medicine, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Sahil Parikh
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York
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Wadhera RK, Secemsky EA, Xu J, Yeh RW, Song Y, Goldhaber SZ. Community Socioeconomic Status, Acute Cardiovascular Hospitalizations, and Mortality in Medicare, 2003 to 2019. Circ Cardiovasc Qual Outcomes 2024; 17:e010090. [PMID: 38597091 DOI: 10.1161/circoutcomes.123.010090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 01/31/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Socioeconomically disadvantaged communities in the United States disproportionately experience poor cardiovascular outcomes. Little is known about how hospitalizations and mortality for acute cardiovascular conditions have changed among Medicare beneficiaries in socioeconomically disadvantaged and nondisadvantaged communities over the past 2 decades. METHODS Medicare files were linked with the Centers for Disease Control and Prevention's social vulnerability index to examine age-sex standardized hospitalizations for myocardial infarction, heart failure, ischemic stroke, and pulmonary embolism among Medicare fee-for-service beneficiaries ≥65 years of age residing in socioeconomically disadvantaged communities (highest social vulnerability index quintile nationally) and nondisadvantaged communities (all other quintiles) from 2003 to 2019, as well as risk-adjusted 30-day mortality among hospitalized beneficiaries. RESULTS A total of 10 942 483 Medicare beneficiaries ≥65 years of age were hospitalized for myocardial infarction, heart failure, stroke, or pulmonary embolism (mean age, 79.2 [SD, 8.7] years; 53.9% female). Although age-sex standardized myocardial infarction hospitalizations declined in socioeconomically disadvantaged (990-650 per 100 000) and nondisadvantaged communities (950-570 per 100 000) from 2003 to 2019, the gap in hospitalizations between these groups significantly widened (adjusted odds ratio 2003, 1.03 [95% CI, 1.02-1.04]; adjusted odds ratio 2019, 1.14 [95% CI, 1.13-1.16]). There was a similar decline in hospitalizations for heart failure in socioeconomically disadvantaged (2063-1559 per 100 000) and nondisadvantaged communities (1767-1385 per 100 000), as well as for ischemic stroke, but the relative gap did not change for both conditions. In contrast, pulmonary embolism hospitalizations increased in both disadvantaged (146-184 per 100 000) and nondisadvantaged communities (153-184 per 100 000). By 2019, risk-adjusted 30-day mortality was similar between hospitalized beneficiaries from socioeconomically disadvantaged and nondisadvantaged communities for myocardial infarction, heart failure, and ischemic stroke but was higher for pulmonary embolism (odds ratio, 1.10 [95% CI, 1.01-1.20]). CONCLUSIONS Over the past 2 decades, hospitalizations for most acute cardiovascular conditions decreased in both socioeconomically disadvantaged and nondisadvantaged communities, although significant disparities remain, while 30-day mortality is now similar across most conditions.
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Affiliation(s)
- Rishi K Wadhera
- Richard and Susan Smith Center for Outcomes Research, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA (R.K.W., E.A.S., J.X., R.W.Y., Y.S.)
| | - Eric A Secemsky
- Richard and Susan Smith Center for Outcomes Research, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA (R.K.W., E.A.S., J.X., R.W.Y., Y.S.)
| | - Jiaman Xu
- Richard and Susan Smith Center for Outcomes Research, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA (R.K.W., E.A.S., J.X., R.W.Y., Y.S.)
| | - Robert W Yeh
- Richard and Susan Smith Center for Outcomes Research, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA (R.K.W., E.A.S., J.X., R.W.Y., Y.S.)
| | - Yang Song
- Richard and Susan Smith Center for Outcomes Research, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA (R.K.W., E.A.S., J.X., R.W.Y., Y.S.)
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.Z.G.)
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Yeh RW, Shlofmitz R, Moses J, Bachinsky W, Dohad S, Rudick S, Stoler R, Jefferson BK, Nicholson W, Altman J, Bateman C, Krishnaswamy A, Grantham JA, Zidar FJ, Marso SP, Tremmel JA, Grines C, Ahmed MI, Latib A, Tehrani B, Abbott JD, Batchelor W, Underwood P, Allocco DJ, Kirtane AJ. Paclitaxel-Coated Balloon vs Uncoated Balloon for Coronary In-Stent Restenosis: The AGENT IDE Randomized Clinical Trial. JAMA 2024; 331:1015-1024. [PMID: 38460161 PMCID: PMC10924708 DOI: 10.1001/jama.2024.1361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/30/2024] [Indexed: 03/11/2024]
Abstract
Importance Drug-coated balloons offer a potentially beneficial treatment strategy for the management of coronary in-stent restenosis. However, none have been previously evaluated or approved for use in coronary circulation in the United States. Objective To evaluate whether a paclitaxel-coated balloon is superior to an uncoated balloon in patients with in-stent restenosis undergoing percutaneous coronary intervention. Design, Setting, and Participants AGENT IDE, a multicenter randomized clinical trial, enrolled 600 patients with in-stent restenosis (lesion length <26 mm and reference vessel diameter >2.0 mm to ≤4.0 mm) at 40 centers across the United States between May 2021 and August 2022. One-year clinical follow-up was completed on October 2, 2023. Interventions Participants were randomized in a 2:1 allocation to undergo treatment with a paclitaxel-coated (n = 406) or an uncoated (n = 194) balloon. Main Outcomes and Measures The primary end point of 1-year target lesion failure-defined as the composite of ischemia-driven target lesion revascularization, target vessel-related myocardial infarction, or cardiac death-was tested for superiority. Results Among 600 randomized patients (mean age, 68 years; 157 females [26.2%]; 42 Black [7%], 35 Hispanic [6%] individuals), 574 (95.7%) completed 1-year follow-up. The primary end point at 1 year occurred in 17.9% in the paclitaxel-coated balloon group vs 28.6% in the uncoated balloon group, meeting the criteria for superiority (hazard ratio [HR], 0.59 [95% CI, 0.42-0.84]; 2-sided P = .003). Target lesion revascularization (13.0% vs 24.7%; HR, 0.50 [95% CI, 0.34-0.74]; P = .001) and target vessel-related myocardial infarction (5.8% vs 11.1%; HR, 0.51 [95% CI, 0.28-0.92]; P = .02) occurred less frequently among patients treated with paclitaxel-coated balloon. The rate of cardiac death was 2.9% vs 1.6% (HR, 1.75 [95% CI, 0.49-6.28]; P = .38) in the coated vs uncoated balloon groups, respectively. Conclusions and Relevance Among patients undergoing coronary angioplasty for in-stent restenosis, a paclitaxel-coated balloon was superior to an uncoated balloon with respect to the composite end point of target lesion failure. Paclitaxel-coated balloons are an effective treatment option for patients with coronary in-stent restenosis. Trial Registration ClinicalTrials.gov Identifier: NCT04647253.
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Affiliation(s)
- Robert W. Yeh
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Jeffrey Moses
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, New York
| | | | - Suhail Dohad
- Cedars Sinai Medical Center, Los Angeles, California
| | - Steven Rudick
- Lindner Center for Research and Education at Christ Hospital, Cincinnati, Ohio
| | - Robert Stoler
- Baylor Scott & White Heart and Vascular Hospital, Dallas, Texas
| | | | | | | | | | | | | | | | - Steven P. Marso
- Overland Park Regional Medical Center, Overland Park, Kansas
| | | | - Cindy Grines
- Northside Hospital Cardiovascular Institute, Atlanta, Georgia
| | | | - Azeem Latib
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Behnam Tehrani
- The Inova Schar Heart and Vascular Institute, Falls Church, Virginia
| | - J. Dawn Abbott
- Lifespan Cardiovascular Institute, Rhode Island Hospital, Providence
| | - Wayne Batchelor
- The Inova Schar Heart and Vascular Institute, Falls Church, Virginia
| | | | | | - Ajay J. Kirtane
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, New York
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Asnani A, Wadhera RK, Yeh RW. Assessing STEMI Outcomes in Patients With Cancer: A Call for Integrated Cardiovascular and Cancer Phenotyping. JACC CardioOncol 2024; 6:130-132. [PMID: 38510284 PMCID: PMC10950433 DOI: 10.1016/j.jaccao.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024] Open
Affiliation(s)
- Aarti Asnani
- Cardio-Oncology Section, CardioVascular Institute, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Rishi K. Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Ferro EG, Alkhouli M, Nair DG, Kapadia SR, Hsu JC, Gibson DN, Freeman JV, Price MJ, Roy K, Allocco DJ, Yeh RW, Piccini JP. Intracardiac vs Transesophageal Echocardiography for Left Atrial Appendage Occlusion With Watchman FLX in the U.S. JACC Clin Electrophysiol 2023; 9:2587-2599. [PMID: 37831030 DOI: 10.1016/j.jacep.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/25/2023] [Accepted: 08/03/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Intraprocedural imaging is critical for device delivery in transcatheter left atrial appendage occlusion (LAAO). Although pivotal trials of LAAO devices were conducted using transesophageal echocardiography (TEE), intracardiac echocardiography (ICE) is an emerging imaging modality. OBJECTIVES This study compared outcomes after ICE- and TEE-guided Watchman FLX implantation in the SURPASS (SURveillance Post Approval AnalySiS Plan) nationwide LAAO registry. METHODS Baseline characteristics were compared using chi-square and t-tests. Outcomes were reported in unadjusted and adjusted comparisons via propensity weighting. RESULTS Between August 2020 and September 2021, LAAO was attempted in 39,759 patients at 698 sites, including 2,272 cases (5.7%) with ICE and 31,835 (80.0%) with TEE. ICE and TEE patients had similar baseline characteristics and mean procedural times (ICE 82 minutes vs TEE 78 minutes). ICE patients were less likely to receive general anesthesia (54% vs 98%, P < 0.01). Successful device implantation (98.3% vs 97.6%) and complete seal rates at 45 days were similar (n = 25,280; 83% vs 82%). Most adverse event rates were similar; unadjusted mortality rates at 45 days were 1.1% for ICE vs 0.8% for TEE (P = 0.14), and 1.0% vs 0.7% (P = 0.27) in adjusted analyses. Even after adjustment, pericardial effusion rates requiring intervention were significantly higher with ICE at 45 days (1.0% vs 0.5%; P = 0.02). This rate decreased as operators performed more ICE-guided procedures, although 82% of operators had performed <10 ICE-guided procedures overall. CONCLUSIONS In the largest comparison to date, ICE use was infrequent. ICE and TEE both achieved high rates of complete LAAO. ICE was associated with significantly higher rates of pericardial effusion requiring intervention.
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Affiliation(s)
- Enrico G Ferro
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Devi G Nair
- St Bernard's Heart and Vascular Center, Jonesboro, Arkansas, USA
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jonathan C Hsu
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Diego, California, USA
| | - Douglas N Gibson
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California, USA
| | - James V Freeman
- Section of Cardiovascular Medicine, Yale University School of Medicine, and Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California, USA
| | - Kristine Roy
- Boston Scientific Corporation, Marlborough, Massachusetts, USA
| | | | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Chung M, Almarzooq ZI, Xu J, Song Y, Baron SJ, Kazi DS, Yeh RW. Days at Home After Transcatheter Versus Surgical Aortic Valve Replacement in Low-Risk Patients. Circ Cardiovasc Qual Outcomes 2023; 16:e010034. [PMID: 38084613 PMCID: PMC10752241 DOI: 10.1161/circoutcomes.123.010034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 09/23/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Days at home (DAH) represents an important patient-oriented outcome that quantifies time spent at home after a medical event; however, this outcome has not been fully evaluated for low-surgical-risk patients undergoing transcatheter aortic valve replacement (TAVR). We sought to compare 1- and 2-year DAH (DAH365 and DAH730) among low-risk patients participating in a randomized trial of TAVR with a self-expanding bioprosthesis versus surgical aortic valve replacement (SAVR). METHODS Using Medicare-linked data from the Evolut Low Risk trial, we identified 619 patients: 606 (322 TAVR/284 SAVR) and 593 (312 TAVR/281 SAVR) were analyzed at 1 and 2 years, respectively. DAH was calculated as days alive and spent outside a hospital, inpatient rehabilitation, skilled nursing facility, long-term acute care hospital, emergency department, or observation stay. Mean DAH was compared using the t test. RESULTS The mean (SD) age and female sex were 74.7 (5.1) and 74.3 (4.9) years and 34.6% (115/332) and 30.3% (87/287) in TAVR and SAVR, respectively. Postprocedural discharge to rehabilitation occurred in ≤3.0% (≤10/332) in TAVR and 4.5% (13/287) in SAVR. The mean DAH365 was comparable in TAVR versus SAVR (352.2±45.4 versus 347.8±39.0; difference in days, 4.5 [95% CI, 2.3-11.2]; P=0.20). DAH730 was also comparable in TAVR versus SAVR (701.6±106.0 versus 699.6±94.5; difference in days, 2.0 [-14.1 to 18.2]; P=0.81). Secondary outcomes DAH30 and DAH90 were higher in TAVR (DAH30, 26.0±3.6 versus 20.7±6.4; difference in days, 5.3 [4.5-6.2]; P<0.001; DAH90, 85.1±8.3 versus 78.7±13.6; difference in days, 6.4 [4.6-8.2]; P<0.001). CONCLUSIONS In the Evolut Low Risk trial linked to Medicare, low-risk patients undergoing TAVR spend a similar number of days at home at 1 and 2 years compared with SAVR. Days spent at home at 30 and 90 days were higher in TAVR. In contrast to higher-risk patients studied in prior work, there is no clear advantage of TAVR versus SAVR for DAH in the first 2 years after AVR in low-surgical-risk patients.
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Affiliation(s)
- Mabel Chung
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
- Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Zaid I. Almarzooq
- Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Jiaman Xu
- Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Yang Song
- Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Suzanne J. Baron
- Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Department of Cardiology, Lahey Hospital & Medical Center, Burlington, MA
- Baim Institute for Clinical Research, Boston, MA
| | - Dhruv S. Kazi
- Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Robert W. Yeh
- Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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Liu M, Aggarwal R, Zheng Z, Yeh RW, Kazi DS, Joynt Maddox KE, Wadhera RK. Cardiovascular Health of Middle-Aged U.S. Adults by Income Level, 1999 to March 2020 : A Serial Cross-Sectional Study. Ann Intern Med 2023; 176:1595-1605. [PMID: 37983825 DOI: 10.7326/m23-2109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Although cardiovascular mortality has increased among middle-aged U.S. adults since 2011, how the burden of cardiovascular risk factors has changed for this population by income level over the past 2 decades is unknown. OBJECTIVE To evaluate trends in the prevalence, treatment, and control of cardiovascular risk factors among low-income and higher-income middle-aged adults and how social determinants contribute to recent associations between income and cardiovascular health. DESIGN Serial cross-sectional study. SETTING NHANES (National Health and Nutrition Examination Survey), 1999 to March 2020. PARTICIPANTS Middle-aged adults (aged 40 to 64 years). MEASUREMENTS Age-standardized prevalence of hypertension, diabetes, hyperlipidemia, obesity, and cigarette use; treatment rates for hypertension, diabetes, and hyperlipidemia; and rates of blood pressure, glycemic, and cholesterol control. RESULTS The study population included 20 761 middle-aged adults. The prevalence of hypertension, diabetes, and cigarette use was consistently higher among low-income adults between 1999 and March 2020. Low-income adults had an increase in hypertension over the study period (37.2% [95% CI, 33.5% to 40.9%] to 44.7% [CI, 39.8% to 49.5%]) but no changes in diabetes or obesity. In contrast, higher-income adults did not have a change in hypertension but had increases in diabetes (7.8% [CI, 5.0% to 10.6%] to 14.9% [CI, 12.4% to 17.3%]) and obesity (33.0% [CI, 26.7% to 39.4%] to 44.0% [CI, 40.2% to 47.7%]). Cigarette use was high and stagnant among low-income adults (33.2% [CI, 28.4% to 38.0%] to 33.9% [CI, 29.6% to 38.3%]) but decreased among their higher-income counterparts (18.6% [CI, 13.5% to 23.7%] to 11.5% [CI, 8.7% to 14.3%]). Treatment and control rates for hypertension were unchanged in both groups (>80%), whereas diabetes treatment rates improved only among the higher-income group (58.4% [CI, 44.4% to 72.5%] to 77.4% [CI, 67.6% to 87.1%]). Income-based disparities in hypertension, diabetes, and cigarette use persisted in more recent years even after adjustment for insurance coverage, health care access, and food insecurity. LIMITATION Sample size limitations could preclude detection of small changes in treatment and control rates. CONCLUSION Over 2 decades in the United States, hypertension increased in low-income middle-aged adults, whereas diabetes and obesity increased in their higher-income counterparts. Income-based disparities in hypertension, diabetes, and smoking persisted even after adjustment for other social determinants of health. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Michael Liu
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts (M.L., R.W.Y., D.S.K., R.K.W.)
| | - Rahul Aggarwal
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, and Heart and Vascular Center, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts (R.A.)
| | - Zhaonian Zheng
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts (Z.Z.)
| | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts (M.L., R.W.Y., D.S.K., R.K.W.)
| | - Dhruv S Kazi
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts (M.L., R.W.Y., D.S.K., R.K.W.)
| | - Karen E Joynt Maddox
- Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri (K.E.J.M.)
| | - Rishi K Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts (M.L., R.W.Y., D.S.K., R.K.W.)
