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Lin KJ, Singer DE, Avorn J, Heist EK, Sreedhara SK, Anand P, Zhang Y, Tsacogianis TN, Schneeweiss S. Patient Characteristics Associated With Using Transcatheter Left Atrial Appendage Occlusion Versus Oral Anticoagulants for Atrial Fibrillation. Circ Cardiovasc Qual Outcomes 2024; 17:e010279. [PMID: 38440888 PMCID: PMC10950527 DOI: 10.1161/circoutcomes.123.010279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 11/30/2023] [Indexed: 03/06/2024]
Abstract
BACKGROUND Transcatheter left atrial appendage occlusion (LAAO) is an alternative to oral anticoagulants (OACs) for stroke prevention in patients with atrial fibrillation, but the predictors of LAAO use in routine care are unclear. We aimed to assess the utilization trends of LAAO and compare the change in characteristics of LAAO users versus OACs since its marketing. METHODS Using the US Medicare claims database (March 15, 2015, to December 31, 2020), we identified patients with atrial fibrillation, ≥65 years, and CHA2DS2-VASc score ≥2 (men) or ≥3 (women), with either first implantation of an LAAO device or initiation of OACs, including apixaban, dabigatran, rivaroxaban, edoxaban, or warfarin. Patient characteristics, measured 365 days before the first LAAO or OAC use date, were compared using logistic regression. RESULTS There were 30 058 LAAO recipients (mean age, 77.74 years; female, 42.1%) and 792 600 OAC initiators (mean age, 78.48; female, 53.3%). In 2020, patients had higher odds of initiating LAAO use than in 2015 (0.52 versus 9.32%; adjusted odds ratio [aOR], 13.64 [95% CI, 12.56-14.81]). Old age (ie, >85 versus 65-75 years; aOR, 0.84 [95% CI, 0.80-0.88]), female sex (aOR, 0.74 [95% CI, 0.71-0.76]), Black race (aOR, 0.63 [95% CI, 0.58-0.68]) versus White race, and Medicaid eligibility (aOR, 0.61 [95% CI, 0.58-0.64]) were associated with lower odds of receiving LAAO. Among clinical characteristics, frailty, cancer, fractures, and venous thromboembolism were associated with lower odds of LAAO use, while history of intracranial and extracranial bleeding, coagulopathy, and falls were associated with higher odds of receiving LAAO. CONCLUSIONS Among patients with atrial fibrillation receiving stroke-preventive therapy, LAAO use increased rapidly from 2015 to 2020 and was positively associated with the risk factors for OAC complications but negatively associated with old age, advanced frailty, and cancer. Black race and female sex were associated with a lower likelihood of receiving LAAO.
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Affiliation(s)
- Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School
| | - Daniel E Singer
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School
| | - Jerry Avorn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School
| | - E. Kevin Heist
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School
| | - Sushama Kattinakere Sreedhara
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School
| | - Priyanka Anand
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School
| | - Yichi Zhang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School
| | - Theodore N. Tsacogianis
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School
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Tertulien T, Bush K, Jackson LR, Essien UR, Eberly L. Racial and Ethnic Disparities in Implantable Cardioverter-Defibrillator Utilization: A Contemporary Review. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2023; 25:771-791. [PMID: 38873495 PMCID: PMC11172403 DOI: 10.1007/s11936-023-01025-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/20/2023] [Indexed: 06/15/2024]
Abstract
Purpose of review Sudden cardiac arrest is associated with high morbidity and mortality. Despite having a disproportionate burden of sudden cardiac death (SCD), rates of primary and secondary prevention of SCD with implantable cardioverter-defibrillator (ICD) therapy are lower among eligible racially minoritized patients. This review highlights the racial and ethnic disparities in ICD utilization, associated barriers to ICD care, and proposed interventions to improve equitable ICD uptake. Recent findings Racially minoritized populations are disproportionately eligible for ICD therapy but are less likely to see cardiac specialists, be counseled on ICD therapy, and ultimately undergo ICD implantation, fueling disparate outcomes. Racial disparities in ICD utilization are multifactorial, with contributions at the patient, provider, health system, and structural/societal level. Summary Racial and ethnic disparities have been demonstrated in preventing SCD with ICD use. Proposed strategies to mitigate these disparities must prioritize care delivery and access to care for racially minoritized patients, increase the diversification of clinical and implementation trial participants and the healthcare workforce, and center reparative justice frameworks to rectify a long history of racial injustice.
