Sex Differences in the Use of Oral Anticoagulants for Atrial Fibrillation: A Report From the National Cardiovascular Data Registry (NCDR®) PINNACLE Registry

BACKGROUND

Despite higher thromboembolism risk, women with atrial fibrillation have lower oral anticoagulation (OAC) use compared to men. The influence of the CHA2DS2-VASc score or the introduction of non-vitamin K OACs on this relationship is not known.

METHODS AND RESULTS

Using the PINNACLE National Cardiovascular Data Registry from 2008 to 2014, we compared the association of sex with OAC use (warfarin or non-vitamin K OACs) overall and by CHA2DS2-VASc score and examined temporal trends in OAC use by sex. Multivariable regression models assessed the association between sex and OAC use in those with CHA2DS2-VASc scores ≥2. Temporal analyses assessed changes in OAC use by sex over time. Of the 691 906 atrial fibrillation patients, 48.5% were women. Women were significantly less likely than men to use any OAC overall (56.7% versus 61.3%; P<0.001) and at all levels of CHA2DS2-VASc score (adjusted risk ratio 9% to 33% lower, all P<0.001). Compared to other thromboembolic risk factors, female sex was associated with lower use of OAC (risk ratio 0.90, 95%CI 0.90-0.91). Over time, non-vitamin K OAC use increased at a slightly higher rate in women (56.2% increase per year, 95%CI 54.6% to 57.9%) compared to men (53.6% increase per year, 95%CI 52.0% to 55.2%), yet women remained less likely to receive any OAC at all time points (P<0.001).

CONCLUSIONS

Among patients with atrial fibrillation, women were significantly less likely to receive OAC at all levels of the CHA2DS2-VASc score. Despite increasing non-vitamin K OAC use, women had persistently lower rates of OAC use compared to men over time.

Outcomes Among Older Patients Receiving Implantable Cardioverter-Defibrillators for Secondary Prevention: From the NCDR ICD Registry

BACKGROUND

Clinical trials of implantable cardioverter-defibrillators (ICDs) for secondary prevention of sudden cardiac death were conducted nearly 2 decades ago and enrolled few older patients.

OBJECTIVES

This study assessed morbidity and mortality of older patients receiving ICDs for secondary prevention in contemporary clinical practice.

METHODS

We identified 12,420 Medicare beneficiaries from the National Cardiovascular Data Registry ICD Registry undergoing first-time secondary prevention ICD implantation between 2006 and 2009 in 956 U.S. hospitals. Risks of death, hospitalization, and admission to a skilled nursing facility (SNF) were assessed over 2 years in age strata (65 to 69, 70 to 74, 75 to 79, and ≥80 years of age) using Medicare claims. The adjusted association between age and outcomes was evaluated using multivariable models.

RESULTS

The mean age was 75 years at the time of implantation; 25.3% were <70 years of age and 25.7% were ≥80 years of age. Overall, the risk of death at 2 years was 21.8%, ranging from 14.7% among those <70 years of age to 28.9% among those ≥80 years of age (adjusted risk ratio [aRR]: 2.01; 95% confidence interval [CI]: 1.85 to 2.33; p for trend <0.001). The cumulative incidence of hospitalizations was 65.4%, ranging from 60.5% in those <70 years of age to 71.5% in those ≥80 years of age (aRR: 1.27; 95% CI: 1.19 to 1.36; p for trend <0.001). The cumulative incidence of admission to a SNF ranged from 13.1% among those <70 years of age to 31.9% among those ≥80 years of age (aRR: 2.67; 95% CI: 2.37 to 3.01; p for trend <0.001); SNF admission risk was highest in the first 30 days.

CONCLUSIONS

Almost 4 in 5 older patients receiving a secondary prevention ICD survives at least 2 years. High hospitalization and SNF admission rates, particularly among the oldest patients, identify substantial care needs after device implantation.

Abstract 168: Racial and Ethnic Differences in Contemporary Use of Left Ventricular Assist Device

Background: Rates of receipt of left ventricular assist devices (LVADs) are less than expected for racial/ethnic minorities. A major etiology of this disparity changed over the past few years with broader access to insurance. Thus, we hypothesized that changes in the census-adjusted rate of receipt of LVADs would be higher for racial/ethnic minorities than Caucasians independent of sex and age.