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11
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Kadakia KT, Kramer DB, Yeh RW. Coverage for Emerging Technologies - Bridging Regulatory Approval and Patient Access. N Engl J Med 2023; 389:2021-2024. [PMID: 38009607 DOI: 10.1056/nejmp2308736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Affiliation(s)
- Kushal T Kadakia
- From Harvard Medical School (K.T.K., D.B.K., R.W.Y.) and the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center (D.B.K., R.W.Y.) - both in Boston
| | - Daniel B Kramer
- From Harvard Medical School (K.T.K., D.B.K., R.W.Y.) and the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center (D.B.K., R.W.Y.) - both in Boston
| | - Robert W Yeh
- From Harvard Medical School (K.T.K., D.B.K., R.W.Y.) and the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center (D.B.K., R.W.Y.) - both in Boston
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12
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Coylewright M, Holmes DR, Kapadia SR, Hsu JC, Gibson DN, Freeman JV, Yeh RW, Piccini JP, Price MJ, Allocco DJ, Nair DG. DAPT Is Comparable to OAC Following LAAC With WATCHMAN FLX: A National Registry Analysis. JACC Cardiovasc Interv 2023; 16:2708-2718. [PMID: 37943200 DOI: 10.1016/j.jcin.2023.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 07/18/2023] [Accepted: 08/08/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Left atrial appendage occlusion (LAAO) is an approved alternative for stroke prevention in atrial fibrillation for patients with an "appropriate rationale" to avoid long-term oral anticoagulation (OAC). Many patients undergoing LAAO are at high risk of bleeding. OBJECTIVES This study sought to investigate whether dual antiplatelet therapy (DAPT) is a safe alternative to OAC (direct oral anticoagulation [DOAC] or warfarin) with aspirin after LAAO. METHODS Using National Cardiovascular Data Registry LAAO registry data, patients undergoing Watchman FLX (Boston Scientific) implantation (August 5, 2020-September 30, 2021) were included in 1:1 propensity-matched analyses comparing discharge medication regimens (DAPT, DOAC/aspirin, or warfarin/aspirin). A composite endpoint (death, stroke, major bleeding, and systemic embolism), its components, and device-related thrombus between discharge and 45 days were evaluated. RESULTS In 49,968 patients implanted with the Watchman FLX during the study period, the mean age was 77 years, and 40% were women. Postimplant DOAC/aspirin was prescribed in 24,497 patients, warfarin/aspirin in 3,913, and DAPT in 4,155. DAPT patients had more comorbid conditions than patients receiving OAC/aspirin. After propensity score matching, the 45-day composite endpoint rates were similar among the groups (DAPT = 3.44% vs DOAC/aspirin: 4.06%; P = 0.13 and DAPT = 3.23% vs warfarin/aspirin: 3.08%; P = 0.75). Death, stroke, and device-related thrombus were also similar; major bleeding was slightly increased in DOAC/aspirin patients (DAPT = 2.48% vs DOAC/aspirin = 3.25%; P = 0.04 and DAPT = 2.25% vs warfarin/aspirin = 2.22%; P = 0.93). CONCLUSIONS In a large registry, DAPT had a similar safety profile compared with current Food and Drug Administration-approved postimplant drug regimens of OAC with aspirin following LAAO with the Watchman FLX. Shared decision making for nonpharmacologic stroke prevention should include a discussion of postprocedure medical therapy options.
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Affiliation(s)
- Megan Coylewright
- University of Tennessee Health Science Center College of Medicine-Chattanooga and Erlanger Health System, Chattanooga, Tennessee, USA.
| | - David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jonathan C Hsu
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Douglas N Gibson
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California, USA
| | - James V Freeman
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jonathan P Piccini
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California, USA
| | | | - Devi G Nair
- Department of Cardiac Electrophysiology, St. Bernard's Heart and Vascular Center, Jonesboro, Arkansas, USA
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13
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Mihatov N, Kirtane AJ, Stoler R, Feldman R, Neumann FJ, Boutis L, Tahirkheli N, Kereiakes DJ, Toelg R, Othman I, Stein B, Allocco D, Windecker S, Yeh RW. Bleeding and Ischemic Risk Prediction in Patients With High Bleeding Risk (an EVOLVE Short DAPT Analysis). Am J Cardiol 2023; 207:370-379. [PMID: 37778226 DOI: 10.1016/j.amjcard.2023.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 06/03/2023] [Accepted: 06/06/2023] [Indexed: 10/03/2023]
Abstract
The EVOLVE Short DAPT study demonstrated the safety of truncated dual antiplatelet therapy (DAPT) in patients with a high bleeding risk (HBR) treated with SYNERGY stent(s) (Boston Scientific Company, Marlborough, Massachusetts). In this population, bleeding and ischemic risk prediction may further inform DAPT decisions. This post hoc analysis of the EVOLVE Short DAPT study identified predictors of ischemic and bleeding events up to 15 months using Cox proportional hazard models. The predicted probabilities of bleeding were calculated using the Breslow method. Of 2,009 enrolled patients, 96.9% of the patients met at least 1 HBR criteria. At 15 months, the cumulative incidences of bleeding and ischemic events were 6.3% and 6.0%, respectively. The risk of bleeding was increased in patients who received oral anticoagulants (hazard ratio [HR] 2.24, 95% confidence interval [CI] 1.50 to 3.36, p <0.001) or had peripheral vascular disease (HR 1.61, 95% CI 1.01 to 2.56, p = 0.045). The risk of ischemic events was increased in patients with diabetes (HR 1.86, 95% CI 1.24 to 2.78, p <0.01) or congestive heart failure (HR 2.06, 95% CI 1.39 to 3.04, p <0.001). Renal insufficiency/failure was associated with both endpoints. There was a strong positive correlation between the predicted probability of ischemic and bleeding events (R = 0.77, p <0.001). In 617 patients with a predicted bleeding risk <4%, ischemic events predominated, and the ischemic and bleeding rates were higher in patients with a predicted bleeding risk ≥4%. Within an HBR cohort, specific characteristics identify patients at a higher risk for ischemic and separately, bleeding events. Increased bleeding risk is tied to increased ischemic risk. In conclusion, standardized risk models are needed to inform DAPT decisions in patients with a higher risk. Clinical Trial Registration: NCT02605447.
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Affiliation(s)
- Nino Mihatov
- New York-Presbyterian Hospital - Brooklyn Methodist & Weill Cornell Medical College, New York, New York; Richard and Susan Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Ajay J Kirtane
- Columbia University Irving Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York
| | - Robert Stoler
- Baylor Scott & White Heart and Vascular Hospital, Dallas, Texas
| | - Robert Feldman
- MediQuest Research at AdventHealth Ocala, Ocala, Florida
| | | | - Loukas Boutis
- North Shore University Hospital, Manhasset, New York
| | | | - Dean J Kereiakes
- Lindner Center for Research and Education at Christ Hospital, Cincinnati, Ohio
| | - Ralph Toelg
- Heart Center Segeberger Kliniken, Bad Segeberg, Germany
| | - Islam Othman
- Duke University Health System, Durham, North Carolina
| | - Bernardo Stein
- Morton Plant Mease Healthcare System, Clearwater, Florida
| | | | - Stephan Windecker
- Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Robert W Yeh
- Beth Israel Deaconess Medical Center, Boston, Massachusetts; Richard and Susan Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.
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14
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Hirai T, Grantham JA, Kandzari DE, Ballard W, Brown WM, Allen KB, Kirtane AJ, Argenziano M, Yeh RW, Khabbaz K, Lombardi W, Lasala J, Kachroo P, Karmpaliotis D, Gosch KL, Salisbury AC. Percutaneous ventricular assist device for higher-risk percutaneous coronary intervention in surgically ineligible patients: Indications and outcomes from the OPTIMUM study. Catheter Cardiovasc Interv 2023; 102:814-822. [PMID: 37676058 DOI: 10.1002/ccd.30834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 07/25/2023] [Accepted: 08/31/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Indications and outcomes for percutaneous ventricular assist device (pVAD) use in surgically ineligible patients undergoing percutaneous coronary intervention (PCI) remain poorly characterized. AIMS We sought to describe the use and timing of pVAD and outcome in surgically ineligible patients. METHODS Among 726 patients enrolled in the prospective OPTIMUM study, clinical and health status outcomes were assessed in patients who underwent pVAD-assisted PCI and those without pVAD. RESULTS Compared with patients not receiving pVAD (N = 579), those treated with pVAD (N = 142) more likely had heart failure, lower left ventricular ejection fraction (30.7 ± 13.6 vs. 45.9 ± 15.5, p < 0.01), and higher STS 30-day predicted mortality (4.2 [2.1-8.0] vs. 3.3 [1.7-6.6], p = 0.01) and SYNTAX scores (36.1 ± 12.2, vs. 31.5 ± 12.1, p < 0.01). While the pVAD group had higher in-hospital (5.6% vs. 2.2%, p = 0.046), 30-day (9.0% vs. 4.0%, p = 0.01) and 6-month (20.4% vs. 11.7%, p < 0.01) mortality compared to patients without pVAD, this difference appeared to be largely driven by significantly higher mortality among the 20 (14%) patients with unplanned pVAD use (30% in-hospital mortality with unplanned PVAD vs. 1.6% with planned, p < 0.01; 30-day mortality, 38.1% vs. 4.5%, p < 0.01). The degree of 6-month health status improvement among survivors was similar between groups. CONCLUSION Surgically ineligible patients with pVAD-assisted PCI had more complex baseline characteristics compared with those without pVAD. Higher mortality in the pVAD group appeared to be driven by very poor outcomes by patients with unplanned, rescue pVAD.
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Affiliation(s)
- Taishi Hirai
- Division of Cardiology, University of Missouri, Columbia, Missouri, USA
| | - J Aaron Grantham
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
- Divison of Cardiology, University of Missouri Kansas City, Kansas City, Missouri, USA
| | | | | | | | - Keith B Allen
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
- Divison of Cardiology, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Ajay J Kirtane
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York, USA
| | - Michael Argenziano
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York, USA
| | - Robert W Yeh
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kamal Khabbaz
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - William Lombardi
- Divsion of Cardiology, University of Washington, Seattle, Washington, USA
| | - John Lasala
- Division of Cardiology, Washington University, St. Louis, Missouri, USA
| | - Puja Kachroo
- Division of Cardiology, Washington University, St. Louis, Missouri, USA
| | | | - Kensey L Gosch
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - Adam C Salisbury
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
- Divison of Cardiology, University of Missouri Kansas City, Kansas City, Missouri, USA
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Law AC, Bosch NA, Song Y, Tale A, Yeh RW, Kahn JM, Stevens JP, Walkey AJ. Patient Outcomes After Long-Term Acute Care Hospital Closures. JAMA Netw Open 2023; 6:e2344377. [PMID: 37988077 PMCID: PMC10663966 DOI: 10.1001/jamanetworkopen.2023.44377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/12/2023] [Indexed: 11/22/2023] Open
Abstract
Importance Long-term acute care hospitals (LTCHs) are common sites of postacute care for patients recovering from severe respiratory failure requiring mechanical ventilation (MV). However, federal payment reform led to the closure of many LTCHs in the US, and it is unclear how closure of LTCHs may have affected upstream care patterns at short-stay hospitals and overall patient outcomes. Objective To estimate the association between LTCH closures and short-stay hospital care patterns and patient outcomes. Design, Setting, and Participants This retrospective, national, matched cohort study used difference-in-differences analysis to compare outcomes at short-stay hospitals reliant on LTCHs that closed during 2012 to 2018 with outcomes at control hospitals. Data were obtained from the Medicare Provider Analysis and Review File, 2011 to 2019. Participants included Medicare fee-for-service beneficiaries aged 66 years and older receiving MV for at least 96 hours in an intensive care unit (ie, patients at-risk for prolonged MV) and the subgroup also receiving a tracheostomy (ie, receiving prolonged MV). Data were analyzed from October 2022 to June 2023. Exposure Admission to closure-affected hospitals, defined as those discharging at least 60% of patients receiving a tracheostomy to LTCHs that subsequently closed, vs control hospitals. Main Outcomes and Measures Upstream hospital care pattern outcomes were short-stay hospital do-not-resuscitate orders, palliative care delivery, tracheostomy placement, and discharge disposition. Patient outcomes included hospital length of stay, days alive and institution free within 90 days, spending per days alive within 90 days, and 90-day mortality. Results Between 2011 and 2019, 99 454 patients receiving MV for at least 96 hours at 1261 hospitals were discharged to 459 LTCHs; 84 LTCHs closed. Difference-in-differences analysis included 8404 patients (mean age, 76.2 [7.2] years; 4419 [52.6%] men) admitted to 45 closure-affected hospitals and 45 matched-control hospitals. LTCH closure was associated with decreased LTCH transfer rates (difference, -5.1 [95% CI -8.2 to -2.0] percentage points) and decreased spending-per-days-alive (difference, -$8701.58 [95% CI, -$13 323.56 to -$4079.60]). In the subgroup of patients receiving a tracheostomy, there was additionally an increase in do-not-resuscitate rates (difference, 10.3 [95% CI, 4.2 to 16.3] percentage points) and transfer to skilled nursing facilities (difference, 10.0 [95% CI, 4.2 to 15.8] percentage points). There was no significant association of closure with 90-day mortality. Conclusions and Relevance In this cohort study, LTCH closure was associated with changes in discharge patterns in patients receiving mechanical ventilation for at least 96 hours and advanced directive decisions in the subgroup receiving a tracheostomy, without change in mortality. Further studies are needed to understand how LTCH availability may be associated with other important outcomes, including functional outcomes and patient and family satisfaction.