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Affiliation(s)
- Tarryn Tertulien
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kelvin Bush
- Division of Cardiology, San Antonio Military Medical Center, Fort Sam Houston, TX, USA
| | - Larry R. Jackson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Utibe R. Essien
- Division of General Internal Medicine – Health Services Research, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Lauren Eberly
- Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
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Boursalie S, MacIntyre C, Sapp JL, Gray C, Abdelwahab A, Gardner M, Lee D, Matheson K, Parkash R. Disparities in Referral and Utilization of Implantable Cardioverter-Defibrillators for Primary Prevention of Sudden Cardiac Death. Can J Cardiol 2023; 39:1610-1616. [PMID: 37423507 DOI: 10.1016/j.cjca.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/26/2023] [Accepted: 07/02/2023] [Indexed: 07/11/2023] Open
Abstract
BACKGROUND Implantable cardioverter-defibrillators (ICDs) reduce mortality in patients with reduced left ventricular ejection fraction (LVEF). We investigated sex disparities in a contemporary Canadian population for utilization of primary prevention ICDs. METHODS This was a retrospective cohort study on patients with reduced LVEF admitted to hospitals from 2010 to 2020 in Nova Scotia (population = 971,935). RESULTS There were 4406 patients eligible for ICDs: 3108 (71%) men and 1298 (29%) women. The mean follow-up time was 3.9 ± 3.0 years. Rates of coronary disease were similar between men and women (45.8% vs 44.0%; P = 0.28), but men had lower LVEF (26.6 ± 5.9% vs 27.2 ± 5.8%; P = 0.0017). The referral rate for ICD was 11% (n = 487), with 13% of men (n = 403) and 6.5% of women (n = 84) referred (P < 0.001). The ICD implantation rate in the population was 8% (n = 358), with 9.5% of men (n = 296) and 4.8% of women (n = 62) (P < 0.001) receiving the device. Men were more likely than women to receive an ICD (odds ratio 2.08, 95% confidence interval 1.61-2.70; P < 0.0001)). There was no significant difference in mortality between men and women (P = 0.2764). There was no significant difference in device therapies between men and women (43.8% vs 31.1%; P = 0.0685). CONCLUSIONS A significant disparity exists in the utilization of primary prevention ICDs between men and women in a contemporary Canadian population.
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Affiliation(s)
- Suzanne Boursalie
- Division of Cardiology, Department of Medicine, Dalhousie, University, Halifax, Nova Scotia, Canada
| | - Ciorsti MacIntyre
- Division of Cardiology, Department of Medicine, Dalhousie, University, Halifax, Nova Scotia, Canada
| | - John L Sapp
- Division of Cardiology, Department of Medicine, Dalhousie, University, Halifax, Nova Scotia, Canada
| | - Chris Gray
- Division of Cardiology, Department of Medicine, Dalhousie, University, Halifax, Nova Scotia, Canada
| | - Amir Abdelwahab
- Division of Cardiology, Department of Medicine, Dalhousie, University, Halifax, Nova Scotia, Canada
| | - Martin Gardner
- Division of Cardiology, Department of Medicine, Dalhousie, University, Halifax, Nova Scotia, Canada
| | - David Lee
- Division of Cardiology, Department of Medicine, Dalhousie, University, Halifax, Nova Scotia, Canada
| | - Kara Matheson
- Research Methods Unit, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Ratika Parkash
- Division of Cardiology, Department of Medicine, Dalhousie, University, Halifax, Nova Scotia, Canada.
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Kiernan K, Dodge SE, Kwaku KF, Jackson LR, Zeitler EP. Racial and ethnic differences in implantable cardioverter-defibrillator patient selection, management, and outcomes. Heart Rhythm O2 2022; 3:807-816. [PMID: 36589011 PMCID: PMC9795300 DOI: 10.1016/j.hroo.2022.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Racial and ethnic differences in treatment-cardiovascular and otherwise-have been documented in many aspects of the American health care system and can be seen in implantable cardioverter-defibrillator (ICD) patient selection, counseling, and management. ICDs have been demonstrated to be a powerful tool in the prevention of sudden cardiac death, yet uptake across all eligible patients has been modest. Although patients who do not identify as White are disproportionately eligible for ICDs in the United States, they are less likely to see specialists, be counseled on ICDs, and ultimately have an ICD implanted. This review explores racial and ethnic differences demonstrated in ICD patient selection, outcomes including shock effectiveness, and postimplantation monitoring for both primary and secondary prevention devices. It also highlights barriers for uptake at the health system, physician, and patient levels and suggests areas of further research needed to clarify the differences, illuminate the driving forces of these differences, and investigate strategies to address them.
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Affiliation(s)
- Katherine Kiernan
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Shayne E. Dodge
- Division of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Kevin F. Kwaku
- Division of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Larry R. Jackson
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Emily P. Zeitler
- Division of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- The Dartmouth Institute, Lebanon, New Hampshire
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5
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Judson GL, Cohen BE, Muniyappa A, Raitt MH, Shen H, Tarasovsky G, Whooley MA, Dhruva SS. Implantable cardioverter-defibrillator placement among patients with left ventricular ejection fraction ≤35 % at least 40 days after acute myocardial infarction. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 19:100186. [PMID: 37886349 PMCID: PMC10601204 DOI: 10.1016/j.ahjo.2022.100186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/16/2022] [Accepted: 07/18/2022] [Indexed: 10/28/2023]
Abstract
Background Implantable cardioverter-defibrillators (ICDs) reduce the risk of sudden cardiac death among patients with persistently reduced (≤35 %) left ventricular ejection fraction (LVEF) at least 40 days following acute myocardial infarction (AMI). Few prior studies have used LVEF measured after the 40-day waiting period to examine primary prevention ICD placement. Methods We sought to determine factors associated with ICD placement among patients who met LVEF criteria post-MI within a large integrated health care system in the U.S by conducting a retrospective cohort study of Veteran patients hospitalized for AMI from 2004 to 2017 who had documented LVEF ≤35 % from echocardiograms performed between 40 and 455 (90 days +1 year) days post-MI. We used multivariable logistic regression to examine factors associated with ICD placement. Results Of 12,893 patients with LVEF ≤35 % at least 40 days post-MI, 2176 (16.9 %) received an ICD between 91- and 455-days post-MI. Younger age, fewer comorbidities, revascularization with PCI, and greater use of GDMT were associated with increased odds of receiving an ICD. However, half of patients treated with a beta-blocker, ACE inhibitor or angiotensin receptor blocker, and mineralocorticoid receptor antagonist prior to LVEF assessment did not receive an ICD. Eligible Black patients were less likely (odds ratio 0.80, 95 % confidence interval 0.69-0.92) to receive an ICD than White patients. Conclusion Many factors affect ICD placement among Veteran patients with a confirmed LVEF ≤35 % at least 40 days post-MI. Greater understanding of factors influencing ICD placement would help clinicians ensure guideline-concordant care.