Methods: Using the Interagency Registry of Mechanically Assisted Circulatory Support, we analyzed 10,795 patients (African-American 24.8%, Asian 1.5%, Caucasian 67.4%, Hispanic 6.3%, female 21.4%) who had an LVAD implanted between 2012-2015. Linear models were fit to annual census-adjusted rate of LVAD implantation, and the rate of change in receipt of LVADs was compared for each racial/ethnic minority to Caucasians, stratified by sex and age group.

Results: Between 2012 and 2015, African-Americans had an increase in the census-adjusted annual rate of receipt of LVADs per 100,000 [+0.26 (95% CI: 0.17-0.34)], while others exhibited no significant changes [Caucasian: +0.06 (95%CI: -0.03-0.14); Hispanic: +0.04 (95%CI: -0.05-0.12); Asian: +0.04 (95%CI: -0.04-0.13)]. When stratified by sex, the observed increase in rate of receipt of LVAD for African-Americans relative to Caucasians was present for both sexes [African-American women: +0.14 (95%CI: 0.01-0.27); African-American men: +0.28 (95%CI: 0.15-0.41)]. No increase was observed in either sex among other racial/ethnic groups ( Figure 1a ). When stratified by age group, the observed increase in rate of receipt of LVAD for African-Americans relative to Caucasians was limited to those aged 40-59 years [African-Americans aged: 20-39: +0.09 (95%CI: -0.20-0.39); 40-49: +0.41 (95%CI: 0.11-0.70); 50-59: +0.31 (95%CI: 0.01-0.60); 60-69: +0.22 (95%CI: -0.08-0.51); 70+: +0.07 (95%CI: -0.23-0.36)]. No differences by age group were observed among other racial/ethnic groups compared to Caucasians ( Figure 1b) .

Conclusions: From 2012-2015, rates of receipt of LVADs increased for African-Americans but not other racial/ethnic groups in comparison to Caucasians. Similar patterns were seen when stratified by sex. When stratified by age, the increase in rate was limited to middle-aged African-Americans.

The Affordable Care Act Medicaid Expansion Correlated With Increased Heart Transplant Listings in African-Americans But Not Hispanics or Caucasians

OBJECTIVES

The aim of this study was to determine if the Affordable Care Act (ACA) Medicaid Expansion was associated with increased census-adjusted heart transplant listing rates for racial/ethnic minorities.

BACKGROUND

Underinsurance limits access to transplants, especially among racial/ethnic minorities. Changes in racial/ethnic listing rates post-ACA Medicaid Expansion are unknown.

METHODS

Using the Scientific Registry of Transplant Recipients, we analyzed 5,651 patients from early adopter states (implemented the ACA Medicaid Expansion by January 2014) and 4,769 patients from non-adopter states (no implementation during the study period) from 2012 to 2015. Piecewise linear models, stratified according to race/ethnicity, were fit to monthly census-adjusted rates of heart transplant listings before and after January 2014.

RESULTS

A significant 30% increase in the rate of heart transplant listings for African-American patients in early adopter states occurred immediately after the ACA Medicaid Expansion on January 1, 2014 (before 0.15 to after 0.20/100,000; increase 0.05/100,000; 95% confidence interval [CI]: 0.01 to 0.08); in contrast, the rates for African-American patients in non-adopter states remained constant (before and after 0.15/100,000; increase 0.006/100,000; 95% CI: -0.03 to 0.04). Hispanic patients experienced an opposite trend, with no significant change in early adopter states (before 0.03 to after 0.04/100,000; increase 0.01/100,000; 95% CI: -0.004 to 0.02) and a significant increase in non-adopter states (before 0.03 to after 0.05/100,000; increase 0.02/100,000; 95% CI: 0.002 to 0.03). There were no significant changes in listing rates among Caucasian patients in either early adopter states or non-adopter states.

CONCLUSIONS

Implementation of the ACA Medicaid Expansion was associated with increased heart transplant listings in African-American patients but not in Hispanic or Caucasian patients. Broadening of the ACA in states with large African-American populations may reduce disparities in heart transplant listings.