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Affiliation(s)
- Anica C. Law
- The Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Richard A and Susan F Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Nicholas A. Bosch
- The Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Yang Song
- Richard A and Susan F Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Archana Tale
- Richard A and Susan F Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Robert W. Yeh
- Richard A and Susan F Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jeremy M. Kahn
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jennifer P. Stevens
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Allan J. Walkey
- The Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Evans Center for Implementation and Improvement Sciences, Boston University School of Medicine, Boston, Massachusetts
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts
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Fazel R, Yeh RW, Cohen DJ, Rao SV, Li S, Song Y, Secemsky EA. Intravascular imaging during percutaneous coronary intervention: temporal trends and clinical outcomes in the USA. Eur Heart J 2023; 44:3845-3855. [PMID: 37464975 PMCID: PMC10567999 DOI: 10.1093/eurheartj/ehad430] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 05/22/2023] [Accepted: 06/22/2023] [Indexed: 07/20/2023] Open
Abstract
AIMS Prior trials have demonstrated that intravascular imaging (IVI)-guided percutaneous coronary intervention (PCI) results in less frequent target lesion revascularization and major adverse cardiovascular events (MACEs) compared with standard angiographic guidance. The uptake and associated outcomes of IVI-guided PCI in contemporary clinical practice in the USA remain unclear. Accordingly, temporal trends and comparative outcomes of IVI-guided PCI relative to PCI with angiographic guidance alone were examined in a broad, unselected population of Medicare beneficiaries. METHODS AND RESULTS Retrospective cohort study of Medicare beneficiary data from 1 January 2013, through 31 December 2019 to evaluate temporal trends and comparative outcomes of IVI-guided PCI as compared with PCI with angiography guidance alone in both the inpatient and outpatient settings. The primary outcomes were 1 year mortality and MACE, defined as the composite of death, myocardial infarction (MI), repeat PCI, or coronary artery bypass graft surgery. Secondary outcomes were MI or repeat PCI at 1 year. Multivariable Cox regression was used to estimate the adjusted association between IVI guidance and outcomes. Falsification endpoints (hospitalized pneumonia and hip fracture) were used to assess for potential unmeasured confounding. The study population included 1 189 470 patients undergoing PCI (38.0% female, 89.8% White, 65.1% with MI). Overall, IVI was used in 10.5% of the PCIs, increasing from 9.5% in 2013% to 15.4% in 2019. Operator IVI use was variable, with the median operator use of IVI 3.92% (interquartile range 0.36%-12.82%). IVI use during PCI was associated with lower adjusted rates of 1 year mortality [adjusted hazard ratio (aHR) 0.96, 95% confidence interval (CI) 0.94-0.98], MI (aHR 0.97, 95% CI 0.95-0.99), repeat PCI (aHR 0.74, 95% CI 0.73-0.75), and MACE (aHR 0.85, 95% CI 0.84-0.86). There was no association with the falsification endpoint of hospitalized pneumonia (aHR 1.02, 95% CI 0.99-1.04) or hip fracture (aHR 1.02, 95% CI 0.94-1.10). CONCLUSION Among Medicare beneficiaries undergoing PCI, use of IVI has increased over the previous decade but remains relatively infrequent. IVI-guided PCI was associated with lower risk-adjusted mortality, acute MI, repeat PCI, and MACE.
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Affiliation(s)
- Reza Fazel
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Robert W Yeh
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - David J Cohen
- Cardiovascular Research Foundation, New York, NY, USA
- St. Francis Hospital and Heart Center, Roslyn, NYUSA
| | - Sunil V Rao
- Division of Cardiology, Department of Medicine, New York University Langone Health System, New York, NY, USA
| | - Siling Li
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Yang Song
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Eric A Secemsky
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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17
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Udelson JE, Kelsey MD, Nanna MG, Fordyce CB, Yow E, Clare RM, Mark DB, Patel MR, Rogers C, Curzen N, Pontone G, Maurovich-Horvat P, De Bruyne B, Greenwood JP, Marinescu V, Leipsic J, Stone GW, Ben-Yehuda O, Berry C, Hogan SE, Redfors B, Ali ZA, Byrne RA, Kramer CM, Yeh RW, Martinez B, Mullen S, Huey W, Anstrom KJ, Al-Khalidi HR, Chiswell K, Vemulapalli S, Douglas PS. Deferred Testing in Stable Outpatients With Suspected Coronary Artery Disease: A Prespecified Secondary Analysis of the PRECISE Randomized Clinical Trial. JAMA Cardiol 2023; 8:915-924. [PMID: 37610768 PMCID: PMC10448368 DOI: 10.1001/jamacardio.2023.2614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 06/26/2023] [Indexed: 08/24/2023]
Abstract
Importance Guidelines recommend deferral of testing for symptomatic people with suspected coronary artery disease (CAD) and low pretest probability. To our knowledge, no randomized trial has prospectively evaluated such a strategy. Objective To assess process of care and health outcomes in people identified as minimal risk for CAD when testing is deferred. Design, Setting, and Participants This randomized, pragmatic effectiveness trial included prespecified subgroup analysis of the PRECISE trial at 65 North American and European sites. Participants identified as minimal risk by the validated PROMISE minimal risk score (PMRS) were included. Intervention Randomization to a precision strategy using the PMRS to assign those with minimal risk to deferred testing and others to coronary computed tomography angiography with selective computed tomography-derived fractional flow reserve, or to usual testing (stress testing or catheterization with PMRS masked). Randomization was stratified by PMRS risk. Main Outcome Composite of all-cause death, nonfatal myocardial infarction (MI), or catheterization without obstructive CAD through 12 months. Results Among 2103 participants, 422 were identified as minimal risk (20%) and randomized to deferred testing (n = 214) or usual testing (n = 208). Mean age (SD) was 46 (8.6) years; 304 were women (72%). During follow-up, 138 of those randomized to deferred testing never had testing (64%), whereas 76 had a downstream test (36%) (at median [IQR] 48 [15-78] days) for worsening (30%), uncontrolled (10%), or new symptoms (6%), or changing clinician preference (19%) or participant preference (10%). Results were normal for 96% of these tests. The primary end point occurred in 2 deferred testing (0.9%) and 13 usual testing participants (6.3%) (hazard ratio, 0.15; 95% CI, 0.03-0.66; P = .01). No death or MI was observed in the deferred testing participants, while 1 noncardiovascular death and 1 MI occurred in the usual testing group. Two participants (0.9%) had catheterizations without obstructive CAD in the deferred testing group and 12 (5.8%) with usual testing (P = .02). At baseline, 70% of participants had frequent angina and there was similar reduction of frequent angina to less than 20% at 12 months in both groups. Conclusion and Relevance In symptomatic participants with suspected CAD, identification of minimal risk by the PMRS guided a strategy of initially deferred testing. The strategy was safe with no observed adverse outcome events, fewer catheterizations without obstructive CAD, and similar symptom relief compared with usual testing. Trial Registration ClinicalTrials.gov Identifier: NCT03702244.
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Affiliation(s)
- James E. Udelson
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Michelle D. Kelsey
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Michael G. Nanna
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Christopher B. Fordyce
- Division of Cardiology, Department of Medicine, and Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric Yow
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Robert M. Clare
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Daniel B. Mark
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Manesh R. Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | | | - Nick Curzen
- Faculty of Medicine, University of Southampton and Cardiothoracic Unit, University Hospital Southampton, Southampton, United Kingdom
| | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino Instituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Pál Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, and Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, Onze Lieve Vrouwziekenhuis-Clinic, Aalst, Belgium
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - John P. Greenwood
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, and Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Victor Marinescu
- Midwest Cardiovascular Institute, Chicago Medical School, Edward-Elmhurst Health, Naperville, Illinois
- Edward-Elmhurst Health, Naperville, Illinois
| | - Jonathon Leipsic
- Departments of Radiology and Medicine (Cardiology), University of British Columbia, Vancouver, British Columbia, Canada
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, United Kingdom
| | - Shea E. Hogan
- CPC Clinical Research, and University of Colorado School of Medicine, Aurora
| | - Bjorn Redfors
- Cardiovascular Research Foundation, New York, New York
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ziad A. Ali
- St Francis Hospital & Heart Center, Roslyn, New York
| | - Robert A. Byrne
- Department of Cardiology and Cardiovascular Research Institute Dublin, Mater Private Network, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | | | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Beth Martinez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | | | | | - Hussein R. Al-Khalidi
- Department of Biostatistics and Bioinformatics, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Pamela S. Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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18
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Douglas PS, Nanna MG, Kelsey MD, Yow E, Mark DB, Patel MR, Rogers C, Udelson JE, Fordyce CB, Curzen N, Pontone G, Maurovich-Horvat P, De Bruyne B, Greenwood JP, Marinescu V, Leipsic J, Stone GW, Ben-Yehuda O, Berry C, Hogan SE, Redfors B, Ali ZA, Byrne RA, Kramer CM, Yeh RW, Martinez B, Mullen S, Huey W, Anstrom KJ, Al-Khalidi HR, Vemulapalli S. Comparison of an Initial Risk-Based Testing Strategy vs Usual Testing in Stable Symptomatic Patients With Suspected Coronary Artery Disease: The PRECISE Randomized Clinical Trial. JAMA Cardiol 2023; 8:904-914. [PMID: 37610731 PMCID: PMC10448364 DOI: 10.1001/jamacardio.2023.2595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/26/2023] [Indexed: 08/24/2023]
Abstract
Importance Trials showing equivalent or better outcomes with initial evaluation using coronary computed tomography angiography (cCTA) compared with stress testing in patients with stable chest pain have informed guidelines but raise questions about overtesting and excess catheterization. Objective To test a modified initial cCTA strategy designed to improve clinical efficiency vs usual testing (UT). Design, Setting, and Participants This was a pragmatic randomized clinical trial enrolling participants from December 3, 2018, to May 18, 2021, with a median of 11.8 months of follow-up. Patients from 65 North American and European sites with stable symptoms of suspected coronary artery disease (CAD) and no prior testing were randomly assigned 1:1 to precision strategy (PS) or UT. Interventions PS incorporated the Prospective Multicenter Imaging Study for the Evaluation of Chest Pain (PROMISE) minimal risk score to quantitatively select minimal-risk participants for deferred testing, assigning all others to cCTA with selective CT-derived fractional flow reserve (FFR-CT). UT included site-selected stress testing or catheterization. Site clinicians determined subsequent care. Main Outcomes and Measures Outcomes were clinical efficiency (invasive catheterization without obstructive CAD) and safety (death or nonfatal myocardial infarction [MI]) combined into a composite primary end point. Secondary end points included safety components of the primary outcome and medication use. Results A total of 2103 participants (mean [SD] age, 58.4 [11.5] years; 1056 male [50.2%]) were included in the study, and 422 [20.1%] were classified as minimal risk. The primary end point occurred in 44 of 1057 participants (4.2%) in the PS group and in 118 of 1046 participants (11.3%) in the UT group (hazard ratio [HR], 0.35; 95% CI, 0.25-0.50). Clinical efficiency was higher with PS, with lower rates of catheterization without obstructive disease (27 [2.6%]) vs UT participants (107 [10.2%]; HR, 0.24; 95% CI, 0.16-0.36). The safety composite of death/MI was similar (HR, 1.52; 95% CI, 0.73-3.15). Death occurred in 5 individuals (0.5%) in the PS group vs 7 (0.7%) in the UT group (HR, 0.71; 95% CI, 0.23-2.23), and nonfatal MI occurred in 13 individuals (1.2%) in the PS group vs 5 (0.5%) in the UT group (HR, 2.65; 95% CI, 0.96-7.36). Use of lipid-lowering (450 of 900 [50.0%] vs 365 of 873 [41.8%]) and antiplatelet (321 of 900 [35.7%] vs 237 of 873 [27.1%]) medications at 1 year was higher in the PS group compared with the UT group (both P < .001). Conclusions and Relevance An initial diagnostic approach to stable chest pain starting with quantitative risk stratification and deferred testing for minimal-risk patients and cCTA with selective FFR-CT in all others increased clinical efficiency relative to UT at 1 year. Additional randomized clinical trials are needed to verify these findings, including safety. Trial Registration ClinicalTrials.gov Identifier: NCT03702244.
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Affiliation(s)
- Pamela S. Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Michael G. Nanna
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Michelle D. Kelsey
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Eric Yow
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Daniel B. Mark
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Manesh R. Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | | | - James E. Udelson
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Christopher B. Fordyce
- Division of Cardiology, Department of Medicine, Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nick Curzen
- Faculty of Medicine, University of Southampton, Cardiothoracic Unit, University Hospital Southampton, Southampton, United Kingdom
| | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino Instituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Pál Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Bernard De Bruyne
- Cardiovascular Center Aalst, Onze Lieve Vrouwziekenhuis Clinic, Aalst, Belgium
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - John P. Greenwood
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds Teaching Hospitals NHS Trust, United Kingdom
| | - Victor Marinescu
- Midwest Cardiovascular Institute, Chicago Medical School, Edward-Elmhurst Health, Naperville, Illinois
| | - Jonathon Leipsic
- Departments of Radiology and Medicine (Cardiology), University of British Columbia, Vancouver, British Columbia, Canada
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, United Kingdom
| | - Shea E. Hogan
- CPC Clinical Research, University of Colorado School of Medicine, Aurora
| | - Bjorn Redfors
- Cardiovascular Research Foundation, New York, New York
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ziad A. Ali
- St Francis Hospital & Heart Center, Roslyn, New York
| | - Robert A. Byrne
- Department of Cardiology, Cardiovascular Research Institute Dublin, Mater Private Network, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | | | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Beth Martinez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | | | | | - Hussein R. Al-Khalidi
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
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19
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Aggarwal R, Ruff CT, Virdone S, Perreault S, Kakkar AK, Palazzolo MG, Dorais M, Kayani G, Singer DE, Secemsky E, Piccini J, Tahir UA, Shen C, Yeh RW. Development and Validation of the DOAC Score: A Novel Bleeding Risk Prediction Tool for Patients With Atrial Fibrillation on Direct-Acting Oral Anticoagulants. Circulation 2023; 148:936-946. [PMID: 37621213 PMCID: PMC10529708 DOI: 10.1161/circulationaha.123.064556] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/23/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Current clinical decision tools for assessing bleeding risk in individuals with atrial fibrillation (AF) have limited performance and were developed for individuals treated with warfarin. This study develops and validates a clinical risk score to personalize estimates of bleeding risk for individuals with atrial fibrillation taking direct-acting oral anticoagulants (DOACs). METHODS Among individuals taking dabigatran 150 mg twice per day from 44 countries and 951 centers in this secondary analysis of the RE-LY trial (Randomized Evaluation of Long-Term Anticoagulation Therapy), a risk score was developed to determine the comparative risk for bleeding on the basis of covariates derived in a Cox proportional hazards model. The risk prediction model was internally validated with bootstrapping. The model was then further developed in the GARFIELD-AF registry (Global Anticoagulant Registry in the Field-Atrial Fibrillation), with individuals taking dabigatran, edoxaban, rivaroxaban, and apixaban. To determine generalizability in external cohorts and among individuals on different DOACs, the risk prediction model was validated in the COMBINE-AF (A Collaboration Between Multiple Institutions to Better Investigate Non-Vitamin K Antagonist Oral Anticoagulant Use in Atrial Fibrillation) pooled clinical trial cohort and the Quebec Régie de l'Assurance Maladie du Québec and Med-Echo Administrative Databases (RAMQ) administrative database. The primary outcome was major bleeding. The risk score, termed the DOAC Score, was compared with the HAS-BLED score. RESULTS Of the 5684 patients in RE-LY, 386 (6.8%) experienced a major bleeding event, within a median follow-up of 1.74 years. The prediction model had an optimism-corrected C statistic of 0.73 after internal validation with bootstrapping and was well-calibrated based on visual inspection of calibration plots (goodness-of-fit P=0.57). The DOAC Score assigned points for age, creatinine clearance/glomerular filtration rate, underweight status, stroke/transient ischemic attack/embolism history, diabetes, hypertension, antiplatelet use, nonsteroidal anti-inflammatory use, liver disease, and bleeding history, with each additional point scored associated with a 48.7% (95% CI, 38.9%-59.3%; P<0.001) increase in major bleeding in RE-LY. The score had superior performance to the HAS-BLED score in RE-LY (C statistic, 0.73 versus 0.60; P for difference <0.001) and among 12 296 individuals in GARFIELD-AF (C statistic, 0.71 versus 0.66; P for difference = 0.025). The DOAC Score had stronger predictive performance than the HAS-BLED score in both validation cohorts, including 25 586 individuals in COMBINE-AF (C statistic, 0.67 versus 0.63; P for difference <0.001) and 11 945 individuals in RAMQ (C statistic, 0.65 versus 0.58; P for difference <0.001). CONCLUSIONS In individuals with atrial fibrillation potentially eligible for DOAC therapy, the DOAC Score can help stratify patients on the basis of expected bleeding risk.