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Affiliation(s)
- Gregory L. Judson
- Division of Cardiology, Department of Medicine, University of California, San Francisco, CA, United States of America
| | - Beth E. Cohen
- Division of General Internal Medicine, University of California, San Francisco, CA, United States of America
- San Francisco Veterans Affairs Health Care System, CA, United States of America
| | - Anoop Muniyappa
- Clinical Informatics, University of California, San Francisco, CA, United States of America
| | - Merritt H. Raitt
- Knight Cardiovascular Institute, Oregon Health and Sciences University, Portland, OR, United States of America
- Portland Veterans Affairs Health Care System, OR, United States of America
| | - Hui Shen
- San Francisco Veterans Affairs Health Care System, CA, United States of America
| | - Gary Tarasovsky
- San Francisco Veterans Affairs Health Care System, CA, United States of America
| | - Mary A. Whooley
- Division of General Internal Medicine, University of California, San Francisco, CA, United States of America
- San Francisco Veterans Affairs Health Care System, CA, United States of America
| | - Sanket S. Dhruva
- Division of Cardiology, Department of Medicine, University of California, San Francisco, CA, United States of America
- San Francisco Veterans Affairs Health Care System, CA, United States of America
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6
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Thalappillil A, Johnson A, Althouse A, Thoma F, Lee J, Estes NAM, Jain S, Lee J, Saba S. Impact of an Automated Best Practice Alert on Sex and Race Disparities in Implantable Cardioverter-Defibrillator Therapy. J Am Heart Assoc 2022; 11:e023669. [PMID: 35301858 PMCID: PMC9075484 DOI: 10.1161/jaha.121.023669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Implantable cardioverter‐defibrillators (ICDs) are indicated in patients with severe left ventricular dysfunction, but many eligible patients do not receive them, especially women and Black patients. Our group had previously demonstrated that a best practice alert (BPA) improves overall rates of electrophysiology referrals and ICD implantations. This study examined the impact of a BPA by sex and race. Methods and Results This is a cluster randomized trial of cardiology (n=106) and primary care (n=89) providers who were randomized to receive (BPA, n=93) or not receive (No BPA, n=102) the alert and managed 1856 patients meeting primary prevention criteria for ICD implantation (965 BPA and 891 No BPA). After a median follow up of 34 months, 630 (34%) patients were referred to electrophysiology, and 522 (28%) patients received an ICD. Compared with the No BPA arm, patients in the BPA arm saw a modest differential increase in the rate of electrophysiology referrals at 18 months in men (+4%) compared with women (+7%) but a profound increase in Black patients (+16%) compared with White patients (+2%), thus closing the sex and race gaps. Similar trends were noted for rates of ICD implantation. Conclusions Use of a BPA improves rates of electrophysiology referrals and ICD implantations in all comers with severe cardiomyopathy and no prior ventricular arrhythmias but has a more pronounced impact in women and Black patients. The use of a BPA at the point of care is an effective tool in the fight against sex and race inequities in health care.
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Affiliation(s)
- Alvin Thalappillil
- Department of Medicine University of Pittsburgh Medical Center Pittsburgh PA
| | - Amber Johnson
- Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh PA
| | - Andrew Althouse
- Department of Medicine University of Pittsburgh Medical Center Pittsburgh PA
| | - Floyd Thoma
- Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh PA
| | - Jae Lee
- Department of Cardiology Inova Heart and Vascular Institute Falls Church VA
| | - N A Mark Estes
- Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh PA
| | - Sandeep Jain
- Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh PA
| | - Joon Lee
- Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh PA
| | - Samir Saba
- Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh PA
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7
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Butzner M, Leslie D, Cuffee Y, Hollenbeak CS, Sciamanna C, Abraham TP. Sex differences in clinical outcomes for obstructive hypertrophic cardiomyopathy in the USA: a retrospective observational study of administrative claims data. BMJ Open 2022; 12:e058151. [PMID: 35264369 PMCID: PMC8915302 DOI: 10.1136/bmjopen-2021-058151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES To evaluate sex differences in demographic and clinical characteristics, treatments and outcomes for patients with diagnosed obstructive hypertrophic cardiomyopathy (oHCM) in the USA. SETTING Retrospective observational study of administrative claims data from MarketScan Commercial Claims and Encounters Database from IBM Watson Health. PARTICIPANTS Of the 28 million covered employees and family members in MarketScan, 9306 patients with oHCM were included in this analysis. MAIN OUTCOME MEASURES oHCM-related outcomes included heart failure, atrial fibrillation, ventricular tachycardia/ fibrillation, sudden cardiac death, septal myectomy, alcohol septal ablation (ASA) and heart transplant. RESULTS Among 9306 patients with oHCM, the majority were male (60.5%, p<0.001) and women were of comparable age to men (50±15 vs 49±15 years, p<0.001). Women were less likely to be prescribed beta blockers (42.7% vs 45.2%, p=0.017) and undergo an implantable cardioverter-defibrillator (1.7% vs 2.6%, p=0.005). Septal reduction therapy was performed slightly more frequently in women (ASA: 0.08% vs 0.05%, p=0.600; SM: 0.35% vs 0.18%, p=0.096), although not statistically significant. Women were less likely to have atrial fibrillation (6.7% vs 9.9%, p<0.001). CONCLUSION Women were less likely to be prescribed beta blockers, ACE inhibitors, anticoagulants, undergo implantable cardioverter-defibrillator and have ventricular tachycardia/fibrillation. Men were more likely to have atrial fibrillation. Future research using large, clinical real-world data are warranted to understand the root cause of these potential treatment disparities in women with oHCM.