Abstract 22: Impact of CHA2DS2-VASc Risk Factors on Anticoagulant Prescription in Patients with Atrial Fibrillation: Insights From the NCDR® PINNACLE Registry

Background: The CHA2DS2-VASc score is a tool to assess thromboembolic risk in patients with non-valvular atrial fibrillation (AF). Whether individual components of the CHA2DS2-VASc score are considered equivalent in decisions to use oral anticoagulant (OAC) in current clinical practice is unknown.

Method: Using data collected in the outpatient National Cardiovascular Data Registry (NCDR) PINNACLE registry from 2010-2014, OAC use (warfarin or novel anti-coagulants versus none) was compared in patients with non-valvular AF and an indication for OAC (CHA2DS2-VASc ≥ 2). We assessed the association between individual CHA2DS2VASc components (female gender, congestive heart failure (CHF), hypertension (HTN), age 64-75, age ≥ 75, diabetes mellitus (DM), vascular disease, and stroke/transient ischemic attack (TIA)) and OAC use, adjusting for demographics, clinical factors, modified HASBLED (mHASBLED) scores, and accounting for clustering by hospital and provider with multivariable logistic regression models.

Result: Of 706,308 patients with non-valvular AF and an indication for OAC use (CHA2DS2-VASc ≥2), 65% were white and mean age was 74.4±10.7. The mean CHA2DS2-VASc score was 3.93±1.42; 48% were female, 26% had CHF, 80% had HTN, 84% were age ≥ 65, 24% had DM, and 4% had stroke/TIA. Among this cohort with an indication for OAC use, in unadjusted models, female gender (OR 0.83, 95% CI 0.82-0.84) and vascular disease (OR 0.75, 95% CI 0.71-0.79) were associated with significantly less OAC use. In adjusted models, gender and vascular disease remained significantly associated lower OAC use whereas age and HTN were associated with higher OAC use. (FIGURE)

Conclusions: Among this cohort of AF patients with an indication for OAC use, older age and HTN were strongly associated with greater OAC use whereas female gender and vascular disease were associated with less OAC use. Further investigation is needed to understand reasons for these differences in how risk factors influence decisions to provide OAC, such as patient or provider preference or gender bias.

Geriatric Conditions in Patients Undergoing Defibrillator Implantation for Prevention of Sudden Cardiac Death: Prevalence and Impact on Mortality

BACKGROUND

Geriatric conditions may influence outcomes among patients receiving implantable cardioverter-defibrillators (ICDs). We sought to determine the prevalence of frailty and dementia among older adults receiving primary prevention ICDs and to determine the impact of multimorbidity on mortality within 1 year of ICD implantation.

METHODS AND RESULTS

The cohort included 83 792 Medicare patients from the National Cardiovascular Data Registry ICD Registry who underwent first primary prevention ICD implantation between 2006 and 2009. These data were merged with Medicare analytic files to determine the prevalence of frailty, dementia, and other conditions before ICD implantation, as well as 1-year mortality. A validated claim-based algorithm was used to identify frail patients. Mutually exclusive patterns of chronic conditions were examined. The association of each pattern with 1-year mortality was assessed using logistic regression models adjusted for selected patient characteristics. Approximately 1 in 10 Medicare patients with heart failure receiving a primary prevention ICD had frailty (10%) or dementia (1%). One-year mortality was 22% for patients with frailty, 27% for patients with dementia, and 12% in the overall cohort. Several multimorbidity patterns were associated with high 1-year mortality rates: dementia with frailty (29%), frailty with chronic obstructive pulmonary disease (25%), and frailty with diabetes mellitus (23%). These patterns were present in 8% of the cohort.

CONCLUSIONS

More than 10% of Medicare beneficiaries with heart failure receiving primary prevention ICDs have frailty or dementia. These patients had significantly higher 1-year mortality than those with other common chronic conditions. Frailty and dementia should be considered in clinical decision-making and guideline development.

Age and sex differences in long-term outcomes following implantable cardioverter-defibrillator placement in contemporary clinical practice: findings from the Cardiovascular Research Network

Background

Patient sex and age may influence rates of death after receiving an implantable cardioverter-defibrillator for primary prevention. Differences in outcomes other than mortality and whether these differences vary by heart failure symptoms, etiology, and left ventricular ejection fraction are not well characterized.