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Affiliation(s)
- Rahul Aggarwal
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Heart and Vascular Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christian T. Ruff
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | | | - Sylvie Perreault
- Faculty of Pharmacy, University of Montreal, Montreal, Quebec, Canada
| | - Ajay K. Kakkar
- Thrombosis Research Institute, London, United Kingdom
- University College London, London, United Kingdom
| | - Michael G. Palazzolo
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Marc Dorais
- StatSciences Inc., Notre-Dame-de-l’Île-Perrot, Quebec, Canada
| | - Gloria Kayani
- Thrombosis Research Institute, London, United Kingdom
| | - Daniel E. Singer
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eric Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jonathan Piccini
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Usman A. Tahir
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Changyu Shen
- Advanced Analytics, Biogen Digital Health and Worldwide Medical, Cambridge, Massachusetts
| | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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20
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Karacsonyi J, Stanberry L, Simsek B, Kostantinis S, Allana SS, Rempakos A, Okeson B, Alaswad K, Basir MB, Jaffer F, Poommipanit P, Khatri J, Patel M, Mahmud E, Sheikh A, Wollmuth JR, Yeh RW, Chandwaney RH, ElGuindy AM, Abi Rafeh N, Schimmel DR, Benzuly K, Burke MN, Rangan BV, Mastrodemos OC, Sandoval Y, Ungi I, Brilakis ES. Development of a Novel Score to Predict Urgent Mechanical Circulatory Support in Chronic Total Occlusion Percutaneous Coronary Intervention. Am J Cardiol 2023; 202:111-118. [PMID: 37429059 DOI: 10.1016/j.amjcard.2023.06.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/30/2023] [Accepted: 06/05/2023] [Indexed: 07/12/2023]
Abstract
Estimating the likelihood of urgent mechanical circulatory support (MCS) can facilitate procedural planning and clinical decision-making in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We analyzed 2,784 CTO PCIs performed between 2012 and 2021 at 12 centers. The variable importance was estimated by a bootstrap applying a random forest algorithm to a propensity-matched sample (a ratio of 1:5 matching cases with controls on center). The identified variables were used to predict the risk of urgent MCS. The performance of the risk model was assessed in-sample and on 2,411 out-of-sample procedures that did not require urgent MCS. Urgent MCS was used in 62 (2.2%) of cases. Patients who required urgent MCS were older (70 [63 to 77] vs 66 [58 to 73] years, p = 0.003) compared with those who did not require urgent MCS. Technical (68% vs 87%, p <0.001) and procedural success (40% vs 85%, p <0.001) was lower in the urgent MCS group compared with cases that did not require urgent MCS. The risk model for urgent MCS use included retrograde crossing strategy, left ventricular ejection fraction, and lesion length. The resulting model demonstrated good calibration and discriminatory capacity with the area under the curve (95% confidence interval) of 0.79 (0.73 to 0.86) and specificity and sensitivity of 86% and 52%, respectively. In the out-of-sample set, the specificity of the model was 87%. The Prospective Global Registry for the Study of Chronic Total Occlusion Intervention CTO MCS score can help estimate the risk of urgent MCS use during CTO PCI.
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Affiliation(s)
- Judit Karacsonyi
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Larissa Stanberry
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Bahadir Simsek
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Spyridon Kostantinis
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Salman S Allana
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Athanasios Rempakos
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Brynn Okeson
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Khaldoon Alaswad
- Department of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Mir B Basir
- Department of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Farouc Jaffer
- Department of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Paul Poommipanit
- Department of Cardiology, University Hospitals, Case Western Reserve University, Cleveland, Ohio
| | - Jaikirshan Khatri
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Mitul Patel
- Cardiovascular Institute, VA San Diego Healthcare System and University of California San Diego, La Jolla, California
| | - Ehtisham Mahmud
- Cardiovascular Institute, VA San Diego Healthcare System and University of California San Diego, La Jolla, California
| | - Abdul Sheikh
- Interventional Cardiology Department, WellStar Health System, Marietta, Georgia
| | - Jason R Wollmuth
- Interventional Cardiology, Providence Heart Institute, Portland, Oregon
| | - Robert W Yeh
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Raj H Chandwaney
- Interventional Cardiology, Oklahoma Heart Institute, Tulsa, Oklahoma
| | - Ahmed M ElGuindy
- Department of Cardiology, Aswan Heart Centre, Magdi Yacoub Foundation, Aswan, Egypt
| | - Nidal Abi Rafeh
- Department of Cardiology, North Oaks Health System, Hammond, Louisiana
| | - Daniel R Schimmel
- Cardiovascular Care, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Keith Benzuly
- Cardiovascular Care, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - M Nicholas Burke
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Bavana V Rangan
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Olga C Mastrodemos
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Yader Sandoval
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Imre Ungi
- Division of Invasive Cardiology, Department of Internal Medicine and Cardiology Center, University of Szeged, Szeged, Hungary
| | - Emmanouil S Brilakis
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota.
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21
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Kochar A, Deo SV, Charest B, Peterman-Rocha F, Elgudin Y, Chu D, Yeh RW, Rao SV, Kim DH, Driver JA, Hall DE, Orkaby AR. Preoperative frailty and adverse outcomes following coronary artery bypass grafting surgery in US veterans. J Am Geriatr Soc 2023; 71:2736-2747. [PMID: 37083188 PMCID: PMC10524307 DOI: 10.1111/jgs.18390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 03/20/2023] [Accepted: 03/24/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Contemporary guidelines emphasize the value of incorporating frailty into clinical decision-making regarding revascularization strategies for coronary artery disease. Yet, there are limited data describing the association between frailty and longer-term mortality among coronary artery bypass grafting (CABG) patients. METHODS We conducted a retrospective cohort study (2016-2020, 40 VA medical centers) of US veterans nationwide that underwent coronary artery bypass grafting (CABG). Frailty was quantified by the Veterans Administration Frailty Index (VA-FI), which applies the cumulative deficit method to render a proportion of 30 pertinent diagnosis codes. Patients were classified as non-frail (VA-FI ≤ 0.1), pre-frail (0.1 < VA-FI ≤ 0.2), or frail (VA-FI > 0.2). We used Cox proportional hazards models to ascertain the association of frailty with all-cause mortality. Our primary study outcome was 5-year all-cause mortality; the co-primary outcome was days alive and out of the hospital within the first postoperative year. RESULTS There were 13,554 CABG patients (median 69 years, 79% White, 1.5% women). The mean pre-operative VA-FI was 0.21 (SD: 0.11); 31% were pre-frail (VA-FI: 0.17) and 47% were frail (VA-FI: 0.31). Frail patients were older and had higher co-morbidity burdens than pre-frail and non-frail patients. Compared with non-frail patients (13.0% [11.4, 14.7]), there was a significant association between frail and pre-frail patients and increased cumulative 5-year all-cause mortality (frail: 24.8% [23.3, 26.1]; HR: 1.75 [95% CI 1.54, 2.00]; pre-frail 16.8% [95% CI 15.3, 18.4]; HR 1.2 [1.08,1.34]). Compared with non-frail patients (mean 362[SD 12]), pre-frail (mean 361 [SD 14]; p < 0.01) and frail patients (mean 358[SD 18]; p < 0.01) spent fewer days alive and out of the hospital in the first postoperative year. CONCLUSIONS Pre-frailty and frailty were prevalent among US veterans undergoing CABG and associated with worse mid-term outcomes. Given the high prevalence of frailty with attendant adverse outcomes, there may be an opportunity to improve outcomes by identifying and mitigating frailty before surgery.
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Affiliation(s)
- Ajar Kochar
- Department of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston USA
- Richard and Susan Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston USA
| | - Salil V Deo
- Surgical Services, Louis Stokes Cleveland VA Medical Center, Cleveland USA
- Case School of Medicine, Case Western Reserve University, Cleveland USA
| | - Brian Charest
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston USA
| | | | - Yakov Elgudin
- Surgical Services, Louis Stokes Cleveland VA Medical Center, Cleveland USA
- Case School of Medicine, Case Western Reserve University, Cleveland USA
| | - Danny Chu
- Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh USA
| | - Robert W Yeh
- Richard and Susan Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston USA
| | - Sunil V Rao
- The Durham Veterans Affairs Healthcare System, Durham, NC, USA
| | - Dae H. Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston USA
| | - Jane A. Driver
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston USA
- New England Geriatric Research, Education, and Clinical Center (GRECC), VA Boston Healthcare system, Boston USA
| | - Daniel E Hall
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh USA
- Center for Health Equity Research and Promotion, Veteran Affairs Pittsburgh Healthcare System, Pittsburgh USA
| | - Ariela R. Orkaby
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), VA Boston Healthcare System, Boston USA
- New England Geriatric Research, Education, and Clinical Center (GRECC), VA Boston Healthcare system, Boston USA
- Division of Aging, Brigham and Women’s Hospital, Harvard Medical School, Boston USA
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22
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Oseran AS, Song Y, Xu J, Dahabreh IJ, Wadhera RK, de Lemos JA, Das SR, Sun T, Yeh RW, Kazi DS. Long term risk of death and readmission after hospital admission with covid-19 among older adults: retrospective cohort study. BMJ 2023; 382:e076222. [PMID: 37558240 PMCID: PMC10475839 DOI: 10.1136/bmj-2023-076222] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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] [Accepted: 07/07/2023] [Indexed: 08/11/2023]
Abstract
OBJECTIVES To characterize the long term risk of death and hospital readmission after an index admission with covid-19 among Medicare fee-for-service beneficiaries, and to compare these outcomes with historical control patients admitted to hospital with influenza. DESIGN Retrospective cohort study. SETTING United States. PARTICIPANTS 883 394 Medicare fee-for-service beneficiaries age ≥65 years discharged alive after an index hospital admission with covid-19 between 1 March 2020 and 31 August 2022, compared with 56 409 historical controls discharged alive after a hospital admission with influenza between 1 March 2018 and 31 August 2019. Weighting methods were used to account for differences in observed characteristics. MAIN OUTCOME MEASURES All cause death within 180 days of discharge. Secondary outcomes included first all cause readmission and a composite of death or readmission within 180 days. RESULTS The covid-19 cohort compared with the influenza cohort was younger (77.9 v 78.9 years, standardized mean difference -0.12) and had a lower proportion of women (51.7% v 57.3%, -0.11). Both groups had a similar proportion of black beneficiaries (10.3% v 8.1%, 0.07) and beneficiaries with dual Medicaid-Medicare eligibility status (20.1% v 19.2%; 0.02). The covid-19 cohort had a lower comorbidity burden, including atrial fibrillation (24.3% v 29.5%, -0.12), heart failure (43.4% v 49.9%, -0.13), and chronic obstructive pulmonary disease (39.2% v 52.9%, -0.27). After weighting, the covid-19 cohort had a higher risk (ie, cumulative incidence) of all cause death at 30 days (10.9% v 3.9%; standardized risk difference 7.0%, 95% confidence interval 6.8% to 7.2%), 90 days (15.5% v 7.1%; 8.4%, 8.2% to 8.7%), and 180 days (19.1% v 10.5%; 8.6%, 8.3% to 8.9%) compared with the influenza cohort. The covid-19 cohort also experienced a higher risk of hospital readmission at 30 days (16.0% v 11.2%; 4.9%, 4.6% to 5.1%) and 90 days (24.1% v 21.3%; 2.8%, 2.5% to 3.2%) but a similar risk at 180 days (30.6% v 30.6%;-0.1%, -0.5% to 0.3%). Over the study period, the 30 day risk of death for patients discharged after a covid-19 admission decreased from 17.9% to 7.2%. CONCLUSIONS Medicare beneficiaries who were discharged alive after a covid-19 hospital admission had a higher post-discharge risk of death compared with historical influenza controls; this difference, however, was concentrated in the early post-discharge period. The risk of death for patients discharged after a covid-19 related hospital admission substantially declined over the course of the pandemic.
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Affiliation(s)
- Andrew S Oseran
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
- Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Yang Song
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Jiaman Xu
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Issa J Dahabreh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
- CAUSALab, Department of Epidemiology, and Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Rishi K Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
- Division of Cardiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - James A de Lemos
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sandeep R Das
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Tianyu Sun
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
- Division of Cardiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Dhruv S Kazi
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
- Division of Cardiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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23
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Jalloh MB, Averbuch T, Kulkarni P, Granger CB, Januzzi JL, Zannad F, Yeh RW, Yancy CW, Fonarow GC, Breathett K, Gibson CM, Van Spall HGC. Bridging Treatment Implementation Gaps in Patients With Heart Failure: JACC Focus Seminar 2/3. J Am Coll Cardiol 2023; 82:544-558. [PMID: 37532425 PMCID: PMC10614026 DOI: 10.1016/j.jacc.2023.05.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/19/2023] [Accepted: 05/25/2023] [Indexed: 08/04/2023]
Abstract
Heart failure (HF) is a leading cause of death and disability in older adults. Despite decades of high-quality evidence to support their use, guideline-directed medical therapies (GDMTs) that reduce death and disease burden in HF have been suboptimally implemented. Approaches to closing care gaps have focused largely on strategies proven to be ineffective, whilst effective interventions shown to improve GDMT uptake have not been instituted. This review synthesizes implementation interventions that increase the uptake of GDMT, discusses barriers and facilitators of implementation, summarizes conceptual frameworks in implementation science that could improve knowledge uptake, and offers suggestions for trial design that could better facilitate end-of-trial implementation. We propose an evidence-to-care conceptual model that could foster the simultaneous generation of evidence and long-term implementation. By adopting principles of implementation science, policymakers, researchers, and clinicians can help reduce the burden of HF on patients and health care systems worldwide.
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Affiliation(s)
- Mohamed B Jalloh
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Tauben Averbuch
- Department of Cardiology, University of Calgary, Calgary Alberta, Canada
| | | | - Christopher B Granger
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - James L Januzzi
- Baim Institute for Clinical Research, Boston, Massachusetts, USA; Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Faiez Zannad
- Université de Lorraine, INSERM and Centre Hospitalier Régional Universitaire, Nancy, France
| | - Robert W Yeh
- Baim Institute for Clinical Research, Boston, Massachusetts, USA; Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Clyde W Yancy
- Baim Institute for Clinical Research, Boston, Massachusetts, USA; Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, California, USA
| | - Khadijah Breathett
- Division of Cardiovascular Medicine, Indiana University, Indianapolis, Indiana, USA
| | - C Michael Gibson
- Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | - Harriette G C Van Spall
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Baim Institute for Clinical Research, Boston, Massachusetts, USA; Research Institute of St Joseph's, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada.
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24
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Yeh RW. Bringing the Credibility Revolution to Observational Research in Cardiology. Circulation 2023; 148:455-458. [PMID: 37549203 PMCID: PMC10421627 DOI: 10.1161/circulationaha.123.064645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Affiliation(s)
- Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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25
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Almarzooq ZI, Song Y, Dahabreh IJ, Kochar A, Ferro EG, Secemsky EA, Major JM, Farb A, Wu C, Zuckerman B, Yeh RW. Comparative Effectiveness of Percutaneous Microaxial Left Ventricular Assist Device vs Intra-Aortic Balloon Pump or No Mechanical Circulatory Support in Patients With Cardiogenic Shock. JAMA Cardiol 2023; 8:744-754. [PMID: 37342056 PMCID: PMC10285672 DOI: 10.1001/jamacardio.2023.1643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 03/29/2023] [Indexed: 06/22/2023]
Abstract
IMPORTANCE Recent studies have produced inconsistent findings regarding the outcomes of the percutaneous microaxial left ventricular assist device (LVAD) during acute myocardial infarction with cardiogenic shock (AMICS). OBJECTIVE To compare the percutaneous microaxial LVAD vs alternative treatments among patients presenting with AMICS using observational analyses of administrative data. DESIGN, SETTING, AND PARTICIPANTS This comparative effectiveness research study used Medicare fee-for-service claims of patients admitted with AMICS undergoing percutaneous coronary intervention from October 1, 2015, through December 31, 2019. Treatment strategies were compared using (1) inverse probability of treatment weighting to estimate the effect of different baseline treatments in the overall population; (2) instrumental variable analysis to determine the effectiveness of the percutaneous microaxial LVAD among patients whose treatment was influenced by cross-sectional institutional practice patterns; (3) an instrumented difference-in-differences analysis to determine the effectiveness of treatment among patients whose treatment was influenced by longitudinal changes in institutional practice patterns; and (4) a grace period approach to determine the effectiveness of initiating the percutaneous microaxial LVAD within 2 days of percutaneous coronary intervention. Analysis took place between March 2021 and December 2022. INTERVENTIONS Percutaneous microaxial LVAD vs alternative treatments (including medical therapy and intra-aortic balloon pump). MAIN OUTCOMES AND MEASURES Thirty-day all-cause mortality and readmissions. RESULTS Of 23 478 patients, 14 264 (60.8%) were male and the mean (SD) age was 73.9 (9.8) years. In the inverse probability of treatment weighting analysis and grace period approaches, treatment with percutaneous microaxial LVAD was associated with a higher risk-adjusted 30-day mortality (risk difference, 14.9%; 95% CI, 12.9%-17.0%). However, patients receiving the percutaneous microaxial LVAD had a higher frequency of factors associated with severe illness, suggesting possible confounding by measures of illness severity not available in the data. In the instrumental variable analysis, 30-day mortality was also higher with percutaneous microaxial LVAD, but patient and hospital characteristics differed across levels of the instrumental variable, suggesting possible confounding by unmeasured variables (risk difference, 13.5%; 95% CI, 3.9%-23.2%). In the instrumented difference-in-differences analysis, the association between the percutaneous microaxial LVAD and mortality was imprecise, and differences in trends in characteristics between hospitals with different percutaneous microaxial LVAD use suggested potential assumption violations. CONCLUSIONS In observational analyses comparing the percutaneous microaxial LVAD to alternative treatments among patients with AMICS, the percutaneous microaxial LVAD was associated with worse outcomes in some analyses, while in other analyses, the association was too imprecise to draw meaningful conclusions. However, the distribution of patient and institutional characteristics between treatment groups or groups defined by institutional differences in treatment use, including changes in use over time, combined with clinical knowledge of illness severity factors not captured in the data, suggested violations of key assumptions that are needed for valid causal inference with different observational analyses. Randomized clinical trials of mechanical support devices will allow valid comparisons across candidate treatment strategies and help resolve ongoing controversies.