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Affiliation(s)
- Michael Butzner
- Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Douglas Leslie
- Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Yendelela Cuffee
- Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
- University of Delaware College of Health Sciences, Newark, New Jersey, USA
| | - Christopher S Hollenbeak
- Department of Health Policy and Administration, The Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Christopher Sciamanna
- Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
- Department of Medicine, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Theodore P Abraham
- Hypertrophic Cardiomyopathy Center of Excellence, University of California, San Francisco, California, USA
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8
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Bhalla JS, Madhavan M. Racial and Sex Disparities in the Management of Hypertrophic Cardiomyopathy. Mayo Clin Proc 2022; 97:442-444. [PMID: 35246284 DOI: 10.1016/j.mayocp.2022.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 01/20/2022] [Indexed: 10/19/2022]
Affiliation(s)
| | - Malini Madhavan
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
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9
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Bolt L, Wertli MM, Haynes AG, Rodondi N, Chiolero A, Panczak R, Aujesky D. Variation in regional implantation patterns of cardiac implantable electronic device in Switzerland. PLoS One 2022; 17:e0262959. [PMID: 35171922 PMCID: PMC8849475 DOI: 10.1371/journal.pone.0262959] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 01/04/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction There is a substantial geographical variation in the rates of pacemaker (PM), implantable cardioverter defibrillator (ICD), and cardiac resynchronization therapy (CRT) device implantation across European countries. We assessed the extent of regional variation and potential determinants of such variation. Methods We conducted a population-based analysis using discharge data for PM/ICD/CRT implantations from all Swiss acute care hospitals during 2013–2016. We derived hospital service areas (HSA) by analyzing patient flows. We calculated age- and sex-standardized rates and quantified variation using the extremal quotient (EQ) and the systemic component of variation (SCV). We estimated the reduction in variance of crude implantation rates across HSAs using multilevel regression models, with incremental adjustment for age and sex, language, socioeconomic factors, population health, diabetes mellitus, and the density of cardiologists on the HSA level. Results We analyzed implantations of 8129 PM, 1461 ICD, and 1411 CRT from 25 Swiss HSAs. The mean age- and sex-standardized implantation rate was 29 (range 8–57) per 100,000 persons for PM, 5 (1–9) for ICD, and 5 (2–8) for CRT. There was a very high variation in PM (EQ 7.0; SCV 12.6) and ICD (EQ 7.2; SCV 11.3) and a high variation in CRT implantation rates (EQ 3.9; SCV 7.1) across HSAs. Adjustments for age and sex, language, socioeconomic factors, population health, diabetes mellitus, and density of cardiologists explained 94% of the variance in ICD and 87.5% of the variance in CRT implantation rates, but only 36.3% of the variance in PM implantation rates. Women had substantially lower PM/ICD/CRT implantation rates than men. Conclusion Switzerland has a very high regional variation in PM/ICD implantation and a high variation in CRT implantation rates. Women had substantially lower implantation rates than men. A large share of the variation in PM procedure rates remained unexplained which might reflect variations in physicians’ preferences and practices.
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Affiliation(s)
- Lucy Bolt
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maria M. Wertli
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- * E-mail:
| | | | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Arnaud Chiolero
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Population Health Laboratory (#PopHealthLab), University of Fribourg, Fribourg, Switzerland
- School of Population and Global Health, McGill University, Montreal, Canada
| | - Radoslaw Panczak
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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10
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Gender Differences in Implantable Cardioverter-Defibrillator Utilization for Primary Prevention of Sudden Cardiac Death. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-021-00954-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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11
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Abstract
PURPOSE OF REVIEW The aim of this review is to discuss racial and sex disparities in the management and outcomes of patients with acute decompensated heart failure (ADHF). RECENT FINDINGS Race and sex have a significant impact on in-hospital admissions and overall outcomes in patients with decompensated heart failure and cardiogenic shock. Black patients not only have a higher incidence of heart failure than other racial groups, but also higher admissions for ADHF and worse overall survival, while women receive less interventions for cardiogenic shock complicating acute myocardial infarction. Moreover, White patients are more likely than Black patients to be cared for by a cardiologist than a noncardiologist in the ICU, which has been linked to overall improved survival. In addition, recent data outline inherent racial and sex bias in the evaluation process for advanced heart failure therapies indicating that Black race negatively impacts referral for transplant, women are judged more harshly on their appearance, and that Black women are perceived to have less social support than others. This implicit bias in the evaluation process may impact appropriate timing of referral for advanced heart failure therapies. SUMMARY Though significant racial and sex disparities exist in the management and treatment of patients with decompensated heart failure, these disparities are minimized when therapies are properly utilized and patients are treated according to guidelines.