Methods and Results

We studied 2954 patients with left ventricular ejection fraction ≤0.35 undergoing first-time implantable cardioverter-defibrillator for primary prevention within the Cardiovascular Research Network; 769 patients (26%) were women, and 2827 (62%) were aged >65 years. In a median follow-up of 2.4 years, outcome rates per 1000 patient-years were 109 for death, 438 for hospitalization, and 111 for heart failure hospitalizations. Procedure-related complications occurred in 8.36%. In multivariable models, women had significantly lower risks of death (hazard ratio 0.67, 95% CI 0.56 to 0.80) and heart failure hospitalization (hazard ratio 0.82, 95% CI 0.68 to 0.98) and higher risks for complications (hazard ratio 1.38, 95% CI 1.01 to 1.90) than men; patients aged >65 years had higher risks of death (hazard ratio 1.55, 95% CI 1.30 to 1.86) and heart failure hospitalization (hazard ratio 1.25, 95% CI 1.05 to 1.49) than younger patients. Age and sex differences were generally consistent in strata according to symptoms, etiology, and severity of left ventricular systolic dysfunction, except the higher risk of complications in women, which differed by New York Heart Association classification (P=0.03 for sex–New York Heart Association interaction), and the risk of heart failure hospitalization in older patients, which differed by etiology of heart failure (P=0.05 for age–etiology interaction).

Conclusions

The burden of adverse outcomes after receipt of an implantable cardioverter-defibrillator for primary prevention is substantial and varies according to patient age and sex. These differences in outcome generally do not vary according to baseline heart failure characteristics.

Abstract 224: No Difference in Complications or Mortality by Implanted Cardioverter Defibrillator Type in Veterans Enrolled in The Outcomes Among Veterans with Implantable Devices (OVID) Registry

Introduction: Dual chamber ICD implantation has been associated with higher complication rates than single chamber ICD implantation without associated decrease in morbidity or mortality in prior reports. If this association is present using validated long term outcomes or whether the same is true for cardiac resynchronization therapy defibrillator (CRT-D) devices is not well described.

Methods: The OVID registry enrolled 3,918 veterans between 2003 and 2009. Retrospective chart abstraction from enrollment to implant date captured pre- and peri-procedural data. Patients were then followed prospectively until death or study conclusion. Abstraction was done by trained abstractors. Clinical outcomes and mortality were abstracted and validated. Mortality was cross referenced with the social security death index. Association of ICD type (single chamber, dual chamber, CRT-D) with mortality, non-fatal major events (major adverse cardiac events, TIA, stroke, cardiogenic syncope, cardiac hospitalization, device complication or infection, procedural complications), and the composite of mortality and non-fatal events was examined using Cox proportional hazards regression, adjusting for baseline clinical characteristics and comorbidities.

Results: There were 786 deaths and 1143 non-fatal major events over 11,290 person years of follow up. In unadjusted analyses, CRT-D was associated with non-fatal major events (HR 1.26, 95% CI 1.09-1.45; p<0.05) and the composite outcome (HR 1.12, 95% CI 1.06-1.35; p<0.05) as was Dual chamber ICD (non-fatal major-HR 1.19, 95% CI 1.03-1.37; p<0.05, composite-HR 1.17, 95% CI 1.04-1.31; p<0.05). No significant difference existed in risk between ICD types in the unadjusted analysis of mortality or for any outcome when adjusted for clinical covariates.

Conclusions: Unadjusted analyses showed an association between dual chamber ICD and CRT-D devices and risk of non-fatal major events and the composite outcome versus single chamber ICD implantation. This did not persist when adjusted for clinical characteristics and comorbidities, though we are underpowered for small differences. Further study is needed as prior reports may not have adjusted adequately for clinical covariates and lacked validated outcomes.

Abstract 180: Variation in the Use of Angiography Between Procedural and Non-procedural Cardiologists

Background: Physician specialty is associated with adherence to practice guidelines; clinical activities may influence management approaches when guidelines create equipoise. In a scenario in which either a non-invasive stress test or invasive angiography is appropriate, we hypothesized that cardiologists who perform cardiac procedures would be more likely to recommend an invasive approach compared to non-procedural cardiologists.