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Affiliation(s)
- Zaid I. Almarzooq
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Cardiology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Yang Song
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Issa J. Dahabreh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- CAUSALab, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Departments of Epidemiology and Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Ajar Kochar
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division of Cardiology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Enrico G. Ferro
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Eric A. Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jacqueline M. Major
- Office of Clinical Evidence and Analysis, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland
| | - Andrew Farb
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland
| | - Changfu Wu
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland
| | - Bram Zuckerman
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland
| | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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26
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Faridi KF, Strom JB, Kundi H, Butala NM, Curtis JP, Gao Q, Song Y, Zheng L, Tamez H, Shen C, Secemsky EA, Yeh RW. Association Between Claims-Defined Frailty and Outcomes Following 30 Versus 12 Months of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention: Findings From the EXTEND-DAPT Study. J Am Heart Assoc 2023; 12:e029588. [PMID: 37449567 PMCID: PMC10382113 DOI: 10.1161/jaha.123.029588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 05/31/2023] [Indexed: 07/18/2023]
Abstract
Background Frailty is rarely assessed in clinical trials of patients who receive dual antiplatelet therapy (DAPT) after percutaneous coronary intervention. This study investigated whether frailty defined using claims data is associated with outcomes following percutaneous coronary intervention, and if there is a differential association in patients receiving standard versus extended duration DAPT. Methods and Results Patients ≥65 years of age in the DAPT (Dual Antiplatelet Therapy) Study, a randomized trial comparing 30 versus 12 months of DAPT following percutaneous coronary intervention, had data linked to Medicare claims (n=1326), and a previously validated claims-based index was used to define frailty. Net adverse clinical events, a composite of all-cause mortality, myocardial infarction, stroke, and major bleeding, were compared between frail and nonfrail patients. Patients defined as frail using claims data (12.0% of the cohort) had higher incidence of net adverse clinical events (23.1%) compared with nonfrail patients (10.7%; P<0.001) at 18-month follow-up and increased risk after multivariable adjustment (adjusted hazard ratio [HR], 2.24 [95% CI, 1.38-3.63]). There were no differences in effects of extended duration DAPT on net adverse clinical events for frail (HR, 1.42 [95% CI, 0.73-2.75]) and nonfrail patients (HR, 1.18 [95% CI, 0.83-1.68]; interaction P=0.61), although analyses were underpowered. Bleeding was highest among frail patients who received extended duration DAPT. Conclusions Among older patients in the DAPT Study, claims-defined frailty was associated with higher net adverse clinical events. Effects of extended duration DAPT were not different for frail patients, although comparisons were underpowered. Further investigation of how frailty influences ischemic and bleeding risks with DAPT are warranted. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT00977938.
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Affiliation(s)
- Kamil F Faridi
- Section of Cardiovascular Medicine, Department of Medicine Yale School of Medicine New Haven CT USA
| | - Jordan B Strom
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine Beth Israel Deaconess Medical Center Boston MA USA
| | - Harun Kundi
- Department of Cardiology Ankara City Hospital Ankara Turkey
| | - Neel M Butala
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine Beth Israel Deaconess Medical Center Boston MA USA
- Cardiology Division, Department of Medicine Massachusetts General Hospital, Harvard Medical School Boston MA USA
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Department of Medicine Yale School of Medicine New Haven CT USA
| | - Qi Gao
- Baim Institute for Clinical Research Boston MA USA
| | - Yang Song
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine Beth Israel Deaconess Medical Center Boston MA USA
| | - Luke Zheng
- Baim Institute for Clinical Research Boston MA USA
| | - Hector Tamez
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine Beth Israel Deaconess Medical Center Boston MA USA
| | - Changyu Shen
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine Beth Israel Deaconess Medical Center Boston MA USA
- Biogen Cambridge MA USA
| | - Eric A Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine Beth Israel Deaconess Medical Center Boston MA USA
| | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine Beth Israel Deaconess Medical Center Boston MA USA
- Baim Institute for Clinical Research Boston MA USA
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27
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Yamga E, Mantena S, Rosen D, Bucholz EM, Yeh RW, Celi LA, Ustun B, Butala NM. Optimized Risk Score to Predict Mortality in Patients With Cardiogenic Shock in the Cardiac Intensive Care Unit. J Am Heart Assoc 2023; 12:e029232. [PMID: 37345819 PMCID: PMC10356069 DOI: 10.1161/jaha.122.029232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 05/01/2023] [Indexed: 06/23/2023]
Abstract
Background Mortality prediction in critically ill patients with cardiogenic shock can guide triage and selection of potentially high-risk treatment options. Methods and Results We developed and externally validated a checklist risk score to predict in-hospital mortality among adults admitted to the cardiac intensive care unit with Society for Cardiovascular Angiography & Interventions Shock Stage C or greater cardiogenic shock using 2 real-world data sets and Risk-Calibrated Super-sparse Linear Integer Modeling (RiskSLIM). We compared this model to those developed using conventional penalized logistic regression and published cardiogenic shock and intensive care unit mortality prediction models. There were 8815 patients in our training cohort (in-hospital mortality 13.4%) and 2237 patients in our validation cohort (in-hospital mortality 22.8%), and there were 39 candidate predictor variables. The final risk score (termed BOS,MA2) included maximum blood urea nitrogen ≥25 mg/dL, minimum oxygen saturation <88%, minimum systolic blood pressure <80 mm Hg, use of mechanical ventilation, age ≥60 years, and maximum anion gap ≥14 mmol/L, based on values recorded during the first 24 hours of intensive care unit stay. Predicted in-hospital mortality ranged from 0.5% for a score of 0 to 70.2% for a score of 6. The area under the receiver operating curve was 0.83 (0.82-0.84) in training and 0.76 (0.73-0.78) in validation, and the expected calibration error was 0.9% in training and 2.6% in validation. Conclusions Developed using a novel machine learning method and the largest cardiogenic shock cohorts among published models, BOS,MA2 is a simple, clinically interpretable risk score that has improved performance compared with existing cardiogenic-shock risk scores and better calibration than general intensive care unit risk scores.
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Affiliation(s)
- Eric Yamga
- Department of Medicine Centre Hospitalier de l'Université de Montréal (CHUM) Montreal QC Canada
| | | | - Darin Rosen
- Johns Hopkins School of Medicine Baltimore MD USA
| | - Emily M Bucholz
- University of Colorado School of Medicine Aurora CO USA
- Heart Institute, Children's Hospital of Colorado Aurora CO USA
| | - Robert W Yeh
- Harvard Medical School Boston MA USA
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology Beth Israel Deaconess Medical Center Boston MA USA
| | - Leo A Celi
- Harvard Medical School Boston MA USA
- Laboratory for Computational Physiology, MIT Institute for Medical Engineering and Science, Massachusetts Institute of Technology Cambridge MA USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health Boston MA USA
| | - Berk Ustun
- Halıcıoğlu Data Science Institute University of California San Diego CA USA
| | - Neel M Butala
- University of Colorado School of Medicine Aurora CO USA
- Rocky Mountain Regional VA Medical Center Aurora CO USA
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28
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Varghese MS, Song Y, Xu J, Dahabreh I, Beatty AL, Sperling LS, Fonarow GC, Keteyian SJ, Yeh RW, Wu WC, Kazi DS. Availability and Use of In-Person and Virtual Cardiac Rehabilitation Among US Medicare Beneficiaries: A Post-Pandemic Update. J Cardiopulm Rehabil Prev 2023; 43:301-303. [PMID: 37158994 PMCID: PMC10843522 DOI: 10.1097/hcr.0000000000000803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Affiliation(s)
- Merilyn S. Varghese
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Yang Song
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jiaman Xu
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA
| | - Issa Dahabreh
- CAUSALab, Harvard T.H. Chan School of Public Health, Boston, MA
- Department of Epidemiology and Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Alexis L. Beatty
- Department of Epidemiology and Biostatistics, Division of Cardiology, Department of Medicine, University of California, San Francisco, CA
| | - Laurence S. Sperling
- Division of Cardiology, Department of Medicine, Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA
| | - Gregg C. Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles, Los Angeles, CA
| | | | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - Wen-Chih Wu
- Providence VA Medical Center and the Miriam Hospital Cardiovascular Rehabilitation Center, Providence, RI
- Department of Medicine, Epidemiology and Center for Global Cardiometabolic Health, Brown University, Providence, RI
| | - Dhruv S. Kazi
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
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29
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Capodanno D, Mehran R, Krucoff MW, Baber U, Bhatt DL, Capranzano P, Collet JP, Cuisset T, De Luca G, De Luca L, Farb A, Franchi F, Gibson CM, Hahn JY, Hong MK, James S, Kastrati A, Kimura T, Lemos PA, Lopes RD, Magee A, Matsumura R, Mochizuki S, O'Donoghue ML, Pereira NL, Rao SV, Rollini F, Shirai Y, Sibbing D, Smits PC, Steg PG, Storey RF, Ten Berg J, Valgimigli M, Vranckx P, Watanabe H, Windecker S, Serruys PW, Yeh RW, Morice MC, Angiolillo DJ. Defining Strategies of Modulation of Antiplatelet Therapy in Patients With Coronary Artery Disease: A Consensus Document from the Academic Research Consortium. Circulation 2023; 147:1933-1944. [PMID: 37335828 DOI: 10.1161/circulationaha.123.064473] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 04/24/2023] [Indexed: 06/21/2023]
Abstract
Antiplatelet therapy is the mainstay of pharmacologic treatment to prevent thrombotic or ischemic events in patients with coronary artery disease treated with percutaneous coronary intervention and those treated medically for an acute coronary syndrome. The use of antiplatelet therapy comes at the expense of an increased risk of bleeding complications. Defining the optimal intensity of platelet inhibition according to the clinical presentation of atherosclerotic cardiovascular disease and individual patient factors is a clinical challenge. Modulation of antiplatelet therapy is a medical action that is frequently performed to balance the risk of thrombotic or ischemic events and the risk of bleeding. This aim may be achieved by reducing (ie, de-escalation) or increasing (ie, escalation) the intensity of platelet inhibition by changing the type, dose, or number of antiplatelet drugs. Because de-escalation or escalation can be achieved in different ways, with a number of emerging approaches, confusion arises with terminologies that are often used interchangeably. To address this issue, this Academic Research Consortium collaboration provides an overview and definitions of different strategies of antiplatelet therapy modulation for patients with coronary artery disease, including but not limited to those undergoing percutaneous coronary intervention, and consensus statements on standardized definitions.
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Affiliation(s)
- Davide Capodanno
- Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Italy (D.C., P.C.)
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute (R.M.), Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Usman Baber
- University of Oklahoma Health Sciences Center, Oklahoma City (U.B.)
| | - Deepak L Bhatt
- Mount Sinai Heart (D.L.B.), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Piera Capranzano
- Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Italy (D.C., P.C.)
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Study Group, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (APHP), Paris, France (J.-P.C.)
| | - Thomas Cuisset
- Interventional Cardiology Unit and Cathlab, Department of Cardiology, University Hospital, La Timone, Marseille, France (T.C.)
| | - Giuseppe De Luca
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G Martino," University of Messina, Italy (G.D.L.)
- Division of Cardiology, IRCCS Hospital Galeazzi-Sant'Ambrogio, Milan, Italy (G.D.L.)
| | - Leonardo De Luca
- UniCamillus-Saint Camillus International University of Health Sciences, Rome, Italy (L.D.L.)
| | - Andrew Farb
- US Food and Drug Administration, Silver Spring, MD (A.F., A.M.)
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (F.F., F.R., D.J.A.)
| | | | - Joo-Yong Hahn
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea (J.-Y.H.)
| | - Myeong-Ki Hong
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (M.-K.H.)
| | - Stefan James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Sweden (S.J.)
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany (A.K.)
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK; German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany (A.K., D.S.)
| | - Takeshi Kimura
- Department of Cardiology, Hirakata Kohsai Hospital, Osaka, Japan (T.K.)
| | - Pedro A Lemos
- Hospital Israelita Albert Einstein, São Paulo, Brazil (P.A.L.)
| | - Renato D Lopes
- Duke University Medical Center, Durham, NC (M.W.K., R.D.L.)
| | - Adrian Magee
- US Food and Drug Administration, Silver Spring, MD (A.F., A.M.)
| | - Ryosuke Matsumura
- Pharmaceuticals and Medical Devices Agency, Tokyo, Japan (R.M., S.M., Y.S.)
| | - Shuichi Mochizuki
- Pharmaceuticals and Medical Devices Agency, Tokyo, Japan (R.M., S.M., Y.S.)
| | - Michelle L O'Donoghue
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.L.O.)
| | - Naveen L Pereira
- Department of Cardiovascular Medicine, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN (N.L.P.)
| | - Sunil V Rao
- NYU Langone Health System, New York, NY (S.V.R.)
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (F.F., F.R., D.J.A.)
| | - Yuko Shirai
- Pharmaceuticals and Medical Devices Agency, Tokyo, Japan (R.M., S.M., Y.S.)
| | - Dirk Sibbing
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK; German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany (A.K., D.S.)
- Ludwig-Maximilians University München, Munich, Germany (D.S.)
- Privatklinik Lauterbacher Mühle am Ostsee, Seeshaupt, Germany (D.S.)
| | - Peter C Smits
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands (P.C.S.)
| | - P Gabriel Steg
- Université Paris-Cité, AP-HP, Paris, France (P.G.S.)
- INSERM U-1148/LVTS, Paris, France (P.G.S.)
- Institut Universitaire de France, Paris (P.G.S.)
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, UK (R.F.S.)
| | - Jurrien Ten Berg
- Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht University Medical Center, the Netherlands (J.t.B.)
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands (J.t.B.)
- Department of Cardiology, University Medical Center Maastricht, the Netherlands (J.t.B.)
| | - Marco Valgimigli
- Cardiocentro Institute, Ente Ospedaliero Cantonale, Università della Svizzera Italiana (USI), Lugano, Switzerland (M.V.)
- University of Bern, Switzerland (M.V.)
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Jessa Ziekenhuis, Hasselt, Belgium (P.V.)
- Faculty of Medicine and Life Sciences, University of Hasselt, Belgium (P.V.)
| | | | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Inselspital (S.W.)
| | | | - Robert W Yeh
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.W.Y.)
| | | | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (F.F., F.R., D.J.A.)