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12
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Postigo A, Martínez-Sellés M. Sex Influence on Heart Failure Prognosis. Front Cardiovasc Med 2020; 7:616273. [PMID: 33409293 PMCID: PMC7779486 DOI: 10.3389/fcvm.2020.616273] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 11/30/2020] [Indexed: 01/06/2023] Open
Abstract
Heart failure (HF) affects 1-2% of the population in developed countries and ~50% of patients living with it are women. Compared to men, women are more likely to be older and suffer hypertension, valvular heart disease, and non-ischemic cardiomyopathy. Since the number of women included in prospective HF studies has been low, much information regarding HF in women has been inferred from clinical trials observations in men and data obtained from registries. Several relevant sex-related differences in HF patients have been described, including biological mechanisms, age, etiology, precipitating factors, comorbidities, left ventricular ejection fraction, treatment effects, and prognosis. Women have greater clinical severity of HF, with more symptoms and worse functional class. However, females with HF have better prognosis compared to males. This survival advantage is particularly impressive given that women are less likely to receive guideline-proven therapies for HF than men. The reasons for this better prognosis are unknown but prior pregnancies may play a role. In this review article we aim to describe sex-related differences in HF and how these differences might explain why women with HF can expect to survive longer than men.
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Affiliation(s)
- Andrea Postigo
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,CIBER-CV, Madrid, Spain.,Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.,CIBER-CV, Madrid, Spain.,Facultad de Medicina, Universidad Complutense, Madrid, Spain.,Facultad de Ciencias Biomédicas y de la Salud, Universidad Europea, Madrid, Spain
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13
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Mistry A, Vali Z, Sidhu B, Budgeon C, Yuyun MF, Pooranachandran V, Li X, Newton M, Watts J, Khunti K, Samani NJ, Ng GA. Disparity in implantable cardioverter defibrillator therapy among minority South Asians in the United Kingdom. Heart 2020; 106:671-676. [PMID: 31924714 DOI: 10.1136/heartjnl-2019-315978] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 12/04/2019] [Accepted: 12/10/2019] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE There are large geographical differences in implantable cardioverter defibrillator (ICD) implantation rates for reasons not completely understood. In an increasingly multiethnic population, we sought out to investigate whether ethnicity influenced ICD implantation rates. METHODS This was a retrospective, cohort study of new ICD implantation or upgrade to ICD from January 2006 to February 2019 in recipients of Caucasian or South Asian ethnicity at a single tertiary centre in the UK. Data were obtained from a routinely collected local registry. Crude rates of ICD implantation were calculated for the population of Leicestershire county and were age-standardised to the UK population using the UK National Census of 2011. RESULTS The Leicestershire population was 980 328 at the time of the Census, of which 761 403 (77.7%) were Caucasian and 155 500 (15.9%) were South Asian. Overall, 2650 ICD implantations were performed in Caucasian (91.9%) and South Asian (8.1%) patients. South Asians were less likely than Caucasians to receive an ICD (risk ratio (RR) 0.43, 95% CI 0.37 to 0.49, p<0.001) even when standardised for age (RR 0.75, 95% CI 0.74 to 0.75, p<0.001). This remained the case for primary prevention indication (age-standardised RR 0.91, 95% CI 0.90 to 0.91, p<0.001), while differences in secondary prevention ICD implants were even greater (age-standardised RR 0.49, 95% CI 0.48 to 0.50, p<0.001). CONCLUSION Despite a universal and free healthcare system, ICD implantation rates were significantly lower in the South Asian than the Caucasian population residing in the UK. Whether this is due to cultural acceptance or an unbalanced consideration is unclear.
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Affiliation(s)
- Amar Mistry
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,Department of Cardiology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Zakariyya Vali
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,Department of Cardiology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Bharat Sidhu
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,Department of Cardiology, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Charley Budgeon
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Matthew F Yuyun
- Department of Medicine, Harvard University, Boston, Massachusetts, USA.,Cardiology and Vascular Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
| | | | - Xin Li
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Michelle Newton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Jamie Watts
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Nilesh J Samani
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,Department of Cardiology, University Hospitals of Leicester NHS Trust, Leicester, UK.,National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Leicester, United Kingdom
| | - G Andre Ng
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK .,Department of Cardiology, University Hospitals of Leicester NHS Trust, Leicester, UK.,National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, Leicester, United Kingdom
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14
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DeFilippis EM, Truby LK, Garan AR, Givens RC, Takeda K, Takayama H, Naka Y, Haythe JH, Farr MA, Topkara VK. Sex-Related Differences in Use and Outcomes of Left Ventricular Assist Devices as Bridge to Transplantation. JACC-HEART FAILURE 2019; 7:250-257. [DOI: 10.1016/j.jchf.2019.01.008] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/16/2019] [Accepted: 01/16/2019] [Indexed: 12/19/2022]
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15
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Ignaszewski MT, Daugherty SL, Russo AM. Implantable Cardioverter-Defibrillators and Cardiac Resynchronization Therapy in Women. Heart Fail Clin 2019; 15:109-125. [PMID: 30449374 DOI: 10.1016/j.hfc.2018.08.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Implantable cardioverter-defibrillator and cardiac resynchronization therapy devices have been prescribed for patients with heart failure for several decades. Factors leading to increased usage include significant enhancements in technology and availability of multiple randomized clinical trials demonstrating their benefit with improved implementation of evidence-based guidelines. Despite these advances, gaps still exist in the utilization and referral of these devices, particularly among women. This article reviews the literature on these devices with a focus on gender differences and proposes reasons for why they exist.