Methods: We developed a web-based, email survey with a 2-part standardized patient case. The first part described a patient with symptoms suggestive of obstructive coronary artery disease (CAD) the second part described an abnormal exercise treadmill test (ETT) result in that patient. In both parts, the scenario was designed to represent an intermediate likelihood of obstructive CAD. Providers were asked to rate the likelihood of obstructive CAD and choose between angiography and stress testing for that patient; both a secondary stress and angiography would be consistent with guidelines. Cardiologists were classified based on self-report to non-procedural (general, non-invasive, heart failure/transplant, congenital) or procedural (invasive, interventional, electrophysiology and cardiothoracic surgery) practice. Multivariable models were used to determine the association between procedural practice and referral for angiography controlling for provider factors (age, gender, years in practice, practice setting) and estimated likelihood of CAD for that patient.

Results: Of the 500 cardiologists who responded, 41.8% were procedural cardiologists. Procedural cardiologists similarly rated the patient as having a high likelihood for CAD (part 1: 38.8% vs 40.9%, p= 0.63; part 2: 81.8% vs 81.1%, p = 0.84) compared to non-procedural cardiologists. Although for a patient with intermediate risk of CAD by symptoms, more procedural cardiologists recommended direct angiography referral (12% vs 5.6%, p <0.01) than non-procedural cardiologists. In multivariable models, procedural practice remained associated with higher direct angiography referral (OR 2.67; 95% CI 1.30, 5.49, p= 0.008). After an intermediate risk ETT result, both groups recommended angiography more often (70.5% vs 68.2% p=0.58) than secondary stress testing.

Conclusions: Procedural cardiologists more often referred a patient with symptoms concerning for CAD directly for angiography compared to non-procedural cardiologists. When presented an abnormal stress test, both groups were equally likely to recommend angiography over additional stress testing. Therefore, clinical activities may influence management approaches; procedural cardiologists pursued an invasive approach earlier in the diagnostic pathway. Efforts to understand variation in invasive procedure use should take physician clinical activities into account.

Clinical effectiveness of cardiac resynchronization therapy versus medical therapy alone among patients with heart failure: analysis of the ICD Registry and ADHERE

Supplemental Digital Content is available in the text.

Background—

Cardiac resynchronization therapy with defibrillator (CRT-D) reduces morbidity and mortality among selected patients with heart failure in clinical trials. The effectiveness of this therapy in clinical practice has not been well studied.

Methods and Results—

We compared a cohort of 4471 patients from the National Cardiovascular Data Registry’s Implantable Cardioverter-Defibrillator (ICD) Registry hospitalized primarily for heart failure and who received CRT-D between April 1, 2006, and December 31, 2009, to a historical control cohort of 4888 patients with heart failure without CRT-D from the Acute Decompensated Heart Failure National Registry (ADHERE) hospitalized between January 1, 2002, and March 31, 2006. Both registries were linked with Medicare claims to evaluate longitudinal outcomes. We included patients from the ICD Registry with left ventricular ejection fraction ≤35% and QRS duration ≥120 ms who were admitted for heart failure. We used Cox proportional hazards models to compare outcomes with and without CRT-D after adjustment for important covariates. After multivariable adjustment, CRT-D was associated with lower 3-year risks of death (hazard ratio, 0.52; 95% confidence interval, 0.48–0.56; P<0.001), all-cause readmission (hazard ratio, 0.69; 95% confidence interval, 0.65–0.73; P<0.001), and cardiovascular readmission (hazard ratio, 0.60; 95% confidence interval, 0.56–0.64; P<0.001). The association of CRT-D with mortality did not vary significantly among subgroups defined by age, sex, race, QRS duration, and optimal medical therapy.

Conclusions—

CRT-D was associated with lower risks of mortality, all-cause readmission, and cardiovascular readmission than medical therapy alone among patients with heart failure in community practice.

Temporal trends in patient characteristics and outcomes among Medicare beneficiaries undergoing primary prevention implantable cardioverter-defibrillator placement in the United States, 2006-2010. Results from the National Cardiovascular Data Registry's Implantable Cardioverter-Defibrillator Registry

BACKGROUND

Contemporary patterns of use and outcomes of implantable cardioverter-defibrillators (ICDs) in community practice settings are not well characterized. We assessed temporal trends in patient characteristics and outcomes among older patients undergoing primary prevention ICD therapy in US hospitals between 2006 and 2010.