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Diamond J, Ayodele I, Fonarow GC, Joynt-Maddox KE, Yeh RW, Hammond G, Allen LA, Greene SJ, Chiswell K, DeVore AD, Yancy C, Wadhera RK. Quality of Care and Clinical Outcomes for Patients With Heart Failure at Hospitals Caring for a High Proportion of Black Adults: Get With The Guidelines-Heart Failure Registry. JAMA Cardiol 2023; 8:545-553. [PMID: 37074702 PMCID: PMC10116383 DOI: 10.1001/jamacardio.2023.0695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 02/26/2023] [Indexed: 04/20/2023]
Abstract
Importance Black adults with heart failure (HF) disproportionately experience higher population-level mortality than White adults with HF. Whether quality of care for HF differs at hospitals with high proportions of Black patients compared with other hospitals is unknown. Objective To compare quality and outcomes for patients with HF at hospitals with high proportions of Black patients vs other hospitals. Design, Setting, and Participants Patients hospitalized for HF at Get With The Guidelines (GWTG) HF sites from January 1, 2016, through December 1, 2019. These data were analyzed from May 2022 through November 2022. Exposures Hospitals caring for high proportions of Black patients. Main Outcomes and Measures Quality of HF care based on 14 evidence-based measures, overall defect-free HF care, and 30-day readmissions and mortality in Medicare patients. Results This study included 422 483 patients (224 270 male [53.1%] and 284 618 White [67.4%]) with a mean age of 73.0 years. Among 480 hospitals participating in GWTG-HF, 96 were classified as hospitals with high proportions of Black patients. Quality of care was similar between hospitals with high proportions of Black patients compared with other hospitals for 11 of 14 GWTG-HF measures, including use of angiotensin-converting enzyme inhibitors/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitors for left ventricle systolic dysfunction (high-proportion Black hospitals: 92.7% vs other hospitals: 92.4%; adjusted odds ratio [OR], 0.91; 95% CI, 0.65-1.27), evidence-based β-blockers (94.7% vs 93.7%; OR, 1.02; 95% CI, 0.82-1.28), angiotensin receptor neprilysin inhibitors at discharge (14.3% vs 16.8%; OR, 0.74; 95% CI, 0.54-1.02), anticoagulation for atrial fibrillation/flutter (88.8% vs 87.5%; OR, 1.05; 95% CI, 0.76-1.45), and implantable cardioverter-defibrillator counseling/placement/prescription at discharge (70.9% vs 71.0%; OR, 0.75; 95% CI, 0.50-1.13). Patients at high-proportion Black hospitals were less likely to be discharged with a follow-up visit made within 7 days or less (70.4% vs 80.1%; OR, 0.68; 95% CI, 0.53-0.86), receive cardiac resynchronization device placement/prescription (50.6% vs 53.8%; OR, 0.63; 95% CI, 0.42-0.95), or an aldosterone antagonist (50.4% vs 53.5%; OR, 0.69; 95% CI, 0.50-0.97). Overall defect-free HF care was similar between both groups of hospitals (82.6% vs 83.4%; OR, 0.89; 95% CI, 0.67-1.19) and there were no significant within-hospital differences in quality for Black patients vs White patients. Among Medicare beneficiaries, the risk-adjusted hazard ratio (HR) for 30-day readmissions was higher at high-proportion Black vs other hospitals (HR, 1.14; 95% CI, 1.02-1.26), but similar for 30-day mortality (HR 0.92; 95% CI,0.84-1.02). Conclusions and Relevance Quality of care for HF was similar across 11 of 14 measures at hospitals caring for high proportions of Black patients compared with other hospitals, as was overall defect-free HF care. There were no significant within-hospital differences in quality for Black patients vs White patients.
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Affiliation(s)
- Jamie Diamond
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | | | - Gregg C. Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles
| | - Karen E. Joynt-Maddox
- Center for Health Economics and Policy, Cardiovascular Division, Washington University School of Medicine, Washington University, St Louis, Missouri
| | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Gmerice Hammond
- Center for Health Economics and Policy, Cardiovascular Division, Washington University School of Medicine, Washington University, St Louis, Missouri
| | - Larry A. Allen
- Division of Cardiology, University of Colorado School of Medicine, Aurora
| | - Stephen J. Greene
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Karen Chiswell
- Duke Clinical Research Institute, Durham, North Carolina
| | - Adam D. DeVore
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Clyde Yancy
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Rishi K. Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
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Ferro EG, Kramer DB, Li S, Locke AH, Misra S, Schmaier AA, Carroll BJ, Song Y, D'Avila AA, Yeh RW, Zimetbaum PJ, Secemsky EA. Incidence, Treatment, and Outcomes of Symptomatic Device Lead-Related Venous Obstruction. J Am Coll Cardiol 2023:S0735-1097(23)05427-X. [PMID: 37204378 DOI: 10.1016/j.jacc.2023.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 04/06/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND The incidence and clinical impact of lead-related venous obstruction (LRVO) among patients with cardiovascular implantable electronic devices (CIEDs) is poorly defined. OBJECTIVES The objectives of this study were to determine the incidence of symptomatic LRVO after CIED implant; describe patterns in CIED extraction and revascularization; and quantify LRVO-related health care utilization based on each type of intervention. METHODS LRVO status was defined among Medicare beneficiaries after CIED implant from October 1, 2015, to December 31, 2020. Cumulative incidence functions of LRVO were estimated by Fine-Gray methods. LRVO predictors were identified using Cox regression. Incidence rates for LRVO-related health care visits were calculated with Poisson models. RESULTS Among 649,524 patients who underwent CIED implant, 28,214 developed LRVO, with 5.0% cumulative incidence at maximum follow-up of 5.2 years. Independent predictors of LRVO included CIEDs with >1 lead (HR: 1.09; 95% CI: 1.07-1.15), chronic kidney disease (HR: 1.17; 95% CI: 1.14-1.20), and malignancies (HR: 1.23; 95% CI: 1.20-1.27). Most patients with LRVO (85.2%) were managed conservatively. Among 4,186 (14.8%) patients undergoing intervention, 74.0% underwent CIED extraction and 26.0% percutaneous revascularization. Notably, 90% of the patients did not receive another CIED after extraction, with low use (2.2%) of leadless pacemakers. In adjusted models, extraction was associated with significant reductions in LRVO-related health care utilization (adjusted rate ratio: 0.58; 95% CI: 0.52-0.66) compared with conservative management. CONCLUSIONS In a large nationwide sample, the incidence of LRVO was substantial, affecting 1 of every 20 patients with CIEDs. Device extraction was the most common intervention and was associated with long-term reduction in recurrent health care utilization.
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Affiliation(s)
- Enrico G Ferro
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel B Kramer
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Siling Li
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew H Locke
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Shantum Misra
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Alec A Schmaier
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Brett J Carroll
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Yang Song
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Andre A D'Avila
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter J Zimetbaum
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
| | - Eric A Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
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Essa M, Ross JS, Dhruva SS, Desai NR, Yeh RW, Faridi KF. Trends in Spending and Claims for P2Y12 Inhibitors by Medicare and Medicaid From 2015 to 2020. J Am Heart Assoc 2023; 12:e028869. [PMID: 37042289 PMCID: PMC10227267 DOI: 10.1161/jaha.122.028869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 03/15/2023] [Indexed: 04/13/2023]
Affiliation(s)
- Mohammed Essa
- New England Heart and Vascular InstituteCatholic Medical CenterManchesterNHUSA
| | - Joseph S. Ross
- Center for Outcomes Research and Evaluation, Yale New Haven Health SystemNew HavenCTUSA
- Section of General Internal Medicine, Department of Medicine, Yale School of MedicineNew HavenCTUSA
- Department of Health Policy and Management, Yale School of Public HealthNew HavenCTUSA
| | - Sanket S. Dhruva
- Section of Cardiology, Department of MedicineUniversity of California at San Francisco School of MedicineSan FranciscoCAUSA
| | - Nihar R. Desai
- Section of Cardiovascular Medicine, Department of MedicineYale School of Medicine; Center for Outcomes Research and Evaluation, Yale New Haven Health SystemNew HavenCTUSA
| | - Robert W. Yeh
- Beth Israel Deaconess Medical Center, Harvard Medical SchoolBostonMAUSA
| | - Kamil F. Faridi
- Section of Cardiovascular Medicine, Department of MedicineYale School of Medicine; Center for Outcomes Research and Evaluation, Yale New Haven Health SystemNew HavenCTUSA
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Aggarwal R, Yeh RW, Joynt Maddox KE, Wadhera RK. Cardiovascular Risk Factor Prevalence, Treatment, and Control in US Adults Aged 20 to 44 Years, 2009 to March 2020. JAMA 2023; 329:899-909. [PMID: 36871237 PMCID: PMC9986841 DOI: 10.1001/jama.2023.2307] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [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: 12/05/2022] [Accepted: 02/10/2023] [Indexed: 03/06/2023]
Abstract
Importance Declines in cardiovascular mortality have stagnated in the US over the past decade, in part related to worsening risk factor control in older adults. Little is known about how the prevalence, treatment, and control of cardiovascular risk factors have changed among young adults aged 20 to 44 years. Objective To determine if the prevalence of cardiovascular risk factors (hypertension, diabetes, hyperlipidemia, obesity, and tobacco use), treatment rates, and control changed among adults aged 20 to 44 years from 2009 through March 2020, overall and by sex and race and ethnicity. Design, Setting, and Participants Serial cross-sectional analysis of adults aged 20 to 44 years in the US participating in the National Health and Nutrition Examination Survey (2009-2010 to 2017-March 2020). Main Outcomes and Measures National trends in the prevalence of hypertension, diabetes, hyperlipidemia, obesity, and smoking history; treatment rates for hypertension and diabetes; and blood pressure and glycemic control in those receiving treatment. Results Among 12 924 US adults aged 20 to 44 years (mean age, 31.8 years; 50.6% women), the prevalence of hypertension was 9.3% (95% CI, 8.1%-10.5%) in 2009-2010 and 11.5% (95% CI, 9.6%-13.4%) in 2017-2020. The prevalence of diabetes (from 3.0% [95% CI, 2.2%-3.7%] to 4.1% [95% CI, 3.5%-4.7%]) and obesity (from 32.7% [95% CI, 30.1%-35.3%] to 40.9% [95% CI, 37.5%-44.3%]) increased from 2009-2010 to 2017-2020, while the prevalence of hyperlipidemia decreased (from 40.5% [95% CI, 38.6%-42.3%] to 36.1% [95% CI, 33.5%-38.7%]). Black adults had high rates of hypertension across the study period (2009-2010: 16.2% [95% CI, 14.0%-18.4%]; 2017-2020: 20.1% [95% CI, 16.8%-23.3%]), and significant increases in hypertension were observed among Mexican American adults (from 6.5% [95% CI, 5.0%-8.0%] to 9.5% [95% CI, 7.3%-11.7%]) and other Hispanic adults (from 4.4% [95% CI, 2.1%-6.8%] to 10.5% [95% CI, 6.8%-14.3%]), while Mexican American adults had a significant rise in diabetes (from 4.3% [95% CI, 2.3%-6.2%] to 7.5% [95% CI, 5.4%-9.6%]). The percentage of young adults treated for hypertension who achieved blood pressure control did not significantly change (from 65.0% [95% CI, 55.8%-74.2%] in 2009-2010 to 74.8% [95% CI, 67.5%-82.1%] in 2017-2020], while glycemic control among young adults receiving treatment for diabetes remained suboptimal throughout the study period (2009-2010: 45.5% [95% CI, 27.7%-63.3%]) to 2017-2020: 56.6% [95% CI, 39.2%-73.9%]). Conclusions and Relevance In the US, diabetes and obesity increased among young adults from 2009 to March 2020, while hypertension did not change and hyperlipidemia declined. There was variation in trends by race and ethnicity.
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Affiliation(s)
- Rahul Aggarwal
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
- Heart and Vascular Center, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Karen E. Joynt Maddox
- Cardiovascular Division, Washington University School of Medicine, St Louis, Missouri
- Associate Editor, JAMA
| | - Rishi K. Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
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Secemsky EA, Song Y, Sun T, Johnson CG, Gatski M, Wang L, Farb A, Lee RE, Shaw A, Xu J, Yeh RW. Comparison of Unibody and Non-Unibody Endografts for Abdominal Aortic Aneurysm Repair in Medicare Beneficiaries: The SAFE-AAA Study. Circulation 2023; 147:1264-1276. [PMID: 36866664 PMCID: PMC10133018 DOI: 10.1161/circulationaha.122.062123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
BACKGROUND Concerns have been raised about the long-term performance of aortic stent grafts for the treatment of abdominal aortic aneurysms, in particular, unibody stent grafts (eg, Endologix AFX AAA stent grafts). Only limited data sets are available to evaluate the long-term risks related to these devices. The SAFE-AAA Study was designed with the Food and Drug Administration to provide a longitudinal assessment of the safety of unibody aortic stent grafts among Medicare beneficiaries. METHODS The SAFE-AAA Study was a prespecified, retrospective cohort study evaluating whether unibody aortic stent grafts are noninferior to non-unibody stent grafts with respect to the composite primary outcome of aortic reintervention, rupture, and mortality. Procedures were evaluated from August 1, 2011, through December 31, 2017. The primary end point was evaluated through December 31, 2019. Inverse probability weighting was used to account for imbalances in observed characteristics. Sensitivity analyses were used to evaluate the effect of unmeasured confounding, including the falsification end points of heart failure, stroke, and pneumonia. A prespecified subgroup includes patients treated from February 22, 2016, through December 31, 2017, corresponding to the market release of the most contemporary unibody endograft (Endologix AFX2 AAA stent graft). RESULTS Of 87 163 patients who underwent aortic stent grafting at 2146 US hospitals, 11 903 (13.7%) received a unibody device. The average age was 77.0±6.7 years, 21.1% were female, 93.5% were White, 90.8% had hypertension, and 35.8% used tobacco. The primary end point occurred in 73.4% of unibody device-treated patients versus 65.0% of non-unibody device-treated patients (hazard ratio, 1.19 [95% CI, 1.15-1.22]; noninferior P value of 1.00; median follow-up, 3.4 years). Falsification end points were negligibly different between groups. In a contemporary subgroup of procedures, the cumulative incidence of the primary end point was 37.5% of unibody device-treated patients and 32.7% of non-unibody device-treated patients (hazard ratio, 1.06 [95% CI, 0.98-1.14]). CONCLUSIONS In the SAFE-AAA Study, unibody endografts failed to meet noninferiority compared with non-unibody endografts with respect to aortic reintervention, rupture, and mortality. These data support the urgency of instituting a prospective longitudinal surveillance program for monitoring safety events related to aortic stent grafts.
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Affiliation(s)
- Eric A Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (E.A.S., Y.S., T.S., J.X., R.W.Y.).,Harvard Medical School, Boston, MA (E.A.S., R.W.Y.).,Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (E.A.S., R.W.Y.)
| | - Yang Song
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (E.A.S., Y.S., T.S., J.X., R.W.Y.)
| | - Tianyu Sun
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (E.A.S., Y.S., T.S., J.X., R.W.Y.)
| | - Carmen Gacchina Johnson
- Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD (C.G.J., M.G., L.W., A.F., R.E.L., A.S.)
| | - Megan Gatski
- Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD (C.G.J., M.G., L.W., A.F., R.E.L., A.S.)
| | - Li Wang
- Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD (C.G.J., M.G., L.W., A.F., R.E.L., A.S.)
| | - Andrew Farb
- Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD (C.G.J., M.G., L.W., A.F., R.E.L., A.S.)
| | - Robert E Lee
- Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD (C.G.J., M.G., L.W., A.F., R.E.L., A.S.)
| | - Aurko Shaw
- Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD (C.G.J., M.G., L.W., A.F., R.E.L., A.S.)
| | - Jiaman Xu
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (E.A.S., Y.S., T.S., J.X., R.W.Y.)
| | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (E.A.S., Y.S., T.S., J.X., R.W.Y.).,Harvard Medical School, Boston, MA (E.A.S., R.W.Y.).,Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (E.A.S., R.W.Y.)