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Affiliation(s)
- Maya T Ignaszewski
- Cooper University Hospital, 1 Cooper Plaza, 3 Dorrance, Camden, NJ 08103, USA.
| | - Stacie L Daugherty
- University of Colorado, Academic Office 1, 12631 East 17th Avenue B130, Aurora, CO 80045, USA
| | - Andrea M Russo
- Cooper University Hospital, 1 Cooper Plaza, 3 Dorrance, Camden, NJ 08103, USA
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16
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Johnson AE, Adhikari S, Althouse AD, Thoma F, Marroquin OC, Koscumb S, Hausmann LRM, Myaskovsky L, Saba SF. Persistent sex disparities in implantable cardioverter-defibrillator therapy. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:1150-1157. [PMID: 29959781 DOI: 10.1111/pace.13435] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 05/17/2018] [Accepted: 06/10/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Clinical guidelines recommend cardioverter defibrillator implantation for patients with heart failure and reduced ejection fraction. Despite this, women and minorities have been less likely to receive implantable cardioverter-defibrillator (ICD) therapy than white men. We examined race and sex differences in ICD implantation in a recent cohort. METHODS Using cross-sectional, retrospective analyses, we mined our health system's outpatient electronic medical records to assess age, race, sex, medications, and comorbidities for patients aged ≥18 years with ejection fraction ≤ 35% during 2014. While adjusting for confounding variables such as medications, age, and comorbidities, we conducted a multivariable logistic regression assessing whether racial and sex differences in ICD therapy persist. RESULTS Among 5,156 outpatients with ejection fraction ≤35%, 1,681 (32.6%) patients had an ICD present at the time of their index outpatient visit in 2014. Women were less likely to have an ICD than men (25.0% vs 36.3%, P < 0.01), and black patients were less likely to have an ICD than white patients (28.0% vs 33.2%, P = 0.02). In adjusted multivariable analyses, women were less like to have ICDs (adjusted odds ratio [OR] = 0.68, 95% confidence interval [CI], 0.58-0.79, P < 0.01) but the race difference dissipated (adjusted OR for black race = 0.86, 95% CI, 0.68-1.08, P = 0.18). CONCLUSIONS In this large, outpatient cohort, we have shown that sex differences in ICD therapy continue to exist, but the difference in ICD prevalence by race was attenuated. Dedicated studies are required to fully understand the causes of persistent sex differences in ICD therapy.
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Affiliation(s)
- Amber E Johnson
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | | | - Floyd Thoma
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Oscar C Marroquin
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,UPMC's Department of Clinical Analytics, Pittsburgh, PA, USA
| | - Stephen Koscumb
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,UPMC's Department of Clinical Analytics, Pittsburgh, PA, USA
| | - Leslie R M Hausmann
- University of Pittsburgh Department of Medicine, Pittsburgh, PA, USA.,Veterans Affairs Pittsburgh Healthcare System Center for Health Equity Research and Promotion, Pittsburgh, PA, USA
| | - Larissa Myaskovsky
- Center for Healthcare Equity in Kidney Disease and Department of Internal Medicine, University of New Mexico, School of Medicine, Albuquerque, NM, USA
| | - Samir F Saba
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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17
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Hwang JK, Gwag HB, Park SJ, Park KM, Kim JS, On YK. Implantable Cardioverter-Defibrillator of Korean Patients in a Single Center Registry. INTERNATIONAL JOURNAL OF ARRHYTHMIA 2017. [DOI: 10.18501/arrhythmia.2017.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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18
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BOVEDA SERGE, NARAYANAN KUMAR, JACOB SOPHIE, PROVIDENCIA RUI, ALGALARRONDO VINCENT, BOUZEMAN ABDESLAM, BEGANTON FRANKIE, DEFAYE PASCAL, PERIER MARIECÉCILE, SADOUL NICOLAS, PIOT OLIVIER, KLUG DIDIER, GRAS DANIEL, FAUCHIER LAURENT, BORDACHAR PIERRE, BABUTY DOMINIQUE, DEHARO JEANCLAUDE, LECLERCQ CHRISTOPHE, MARIJON ELOI. Temporal Trends Over a Decade of Defibrillator Therapy for Primary Prevention in Community Practice. J Cardiovasc Electrophysiol 2017; 28:666-673. [DOI: 10.1111/jce.13198] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 02/10/2017] [Accepted: 02/24/2017] [Indexed: 11/29/2022]
Affiliation(s)
| | - KUMAR NARAYANAN
- Paris Cardiovascular Research Center (Inserm U970); Paris France
| | - SOPHIE JACOB
- IRSN; Laboratory of Epidemiology; Fontenay-aux-Roses France
| | | | | | | | - FRANKIE BEGANTON
- Paris Cardiovascular Research Center (Inserm U970); Paris France
| | | | | | | | - OLIVIER PIOT
- Centre Cardiologique du Nord; Saint Denis France
| | | | - DANIEL GRAS
- Nouvelles Cliniques Nantaises; Nantes France
| | | | | | | | | | | | - ELOI MARIJON
- Paris Cardiovascular Research Center (Inserm U970); Paris France
- European Georges Pompidou Hospital; Paris France
- Paris Descartes University; Paris France
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19
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20
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Pokorney SD, Miller AL, Chen AY, Thomas L, Fonarow GC, de Lemos JA, Al-Khatib SM, Velazquez EJ, Peterson ED, Wang TY. Reassessment of Cardiac Function and Implantable Cardioverter-Defibrillator Use Among Medicare Patients With Low Ejection Fraction After Myocardial Infarction. Circulation 2017; 135:38-47. [DOI: 10.1161/circulationaha.116.022359] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 10/21/2016] [Indexed: 11/16/2022]
Abstract
Background:
Guidelines recommend that patients with low ejection fraction (EF) after myocardial infarction (MI) have their EF reassessed 40 days after MI for implantable cardioverter-defibrillator (ICD) candidacy. This study examines rates of EF reassessment and their association with 1-year ICD implantation in post-MI patients with low EF.