METHODS AND RESULTS

Using the National Cardiovascular Data Registry's ICD Registry, we identified Medicare fee-for-service beneficiaries aged ≥65 years and older with left ventricular ejection fraction ≤35% who underwent primary prevention ICD implantation, including those receiving concomitant cardiac resynchronization therapy between 2006 and 2010 and could be matched to Medicare claims. Outcomes were mortality and hospitalization (all-cause and heart failure) at 180 days, and device-related complications. We used multivariable hierarchical logistic regression to assess temporal trends in outcomes accounting for changes in patient, physician, and hospital characteristics. The cohort included 117 100 patients. Between 2006 and 2010, only modest changes in patient characteristics were noted. Fewer single lead devices and more cardiac resynchronization therapy devices were used over time. Between 2006 and 2010, there were significant improvements in all outcomes, including 6-month all cause mortality (7.1% in 2006, 6.5% 2010; adjusted odds ratio, 0.88; 95% confidence interval, 0.82-0.95), 6-month rehospitalization (36.3% in 2006, 33.7% in 2010; adjusted odds ratio, 0.87; 95% confidence interval, 0.83-0.91), and device-related complications (5.8% in 2006, 4.8% in 2010; adjusted odds ratio, 0.80; 95% confidence interval, 0.74-0.88).

CONCLUSIONS

The clinical characteristics of this national population of Medicare patients undergoing primary prevention ICD implantation were stable between 2006 and 2010. Simultaneous improvements in outcomes suggest meaningful advances in the care for this patient population.

Abstract 317: Outcomes after Primary Prevention Implantable Cardioverter Defibrillator Placement: Results of the Cardiovascular Research Network Longitudinal Study of Implantable Cardioverter Defibrillators

Background: Implantable cardioverter defibrillators (ICDs) are commonly used for the primary prevention of sudden cardiac death. Controversies persist, however, about outcomes in representative cohorts and in clinically important patient subgroups. Observational studies of outcomes following primary prevention ICD implantation are typically limited to relatively restricted cohorts (e.g. Medicare) or with short follow up.

Methods: In the Cardiovascular Research Network (CVRN), we conducted a study in 7 integrated health care delivery systems to identify patients undergoing primary prevention ICD implantation for left ventricular systolic dysfunction between 2006-2010. Baseline procedural and clinical data were obtained from the NCDR ICD Registry; longitudinal data to ascertain outcomes after implantation were obtained through clinical health system data from the CVRN Virtual Data Warehouse. We assessed the occurrence of complications at 90 days and mortality, all-cause hospitalization, and heart failure hospitalization up to 5 years after implantation in clinical strata designated a priori. Multivariable models accounting for clustering of patients within site were used to assess the relationship between clinical variables and each outcome. Clinical variables of interest (Table) were included in all models; additional variables were assessed with forward selection to account for possible confounders.

Results: Among 2953 eligible patients, median age was 69 years and 26% were women Coexisting conditions, including hypertension (74%), atrial fibrillation (32%), COPD (20%), and diabetes (42%), were common. Overall event rates (per 1000 patient years) were 110 for death, 438 for any hospitalization, and 58 for heart failure hospitalization. The association between clinically important variables and outcomes are shown in the Table.

Conclusions: In a diverse population of patients undergoing ICD implantation in contemporary practice we identified specific clinical variables associated with adverse outcomes. These data can inform prognosis in clinical care and guide the design of future trials of this therapy.

Comparative effectiveness of cardiac resynchronization therapy with an implantable cardioverter-defibrillator versus defibrillator therapy alone: a cohort study

BACKGROUND

Trials comparing implantable cardioverter-defibrillator (ICD) therapy with cardiac resynchronization therapy with a defibrillator (CRT-D) are limited to selected patients treated at centers with extensive experience.

OBJECTIVE

To compare outcomes after CRT-D versus ICD therapy in contemporary practice.

DESIGN

Retrospective cohort study using the National Cardiovascular Data Registry's ICD Registry linked with Medicare claims.

SETTING

780 U.S. hospitals implanting both CRT-D and ICD devices.

PATIENTS

7090 propensity-matched patients older than 65 years with reduced left ventricular ejection fraction (&lt;0.35) and prolonged QRS duration on electrocardiography (≥120 ms) having CRT-D or ICD implantation between 1 April 2006 and 31 December 2009.