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Aggarwal R, Yeh RW, Maddox KEJ, Wadhera R. CARDIOVASCULAR RISK FACTOR BURDEN AND CONTROL AMONG YOUNG ADULTS AGE 18 TO 44 YEARS IN THE UNITED STATES, 2009-2020. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02096-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: 03/06/2023]
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Narasimmaraj P, Oseran A, Tale AP, Xu J, Kazi D, Yeh RW, Wadhera R. THE INFLATION REDUCTION ACT'S OUT-OF-POCKET PRESCRIPTION DRUG COST CAP WILL BENEFIT OVER 1 MILLION MEDICARE PATIENTS WITH CARDIOVASCULAR RISK FACTORS OR DISEASE. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02112-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Fazel R, Yeh RW, Cohen D, Rao SV, Song Y, Secemsky EA, Richard A, Smith SF. TEMPORAL TRENDS AND CLINICAL OUTCOMES ASSOCIATED WITH INTRAVASCULAR IMAGING DURING PERCUTANEOUS CORONARY INTERVENTIONS IN THE UNITED STATES. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01423-7] [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: 03/06/2023]
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Wang A, Ferro EG, Xu J, Song Y, Sun T, Strom JB, Kim DH, Yeh RW, Ko D, Kramer DB. Comparative performance of distinct frailty measures among patients undergoing percutaneous left atrial appendage closure. Pacing Clin Electrophysiol 2023; 46:242-250. [PMID: 36530151 PMCID: PMC9998344 DOI: 10.1111/pace.14649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 12/10/2022] [Indexed: 12/23/2022]
Abstract
AIMS Frailty is associated with increased morbidity and mortality in patients undergoing left atrial appendage closure (LAAC). This study aimed to compare the performance of two claims-based frailty measures in predicting adverse outcomes following LAAC. METHODS We identified patients 66 years and older who underwent LAAC between October 1, 2016, and December 31, 2019, in Medicare fee-for-service claims. Frailty was assessed using the previously validated Hospital Frailty Risk Score (HFRS) and Kim Claims-based Frailty Index (CFI). Patients were identified as frail based on HFRS ≥5 and CFI ≥0.25. RESULTS Of the 21,787 patients who underwent LAAC, frailty was identified in 45.6% by HFRS and 15.4% by CFI. There was modest agreement between the two frailty measures (kappa 0.25, Pearson's correlation 0.62). After adjusting for age, sex, and comorbidities, frailty was associated with higher risk of 30-day mortality, 1-year mortality, 30-day readmission, long hospital stay, and reduced days at home (p < .01 for all) regardless of the frailty measure used. The addition of frailty to standard comorbidities significantly improved model performance to predict 1-year mortality, long hospital stay, and reduced days at home (Delong p-value < .001). CONCLUSION Despite significant variation in frailty detection and modest agreement between the two frailty measures, frailty status remained highly predictive of mortality, readmissions, long hospital stay, and reduced days at home among patients undergoing LAAC. Measuring frailty in clinical practice, regardless of the method used, may provide prognostic information useful for patients being considered for LAAC, and may inform shared decision-making in this population.
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Affiliation(s)
- Allen Wang
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Enrico G Ferro
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Jiaman Xu
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Yang Song
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Tianyu Sun
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Jordan B Strom
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Dae H Kim
- Harvard Medical School, Boston, Massachusetts, USA
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Darae Ko
- Section of Cardiovascular Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Daniel B Kramer
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Karacsonyi J, Stanberry L, Simsek B, Kostantinis S, Allana SS, Alaswad K, Jaffer FA, Poommipanit P, Khatri JJ, Patel MP, Sheikh A, Wollmuth JR, Uretsky BF, Yeh RW, Chandwaney RH, Rempakos A, ElGuindy AM, Rafeh NA, Sandoval Y, Burke MN, Mastrodemos O, Okeson B, Rangan BV, Ungi I, Brilakis ES. URGENT MECHANICAL CIRCULATORY SUPPORT SCORE IN CHRONIC TOTAL OCCLUSION PERCUTANEOUS CORONARY INTERVENTION. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01219-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Parikh RV, Hebbe A, Barón AE, Grunwald GK, Plomondon ME, Gordin J, Yeh RW, Jneid H, Swaminathan RV, Waldo SW, Monto A, Secemsky E, Hsue PY. Clinical Characteristics and Outcomes Among People Living With HIV Undergoing Percutaneous Coronary Intervention: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program. J Am Heart Assoc 2023; 12:e028082. [PMID: 36789851 PMCID: PMC10111473 DOI: 10.1161/jaha.122.028082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Background Clinical characteristics and outcomes in people living with HIV (PLWH) undergoing percutaneous coronary intervention (PCI) remain poorly described. We sought to compare real-world treatment of coronary artery disease, as well as patient and procedural factors and outcomes after PCI between PLWH and uninfected controls. Methods and Results We utilized procedural registry data from the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program between January 1, 2009 and December 31, 2019 to analyze patients with obstructive coronary artery disease on angiography. In the PCI subgroup, we used inverse probability of treatment weighting and applied Cox proportional hazards to evaluate the association of HIV serostatus with outcomes, including all-cause mortality at 5 years. Among 184 310 patients with obstructive coronary artery disease, treatment strategy was similar between PLWH and controls-35.7% versus 34.2% PCI, 13.6% versus 15% coronary artery bypass grafting, and 50.7% versus 50.8% medical therapy. The PCI cohort consisted of 546 (0.9%) PLWH and 56 811 (99.1%) controls. PLWH undergoing PCI had well-controlled HIV disease, and compared with controls, were younger, more likely to be Black, had fewer traditional risk factors, more acute coronary syndrome, less extensive coronary artery disease, and similar types of stents and P2Y12 therapy. However, PLWH experienced worse survival as early as 6 months post-PCI, which persisted over time and amounted to a 21% increased mortality risk by 5 years (hazard ratio, 1.21 [95% CI, 1.03-1.42; P=0.02]). Conclusions Despite well-controlled HIV disease, a more favorable overall cardiovascular risk profile, and similar PCI procedural metrics, PLWH still have significantly worse long-term survival following PCI than controls.
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Affiliation(s)
- Rushi V Parikh
- Division of Cardiology University of California, Los Angeles Los Angeles CA USA
| | - Annika Hebbe
- Rocky Mountain Regional Veterans Affairs Medical Center Aurora CO USA.,CART Program, Office of Quality and Patient Safety Veterans Health Administration Washington DC USA
| | - Anna E Barón
- Rocky Mountain Regional Veterans Affairs Medical Center Aurora CO USA.,Department of Biostatistics and Informatics University of Colorado Aurora CO USA
| | - Gary K Grunwald
- Rocky Mountain Regional Veterans Affairs Medical Center Aurora CO USA.,Department of Biostatistics and Informatics University of Colorado Aurora CO USA
| | - Mary E Plomondon
- CART Program, Office of Quality and Patient Safety Veterans Health Administration Washington DC USA
| | - Jonathan Gordin
- Division of Cardiology University of California, Los Angeles Los Angeles CA USA
| | - Robert W Yeh
- Smith Center for Outcomes Research in Cardiology, Division of Cardiology Beth Israel Deaconess Medical Center Boston MA USA
| | - Hani Jneid
- Division of Cardiology Baylor College of Medicine Houston TX USA
| | - Rajesh V Swaminathan
- Department of Medicine, Division of Cardiology Duke University School of Medicine Durham NC USA.,Duke Clinical Research Institute Durham NC USA.,Durham VA Healthcare System Durham NC USA
| | - Stephen W Waldo
- Rocky Mountain Regional Veterans Affairs Medical Center Aurora CO USA.,CART Program, Office of Quality and Patient Safety Veterans Health Administration Washington DC USA.,Division of Cardiology University of Colorado School of Medicine Aurora CO USA
| | - Alexander Monto
- San Francisco Veterans Affairs Medical Center San Francisco CA
| | - Eric Secemsky
- Smith Center for Outcomes Research in Cardiology, Division of Cardiology Beth Israel Deaconess Medical Center Boston MA USA
| | - Priscilla Y Hsue
- Division of Cardiology, Zuckerberg San Francisco General Hospital University of California, San Francisco San Francisco CA USA
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Karacsonyi J, Deffenbacher K, Benzuly KH, Flaherty JD, Alaswad K, Basir M, Megaly MS, Jaffer F, Doshi D, Poommipanit P, Khatri J, Patel M, Riley R, Sheikh A, Wollmuth JR, Korngold E, Uretsky BF, Yeh RW, Chandwaney RH, Elguindy AM, Tammam K, AbiRafeh N, Schmidt CW, Okeson B, Kostantinis S, Simsek B, Rangan BV, Brilakis ES, Schimmel DR. Use of Mechanical Circulatory Support in Chronic Total Occlusion Percutaneous Coronary Intervention. Am J Cardiol 2023; 189:76-85. [PMID: 36512989 DOI: 10.1016/j.amjcard.2022.10.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 10/03/2022] [Accepted: 10/21/2022] [Indexed: 12/14/2022]
Abstract
The use of mechanical circulatory support (MCS) in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. We analyzed the clinical and angiographic characteristics, and procedural outcomes of 7,171 CTO PCIs performed between 2012 and 2021 at 35 international centers. Mean age was 64.5 ± 10 years, mean left ventricular ejection fraction was 50 ± 13%. MCS was used in 4.5%, prophylactically in 78.7%, and urgently in 21.3%. The most common type of MCS overall was Impella CP (Abiomed) (55.5%), followed by intra-aortic balloon pump (14.8%) and TandemHeart (LivaNova Inc.) (10.0%). Prophylactic MCS patients were more likely to have diabetes mellitus (55% vs 42%, p <0.001) and had more complex lesions compared with cases without prophylactic MCS (Japan-CTO score: 2.80 ± 1.22 vs 2.39 ± 1.27, p <0.001). Cases with prophylactic MCS had similar technical (86% vs 87%, p = 0.643) but lower procedural (80% vs 86%, p = 0.028) success rates and higher rates of periprocedural major cardiac adverse events compared with no prophylactic MCS use (6.55% vs 1.68%, p <0.001). Urgent MCS use was associated with lower technical (68% vs 87%, p <0.001) and procedural (39% vs 86%, p <0.001) success rates and higher major cardiac adverse events compared with no-MCS use (32.26% vs 1.68%, p <0.001). The differences persisted in multivariable analyses. In summary, in this contemporary multicenter registry, MCS was used in 4.5% of CTO PCIs, mostly prophylactically (78.7%). Elective MCS cases had similar technical success but a higher risk of complications. Urgent MCS cases had lower technical and procedural success and higher periprocedural major complication rates.
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Affiliation(s)
- Judit Karacsonyi
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Karen Deffenbacher
- Interventional Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Keith H Benzuly
- Interventional Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - James D Flaherty
- Interventional Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Khaldoon Alaswad
- Interventional Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Mir Basir
- Interventional Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Michael S Megaly
- Interventional Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Farouc Jaffer
- Cardiovascular Research Center, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Darshan Doshi
- Cardiovascular Research Center, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Paul Poommipanit
- Cardiac Catheterization Laboratory, University Hospitals, Case Western Reserve University, Cleveland, Ohio
| | | | - Mitul Patel
- Interventional Cardiology, VA San Diego Healthcare System and University of California San Diego, San Diego, California
| | - Robert Riley
- Cardiology, Overlake Medical Center, Bellevue, Washington
| | - Abdul Sheikh
- Cardiovascular Medicine, Wellstar Health System, Marietta, Georgia
| | - Jason R Wollmuth
- Interventional Cardiology, Providence Heart Institute, Portland, Oregon
| | - Ethan Korngold
- Interventional Cardiology, Providence Heart Institute, Portland, Oregon
| | - Barry F Uretsky
- Interventional Cardiology, Central Arkansas Veterans Healthcare System, and University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Robert W Yeh
- Medicine Department, Beth Israe, Deaconess Medical Center, Boston, Massachusetts
| | - Raj H Chandwaney
- Interventional Cardiology, Oklahoma Heart Institute, Tulsa, Oklahoma
| | - Ahmed M Elguindy
- Department of Cardiology, Aswan Heart Centre, Magdi Yacoub Foundation, Aswan, Egypt
| | - Khalid Tammam
- Interventional Cardiology, International Medical Center, Jeddah, Saudi Arabia
| | - Nidal AbiRafeh
- Cardiology, North Oaks Health System, Hammond, Louisiana
| | - Christian W Schmidt
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Brynn Okeson
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Spyridon Kostantinis
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Bahadir Simsek
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Bavana V Rangan
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Emmanouil S Brilakis
- Center for Coronary Artery Disease, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Daniel R Schimmel
- Interventional Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
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Kramer DB, Yeh RW. Quantitative Analyses of Regulatory Policies for Medical Devices: Matching the Methods to the Moment. JAMA 2023; 329:467-469. [PMID: 36626181 DOI: 10.1001/jama.2022.23888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Daniel B Kramer
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Salisbury AC, Grantham JA, Brown WM, Ballard WL, Allen KB, Kirtane AJ, Argenziano M, Yeh RW, Khabbaz K, Lasala J, Kachroo P, Karmpaliotis D, Moses J, Lombardi WL, Nugent K, Ali Z, Gosch KL, Spertus JA, Kandzari DE. Outcomes of Medical Therapy Plus PCI for Multivessel or Left Main CAD Ineligible for Surgery. JACC Cardiovasc Interv 2023; 16:261-273. [PMID: 36792252 DOI: 10.1016/j.jcin.2023.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 12/09/2022] [Accepted: 01/02/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) is increasingly used to revascularize patients ineligible for CABG, but few studies describe these patients and their outcomes. OBJECTIVES This study sought to describe characteristics, utility of risk prediction, and outcomes of patients with left main or multivessel coronary artery disease ineligible for coronary bypass grafting (CABG). METHODS Patients with complex coronary artery disease ineligible for CABG were enrolled in a prospective registry of medical therapy + PCI. Angiograms were evaluated by an independent core laboratory. Observed-to-expected 30-day mortality ratios were calculated using The Society for Thoracic Surgeons (STS) and EuroSCORE (European System for Cardiac Operative Risk Evaluation) II scores, surgeon-estimated 30-day mortality, and the National Cardiovascular Data Registry (NCDR) CathPCI model. Health status was assessed at baseline, 1 month, and 6 months. RESULTS A total of 726 patients were enrolled from 22 programs. The mean SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score was 32.4 ± 12.2 before and 15.0 ± 11.7 after PCI. All-cause mortality was 5.6% at 30 days and 12.3% at 6 months. Observed-to-expected mortality ratios were 1.06 (95% CI: 0.71-1.36) with The Society for Thoracic Surgeons score, 0.99 (95% CI: 0.71-1.27) with the EuroSCORE II, 0.59 (95% CI: 0.42-0.77) using cardiac surgeons' estimates, and 4.46 (95% CI: 2.35-7.99) using the NCDR CathPCI score. Health status improved significantly from baseline to 6 months: SAQ summary score (65.9 ± 22.5 vs 86.5 ± 15.1; P < 0.0001), Kansas City Cardiomyopathy Questionnaire summary score (54.1 ± 27.2 vs 82.6 ± 19.7; P < 0.0001). CONCLUSIONS Patients ineligible for CABG who undergo PCI have complex clinical profiles and high disease burden. Following PCI, short-term mortality is considerably lower than surgeons' estimates, similar to surgical risk model predictions but is over 4-fold higher than estimated by the NCDR CathPCI model. Patients' health status improved significantly through 6 months.