Methods:
We examined rates of postdischarge EF reassessment and ICD implantation among 10 289 Medicare-insured patients ≥65 years of age with an EF≤35% during the index MI admission from January 2007 through September 2010 in ACTION Registry–GWTG (Acute Coronary Treatment and Intervention Outcomes Network Registry
–
Get With The Guidelines). Multivariable Cox models tested the association between time-dependent EF reassessment and 1-year ICD implantation, stratified by revascularization status during the index MI admission.
Results:
Among patients with EF ≤35% during the index MI admission, 66.8% (95% confidence interval [CI], 65.9–67.8) had EF reassessment within the next year. Revascularized patients were more likely to have EF reassessment (76.9% [95% CI, 75.8–78.0)] versus 53.7% [95% CI, 52.2–55.2];
P
<0.001) and had shorter times to EF reassessment (median, 67 versus 84 days;
P
<0.001) than nonrevascularized patients. Among patients with EF reassessment, only 11% received an ICD within 1 year. Reassessment of EF was associated with a higher likelihood of ICD implantation for both revascularized (unadjusted, 12.1% versus 2.4%,
P
<0.001; adjusted hazard ratio, 10.6, 95% CI, 7.7–14.8) and nonrevascularized (unadjusted, 10.0% versus 1.7%,
P
<0.001; adjusted hazard ratio, 6.1, 95% CI, 4.1–9.2) patients.
Conclusions:
In US practice, EF reassessments are commonly performed among patients with MI with an initially reduced EF. Although 1-year EF reassessment is associated with increased likelihood of ICD implantation, 1-year ICD implantation rates remain very low even among patients with EF reassessment, regardless of revascularization status.
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Affiliation(s)
- Sean D. Pokorney
- From Duke University Medical Center, Durham, NC (S.D.P., S.M.A.-K., E.J.V., E.D.P., T.Y.W.); Duke Clinical Research Institute, Durham, NC (S.D.P., A.Y.C., L.T., S.M.A.-K., E.J.V., E.D.P., T.Y.W.); Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (A.L.M.); UCLA Health System, Los Angeles, CA (G.C.F.); and UT Southwestern Medical Center, Dallas, TX (J.A.d.L.)
| | - Amy L. Miller
- From Duke University Medical Center, Durham, NC (S.D.P., S.M.A.-K., E.J.V., E.D.P., T.Y.W.); Duke Clinical Research Institute, Durham, NC (S.D.P., A.Y.C., L.T., S.M.A.-K., E.J.V., E.D.P., T.Y.W.); Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (A.L.M.); UCLA Health System, Los Angeles, CA (G.C.F.); and UT Southwestern Medical Center, Dallas, TX (J.A.d.L.)
| | - Anita Y. Chen
- From Duke University Medical Center, Durham, NC (S.D.P., S.M.A.-K., E.J.V., E.D.P., T.Y.W.); Duke Clinical Research Institute, Durham, NC (S.D.P., A.Y.C., L.T., S.M.A.-K., E.J.V., E.D.P., T.Y.W.); Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (A.L.M.); UCLA Health System, Los Angeles, CA (G.C.F.); and UT Southwestern Medical Center, Dallas, TX (J.A.d.L.)
| | - Laine Thomas
- From Duke University Medical Center, Durham, NC (S.D.P., S.M.A.-K., E.J.V., E.D.P., T.Y.W.); Duke Clinical Research Institute, Durham, NC (S.D.P., A.Y.C., L.T., S.M.A.-K., E.J.V., E.D.P., T.Y.W.); Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (A.L.M.); UCLA Health System, Los Angeles, CA (G.C.F.); and UT Southwestern Medical Center, Dallas, TX (J.A.d.L.)
| | - Gregg C. Fonarow
- From Duke University Medical Center, Durham, NC (S.D.P., S.M.A.-K., E.J.V., E.D.P., T.Y.W.); Duke Clinical Research Institute, Durham, NC (S.D.P., A.Y.C., L.T., S.M.A.-K., E.J.V., E.D.P., T.Y.W.); Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (A.L.M.); UCLA Health System, Los Angeles, CA (G.C.F.); and UT Southwestern Medical Center, Dallas, TX (J.A.d.L.)