MEASUREMENTS

Risks for death, readmission, and device-related complications over 3 years.

RESULTS

Compared with ICD therapy, CRT-D was associated with lower risks for mortality (cumulative incidence, 25.7% vs. 29.8%; adjusted hazard ratio [HR], 0.82 [99% CI, 0.73 to 0.93]), all-cause readmission (cumulative incidence, 68.6% vs. 72.8%; adjusted HR, 0.86 [CI, 0.81 to 0.93]), cardiovascular readmission (cumulative incidence, 45.0% vs. 52.4%; adjusted HR, 0.80 [CI, 0.73 to 0.88]), and heart failure readmission (cumulative incidence, 24.3% vs. 29.4%; adjusted HR, 0.78 [CI, 0.69 to 0.88]). It was also associated with greater risks for device-related infection (cumulative incidence, 1.9% vs. 1.0%; adjusted HR, 1.90 [CI, 1.07 to 3.37]). The lower risks for heart failure readmission associated with CRT-D compared with ICD therapy were most pronounced among patients with left bundle branch block or a QRS duration at least 150 ms and in women.

LIMITATIONS

Patients were not randomly assigned to treatment groups, and few patients could be propensity-matched. The findings may not extend to younger patients or those outside of fee-for-service Medicare.

CONCLUSION

In older patients with reduced left ventricular ejection fraction and prolonged QRS duration, CRT-D was associated with lower risks for death and readmission than ICD therapy alone.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality.

Hospital variation in intravenous inotrope use for patients hospitalized with heart failure: insights from Get With The Guidelines

BACKGROUND

Prior claims analyses suggest that the use of intravenous inotropic therapy for patients hospitalized with heart failure varies substantially by hospital. Whether differences in the clinical characteristics of the patients explain observed differences in the use of inotropic therapy is not known.

METHODS AND RESULTS

We sought to characterize institutional variation in inotrope use among patients hospitalized with heart failure before and after accounting for clinical factors of patients. Hierarchical generalized linear regression models estimated risk-standardized hospital-level rates of inotrope use within 209 hospitals participating in Get With The Guidelines-Heart Failure (GWTG-HF) registry between 2005 and 2011. The association between risk-standardized rates of inotrope use and clinical outcomes was determined. Overall, an inotropic agent was administered in 7691 of 126 564 (6.1%) heart failure hospitalizations: dobutamine 43%, dopamine 24%, milrinone 17%, or a combination 16%. Patterns of inotrope use were stable during the 7-year study period. Use of inotropes varied significantly between hospitals even after accounting for patient and hospital characteristics (median risk-standardized hospital rate, 5.9%; interquartile range, 3.7%-8.6%; range, 1.3%-32.9%). After adjusting for case-mix and hospital structural differences, model intraclass correlation indicated that 21% of the observed variation in inotrope use was potentially attributable to random hospital effects (ie, institutional preferences). Hospitals with higher risk-standardized inotrope use had modestly longer risk-standardized length of stay (P=0.005) but had no difference in risk-standardized inpatient mortality (P=0.12).

CONCLUSIONS

Use of intravenous inotropic agents during hospitalization for heart failure varies significantly among US hospitals even after accounting for patient and hospital factors.

Prevalence, correlates, and temporal trends in antiarrhythmic drug use at discharge after implantable cardioverter defibrillator placement (from the National Cardiovascular Data Registry [NCDR])