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Affiliation(s)
- Adam C Salisbury
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri-Kansas City, Kansas City, Missouri, USA.
| | - J Aaron Grantham
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri-Kansas City, Kansas City, Missouri, USA
| | | | | | - Keith B Allen
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Ajay J Kirtane
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York, USA
| | - Michael Argenziano
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York, USA
| | - Robert W Yeh
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kamal Khabbaz
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - John Lasala
- Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Puja Kachroo
- Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Dimitri Karmpaliotis
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York, USA
| | - Jeffrey Moses
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York, USA
| | | | - Karen Nugent
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - Ziad Ali
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York, USA
| | - Kensey L Gosch
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri-Kansas City, Kansas City, Missouri, USA
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Narasimmaraj PR, Oseran A, Tale A, Xu J, Essien UR, Kazi DS, Yeh RW, Wadhera RK. Out-of-Pocket Drug Costs for Medicare Beneficiaries with Cardiovascular Risk Factors/Conditions Under the Inflation Reduction Act. J Am Coll Cardiol 2023; 81:1491-1501. [PMID: 37045519 DOI: 10.1016/j.jacc.2023.02.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 02/02/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND High out-of-pocket prescription drug costs contribute to financial toxicity, medication nonadherence, and adverse cardiovascular (CV) outcomes. Policymakers recently passed the Inflation Reduction Act, which will cap Medicare out-of-pocket drug costs at $2,000/year and expand full low-income subsidies (LIS). It is unclear how these provisions will affect Medicare beneficiaries with CV risk factors and/or conditions. OBJECTIVES The authors sought to characterize the population of Medicare beneficiaries with CV risk factors/conditions experiencing out-of-pocket prescription drug costs >$2,000/year and estimate their potential savings under the Inflation Reduction Act's spending cap; identify sociodemographic characteristics associated with out-of-pocket costs >$2,000/year; and characterize beneficiaries newly eligible for LIS under the Inflation Reduction Act. METHODS This was a cross-sectional study of Medicare beneficiaries aged ≥65 years with ≥1 CV risk factor/condition from 2016 to 2019. RESULTS An annual estimated 34,056,335 ± 855,653 Medicare beneficiaries (mean ± SE) had ≥1 CV risk factor/condition, of whom 1,020,484 ± 77,055 experienced out-of-pocket drug costs >$2,000/year. The likelihood of experiencing out-of-pocket drug costs >$2,000/year was lower among adults ≥75 years vs 65 to 74 years (adjusted OR: 0.67; 95% CI: 0.49-0.93) and for low-income vs higher-income adults. Among beneficiaries currently spending >$2,000/year, estimated median out-of-pocket drug savings would be $855/year and total annual savings $1,723,031,307 ± $91,150,609 under the Inflation Reduction Act. An estimated 1,289,861 beneficiaries would also become newly eligible for LIS. CONCLUSIONS More than 1 million older adults with CV risk factors and/or conditions spend >$2,000/year out-of-pocket on prescription drugs and will likely benefit from the Inflation Reduction Act's cap, with estimated total out-of-pocket savings of $1.7 billion/year, while another 1.3 million will also become newly eligible for LIS.
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Chung M, Butala NM, Faridi KF, Almarzooq ZI, Liu D, Xu J, Song Y, Baron SJ, Shen C, Kazi DS, Yeh RW. Days at home after transcatheter or surgical aortic valve replacement in high-risk patients. Am Heart J 2023; 255:125-136. [PMID: 36309128 DOI: 10.1016/j.ahj.2022.10.080] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 05/26/2022] [Revised: 10/14/2022] [Accepted: 10/20/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Days at home (DAH) quantifies time spent at home after a medical event but has not been fully evaluated for TAVR. We sought to compare 1- and 5-year DAH (DAH365, DAH1825) among high-risk patients participating in a randomized trial of transcatheter aortic valve replacement (TAVR) with a self-expanding bioprosthesis versus surgical aortic valve replacement (SAVR). METHODS We linked data from the U.S. CoreValve High Risk Trial to Medicare Fee-for-Service claims in 456 patients with 450 (234 TAVR/216 SAVR) and 427 (222 TAVR/205 SAVR) analyzed at 1 and 5 years. DAH was calculated as the number of days alive and spent outside of a hospital, skilled nursing facility, rehabilitation, long-term acute care hospital, emergency department, or observation stay. RESULTS Mean DAH365 was higher in patients who underwent TAVR compared with SAVR (295.1 ± 106.9 vs 267.8 ± 122.3, difference in days 27.2 [95% CI 6.0, 48.5], P = .01). Compared with SAVR, TAVR patients had a shorter index length of stay (LOS) (7.4 ± 4.5 vs 12.5 ± 9.0, difference in days -5.1 [-6.5, -3.8], P < .001). The largest contributions to decreased DAH365 were mortality days and total facility days after discharge from the index hospitalization (mortality days-TAVR: 34.7 ± 93.1 vs SAVR: 48.0 ± 108.8, difference in days -13.3 [95% CI -32.1, 5.5], P = .17; total facility days-TAVR: 27.9 ± 47.4 vs SAVR: 36.7 ± 48.9, difference in days -8.8 [95% CI -17.8, 0.1], P = .05). Mean DAH1825 was numerically but not statistically significantly higher in TAVR (TAVR: 1154.2 ± 659.0 vs SAVR: 1067.6 ± 697.3, difference in days 86.6 [95% CI -42.3, 215.6], P = .19). Landmark analysis showed no difference in DAH from years 1 to 5 (TAVR: 1040.4 ± 477.5 vs SAVR: 1022.9 ± 489.3, P = .74). CONCLUSIONS In the U.S. CoreValve High Risk Trial linked to Medicare, high-risk patients undergoing TAVR spend an average of 27 additional DAH compared with SAVR in the first year after the procedure due to a shorter index LOS and the additive effect of fewer but nonsignificantly different mortality and total facility days after discharge from the index hospitalization compared with SAVR. After the first year, both groups spend a similar number of DAH. These results describe the postprocedural course of high-risk patients from a patient-centered perspective, which may guide expectations regarding longitudinal health care needs and inform shared decision-making.
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Affiliation(s)
- Mabel Chung
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA; Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
| | - Neel M Butala
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Kamil F Faridi
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Zaid I Almarzooq
- Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Dingning Liu
- Baim Institute for Clinical Research, Boston, MA
| | - Jiaman Xu
- Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Yang Song
- Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Suzanne J Baron
- Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Department of Cardiology, Lahey Hospital & Medical Center, Burlington, MA
| | - Changyu Shen
- Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Biogen, Cambridge, MA
| | - Dhruv S Kazi
- Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Robert W Yeh
- Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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Sedhom R, Cortese B, Khedr M, Bharadwaj A, Brilakis ES, Pershad A, Basir MB, Alaswad K, Yeh RW, Megaly M. Utilization of Non-Drug-Eluting Devices for Inpatient Percutaneous Coronary Intervention in the United States. Am J Cardiol 2023; 186:209-215. [PMID: 36328830 DOI: 10.1016/j.amjcard.2022.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/11/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022]
Abstract
There is a paucity of data on the contemporary use of non-drug-eluting devices (balloon angioplasty or bare-metal stents) in contemporary percutaneous coronary intervention (PCI) in the United States. We utilized the Nationwide Readmissions Database to identify patients hospitalized to undergo PCI with non-drug-eluting devices from 2016 to 2019. The main outcome of interest was the trends in utilization over the study years. Among 1,870,262 PCI procedures, 127,810 (6.8%) were performed with non-drug-eluting devices; 72% of these were in the setting of acute myocardial infarction (MI). The use of non-drug-eluting devices decreased throughout the study period from 12.9% of all PCI in the first quarter of 2016 to 3.4% in the last quarter of 2019 (p <0.001). Factors associated with their use included advanced age and high bleeding risk. Only a small percentage were used as a bridge to coronary artery bypass graft surgery (2%) and for treatment of in-stent restenosis (3%). The in-hospital mortality was 5.8% for the entire cohort and 6.6% when the indication for use was an acute MI. In patients presenting with an acute MI, reinfarction within 30 days was common and occurred in 18% of the patients. In conclusion, the use of non-drug-eluting devices in PCI in the United States decreased from 2016 to 2019. Factors associated with their use included old age and high bleeding risk. Due to suboptimal outcomes in patients currently being treated with non-drug-eluting devices, there remains an unmet clinical need for alternative treatment options.
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Affiliation(s)
- Ramy Sedhom
- Division of Cardiology, Loma Linda University Health, Loma Linda, California
| | - Bernardo Cortese
- Foundation for Cardiovascular Research and Innovation, Milan, Italy
| | - Mohamed Khedr
- Faculty of Medicine, Menoufia University, Menoufia, Egypt
| | - Aditya Bharadwaj
- Division of Cardiology, Loma Linda University Health, Loma Linda, California
| | | | - Ashish Pershad
- Division of Cardiology, Chandler Regional Medical Center, Chandler, Arizona
| | - Mir B Basir
- Department of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Khaldoon Alaswad
- Department of Cardiology, Henry Ford Hospital, Detroit, Michigan
| | - Robert W Yeh
- Department of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Michael Megaly
- Department of Cardiology, Henry Ford Hospital, Detroit, Michigan.
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Secemsky EA, Barrette E, Bockstedt L, Yeh RW. Assessment of the Social Security Administration Death Master File for Comparative Analysis Studies of Peripheral Vascular Devices. Value Health 2023; 26:55-59. [PMID: 35680547 PMCID: PMC9722978 DOI: 10.1016/j.jval.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 04/04/2022] [Accepted: 05/01/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES The objective of this study was to assess the reliability the Social Security Administration Death Master File (SSADMF) for evaluating mortality in comparative peripheral vascular device studies. METHODS We leveraged 2 versions of an administrative claims data set that were identical except for the source of mortality data. The SSADMF was the primary source of mortality records in one version. The SSADMF was combined with mortality from Medicare beneficiary records in the other. Our study was set in the context of a comparative effectiveness analysis of recent Food and Drug Administration interest involving peripheral paclitaxel-coated devices. Mortality of patients with Medicare Advantage insurance coverage from 2015 to 2018 who underwent femoropopliteal artery revascularization with a drug-coated device (DCD) or non-DCD was assessed through 2019. Covariate differences between treatment groups were adjusted by inverse propensity treatment weighting. The hazard ratio of DCD to non-DCD mortality was estimated using Cox regression. RESULTS The cumulative incidences of mortality differed substantially between versions of the data. Nevertheless, we could not reject the null hypothesis that the hazard ratios of the SSADMF (1.05; 95% confidence interval 0.95-1.17) and the Master Beneficiary Summary File/SSADMF (1.03; 95% confidence interval 0.96-1.11) were the same (P = .63). CONCLUSIONS The SSADMF is a common source of mortality records in the United States that can be linked to real-world data sources but is known to underreport mortality rates. We find that the SSADMF provides a reliable source of all-cause mortality for a comparative study assessing the safety of peripheral vascular devices.
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Affiliation(s)
- Eric A Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | | | | | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Raja A, Wadhera RK, Choi E, Chen S, Shen C, Figueroa JF, Yeh RW, Secemsky EA. Association of Clinical Setting With Sociodemographics and Outcomes Following Endovascular Femoropopliteal Artery Revascularization in the United States. Circ Cardiovasc Qual Outcomes 2023; 16:e009199. [PMID: 36472193 PMCID: PMC9851941 DOI: 10.1161/circoutcomes.122.009199] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 09/13/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND After the Centers for Medicare and Medicaid Services modified reimbursement rates for outpatient peripheral vascular intervention in 2008 with the intent of improving access to care, providers began to increasingly perform peripheral vascular interventions in privately owned office-based clinics. Little is known about the characteristics of patients treated in this setting and their long-term outcomes as compared with those treated in hospital-based centers. METHODS In this retrospective cohort study, Medicare beneficiaries ≥66 years undergoing outpatient femoropopliteal peripheral vascular interventions in office-based clinics and hospital-based centers from 2015 to 2017 were identified. Sociodemographics, comorbidities, and institutional characteristics were compared across sites. Multivariable Cox proportional hazards models were used to estimate the adjusted associations between practice site location and outcomes. The primary outcome was the composite of major amputation or death analyzed through the end of follow-up. RESULTS Among 134 869 patients, 29.9% were treated in office-based clinics and 70.1% in hospital-based centers. Patients treated in office-based clinics were more often Black (16.9% versus 11.9%), dually enrolled in Medicaid (26.3% versus 19.6%), and residents of lower-resourced regions (32.6% versus 25.6%). Over a median follow-up time of 800 days (interquartile range, 531-1119 days), patients treated in office-based clinics had reduced risks of major amputation or death compared with outpatients treated in hospital-based centers (hazard ratio, 0.92 [95% CI, 0.89-0.95]). They also had lower adjusted all-cause mortality (hazard ratio, 0.93 [95% CI, 0.90-0.96]), major lower extremity amputation (hazard ratio, 0.84 [95% CI, 0.79-0.89]), and all-cause hospitalization (hazard ratio, 0.86 [95% CI, 0.84-0.88]). These findings persisted after stratification by critical limb ischemia, race, dual enrollment, and regional socioeconomic status, as well as among operators treating patients in both clinical settings. CONCLUSIONS In this large nationwide analysis of Medicare beneficiaries, office-based clinics treated a more socioeconomically disadvantaged population compared with hospital-based centers. Long-term outcomes were comparable between locations. As such, these clinics appear to be selecting lower-risk patients for outpatient peripheral vascular interventions, although there remains the possibility of unmeasured confounding.
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Affiliation(s)
- Aishwarya Raja
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine; Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Rishi K. Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine; Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Cardiology, Department of Medicine; Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Eunhee Choi
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine; Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Siyan Chen
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine; Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Changyu Shen
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine; Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine; Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Cardiology, Department of Medicine; Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Eric A. Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine; Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Cardiology, Department of Medicine; Beth Israel Deaconess Medical Center, Boston, MA, USA
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Kostantinis S, Simsek B, Karacsonyi J, Alaswad K, Krestyaninov O, Khelimskii D, Karmpaliotis D, Jaffer FA, Khatri JJ, Poommipanit P, Choi JW, Jaber WA, Rinfret S, Nicholson W, Patel MP, Mahmud E, Dattilo P, Gorgulu S, Koutouzis M, Tsiafoutis I, Elbarouni B, Sheikh AM, Uretsky BF, ElGuindy AM, Jefferson BK, Patel TN, Wollmuth J, Riley RF, Benton SM, Davies RE, Chandwaney RH, Toma C, Yeh RW, Schimmel DR, Abi Rafeh N, Goktekin O, Kerrigan JL, Mastrodemos OC, Rangan BV, Garcia S, Sandoval Y, Burke MN, Brilakis E. In-hospital outcomes and temporal trends of percutaneous coronary interventions for chronic total occlusion. EUROINTERVENTION 2022; 18:e929-e932. [PMID: 36065983 PMCID: PMC9743233 DOI: 10.4244/eij-d-22-00599] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 08/02/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Spyridon Kostantinis
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Bahadir Simsek
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Judit Karacsonyi
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Khaldoon Alaswad
- Cardiovascular Division, Henry Ford Hospital Cardiology Heart Care, Detroit, MI, USA
| | | | | | | | | | | | - Paul Poommipanit
- University Hospitals, Case Western Reserve University, Cleveland, OH, USA
| | - James W Choi
- Texas Health Presbyterian Hospital, Dallas, TX, USA
| | | | | | | | | | | | - Philip Dattilo
- UC Health Medical Center of the Rockies, Loveland, CO, USA
| | | | | | | | - Basem Elbarouni
- St. Boniface General Hospital, Winnipeg, Manitoba, MB, Canada
| | | | - Barry F Uretsky
- Central Arkansas Veterans Healthcare System, Little Rock, AR, USA
| | | | | | - Taral N Patel
- Tristar Centennial Medical Center, Nashville, TN, USA
| | - Jason Wollmuth
- Providence Heart and Vascular Institute, Portland, OR, USA
| | | | | | | | | | - Catalin Toma
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Robert W Yeh
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | | | | | - Olga C Mastrodemos
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Bavana V Rangan
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Santiago Garcia
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Yader Sandoval
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - M Nicholas Burke
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Emmanouil Brilakis
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA
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50
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Oseran AS, Yeh RW. Time to Treatment in ST-Segment Elevation Myocardial Infarction: Identifying Dangerous Delays or Diminishing Returns? JAMA 2022; 328:2016-2017. [PMID: 36335507 DOI: 10.1001/jama.2022.19441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Andrew S Oseran
- Richard A. and Susan F. Smith Center for Outcomes Research, Cardiology Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Division of Cardiology, Massachusetts General Hospital, Boston
| | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Cardiology Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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