Patients with implantable cardioverter defibrillators (ICDs) can require antiarrhythmic drugs to manage arrhythmias and prevent device shocks. We sought to determine the prevalence, clinical correlates, and institutional variation in the use of antiarrhythmic drugs over time after ICD implantation. From the ICD Registry (2006 to 2011), we analyzed the trends in the use of antiarrhythmic agents prescribed at hospital discharge for patients undergoing first-time ICD placement. The patient, provider, and facility level variables associated with antiarrhythmic use were determined using multivariate logistic regression models. A median odds ratio was calculated to assess the hospital-level variation in the use of antiarrhythmic drugs. Of the cohort (n = 500,995), 15% had received an antiarrhythmic drug at discharge. The use of class III agents increased modestly (13.9% to 14.9%, p <0.01). Amiodarone was the most commonly prescribed drug (82%) followed by sotalol (10%). Among the subgroups, the greatest increase in prescribing was for patients who had received a secondary prevention ICD (26% in 2006% and 30% in 2011, p <0.01) or with a history of ventricular tachycardia (23% to 27%, p <0.01). The median odds ratio for antiarrhythmic prescription was 1.45, indicating that 2 randomly selected hospitals would have had a 45% difference in the odds of treating identical patients with an antiarrhythmic drug. In conclusion, antiarrhythmic drug use, particularly class III antiarrhythmic drugs, is common among ICD recipients at hospital discharge and varies by hospital, suggesting an influence from local treatment patterns. The observed hospital variation suggests a role for augmentation of clinical guidelines regarding the use of antiarrhythmic drugs for patients undergoing implantation of an ICD.

Guideline concordance of testing for hyperkalemia and kidney dysfunction during initiation of mineralocorticoid receptor antagonist therapy in patients with heart failure

BACKGROUND

Mineralocorticoid receptor antagonists (MRA) reduce morbidity and mortality in heart failure with reduced ejection fraction but can cause hyperkalemia and acute kidney injury. Guidelines recommend measurement of serum potassium (K) and creatinine (Cr) before and serially after MRA initiation, but the extent to which this occurs is unknown.

METHODS AND RESULTS

Using electronic data from 3 health systems 2005 to 2008, we performed a retrospective review of laboratory monitoring among 490 patients hospitalized for heart failure with reduced ejection fraction who were subsequently initiated on MRA therapy. Median age at time of MRA initiation was 73 years, and 37.1% were women. Spironolactone accounted for 99.4% of MRA use. Initial ambulatory MRA dispensing occurred at hospital discharge in 70.0% of cases. In the 30 days before MRA initiation, 94.3% of patients had a K or Cr measurement. Preinitiation K was >5.0 mmol/L in 1.4% and Cr>2.5 mg/dL in 1.7%. In the 7 days after MRA initiation among patients who remained alive and out of the hospital, 46.5% had no evidence of K measurement; by 30 days, 13.6% remained untested. Patient factors explained a small portion of postinitiation K testing (c-statistic, 0.67).

CONCLUSIONS

Although laboratory monitoring before MRA initiation for heart failure with reduced ejection fraction is common, laboratory monitoring after MRA initiation frequently does not meet guideline recommendations, even in patients at higher risk for complications. Quality improvement efforts that encourage the use of MRA should also include mechanisms to address recommended monitoring.

Variations in coronary artery disease secondary prevention prescriptions among outpatient cardiology practices: insights from the NCDR (National Cardiovascular Data Registry)

OBJECTIVES

This study assessed practice variations in secondary prevention medication prescriptions among coronary artery disease (CAD) patients treated in outpatient practices participating in the National Cardiovascular Data Registry (NCDR) Practice Innovation and Clinical Excellence (PINNACLE) registry.

BACKGROUND

Among patients with CAD, secondary prevention with a combination of beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and statins reduces cardiac mortality and myocardial infarction (MI). Accordingly, every CAD patient should receive the combination of these medications for which they are eligible. However, little is known about current prescription patterns of these medications and the variation in use among outpatient cardiology clinics.

METHODS

Using data from NCDR PINNACLE registry, a national outpatient cardiology practice registry, we assessed medication prescription patterns among eligible CAD patients, between July 2008 and December 2010. Overall rates of prescription and variation by practice were calculated, adjusting for patient characteristics.

RESULTS

Among 156,145 CAD patients in 58 practices, 103,830 (66.5%) patients were prescribed the optimal combination of medications for which they were eligible. The median rate of optimal combined prescription by practice was 73.5% and varied from 28.8% to 100%. After adjustment for patient factors, the practice median rate ratio for prescription was 1.25 (95% confidence interval: 1.20 to 1.32), indicating a 25% likelihood that 2 random practices would differ in treating identical CAD patients.

CONCLUSIONS

Among a national registry of CAD patients treated in outpatient cardiology practices, over one-third of patients failed to receive their optimal combination of secondary prevention medications. Significant variation was observed across practices, even after adjusting for patient characteristics, suggesting that quality improvement efforts may be needed to support more uniform practice.