| | - James A. de Lemos
- From Duke University Medical Center, Durham, NC (S.D.P., S.M.A.-K., E.J.V., E.D.P., T.Y.W.); Duke Clinical Research Institute, Durham, NC (S.D.P., A.Y.C., L.T., S.M.A.-K., E.J.V., E.D.P., T.Y.W.); Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (A.L.M.); UCLA Health System, Los Angeles, CA (G.C.F.); and UT Southwestern Medical Center, Dallas, TX (J.A.d.L.)
| | - Sana M. Al-Khatib
- From Duke University Medical Center, Durham, NC (S.D.P., S.M.A.-K., E.J.V., E.D.P., T.Y.W.); Duke Clinical Research Institute, Durham, NC (S.D.P., A.Y.C., L.T., S.M.A.-K., E.J.V., E.D.P., T.Y.W.); Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (A.L.M.); UCLA Health System, Los Angeles, CA (G.C.F.); and UT Southwestern Medical Center, Dallas, TX (J.A.d.L.)
| | - Eric J. Velazquez
- From Duke University Medical Center, Durham, NC (S.D.P., S.M.A.-K., E.J.V., E.D.P., T.Y.W.); Duke Clinical Research Institute, Durham, NC (S.D.P., A.Y.C., L.T., S.M.A.-K., E.J.V., E.D.P., T.Y.W.); Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (A.L.M.); UCLA Health System, Los Angeles, CA (G.C.F.); and UT Southwestern Medical Center, Dallas, TX (J.A.d.L.)
| | - Eric D. Peterson
- From Duke University Medical Center, Durham, NC (S.D.P., S.M.A.-K., E.J.V., E.D.P., T.Y.W.); Duke Clinical Research Institute, Durham, NC (S.D.P., A.Y.C., L.T., S.M.A.-K., E.J.V., E.D.P., T.Y.W.); Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (A.L.M.); UCLA Health System, Los Angeles, CA (G.C.F.); and UT Southwestern Medical Center, Dallas, TX (J.A.d.L.)
| | - Tracy Y. Wang
- From Duke University Medical Center, Durham, NC (S.D.P., S.M.A.-K., E.J.V., E.D.P., T.Y.W.); Duke Clinical Research Institute, Durham, NC (S.D.P., A.Y.C., L.T., S.M.A.-K., E.J.V., E.D.P., T.Y.W.); Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (A.L.M.); UCLA Health System, Los Angeles, CA (G.C.F.); and UT Southwestern Medical Center, Dallas, TX (J.A.d.L.)
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21
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Trends in percutaneous pericardial access during catheter ablation of ventricular arrhythmias: a single-center experience. J Interv Card Electrophysiol 2016; 47:109-115. [DOI: 10.1007/s10840-016-0132-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 04/14/2016] [Indexed: 10/21/2022]
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22
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Providência R, Marijon E, Lambiase PD, Bouzeman A, Defaye P, Klug D, Amet D, Perier MC, Gras D, Algalarrondo V, Deharo JC, Leclercq C, Fauchier L, Babuty D, Bordachar P, Sadoul N, Piot O, Boveda S. Primary Prevention Implantable Cardioverter Defibrillator (ICD) Therapy in Women-Data From a Multicenter French Registry. J Am Heart Assoc 2016; 5:e002756. [PMID: 26873687 PMCID: PMC4802475 DOI: 10.1161/jaha.115.002756] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 12/21/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND There are limited data describing sex specificities regarding implantable cardioverter defibrillators (ICDs) in the real-world European setting. METHODS AND RESULTS Using a large multicenter cohort of consecutive patients referred for ICD implantation for primary prevention (2002-2012), in ischemic and nonischemic cardiomyopathy, we examined the sex differences in subjects' characteristics and outcomes. Of 5539 patients, only 837 (15.1%) were women and 53.8% received cardiac resynchronization therapy. Compared to men, women presented a significantly higher proportion of nonischemic cardiomyopathy (60.2% versus 36.2%, P<0.001), wider QRS complex width (QRS >120 ms: 74.6% versus 68.5%, P=0.003), higher New York Heart Association functional class (≥III in 54.2%♀ versus 47.8%♂, P=0.014), and lower prevalence of atrial fibrillation (18.7% versus 24.9%, P<0.001). During a 16 786 patient-years follow-up, overall, fewer appropriate therapies were observed in women (hazard ratio=0.59, 95% CI 0.45-0.76; P<0.001). By contrast, no sex-specific interaction was observed for inappropriate shocks (odds ratio ♀=0.84, 95% CI 0.50-1.39, P=0.492), early complications (odds ratio=1.00, 95% CI 0.75-1.32, P=0.992), and all-cause mortality (hazard ratio=0.87 95% CI 0.66-1.15, P=0.324). Analysis of sex-by- cardiac resynchronization therapy interaction shows than female cardiac resynchronization therapy recipients experienced fewer appropriate therapies than men (hazard ratio=0.62, 95% CI 0.50-0.77; P<0.001) and lower mortality (hazard ratio=0.68, 95% CI 0.47-0.97; P=0.034). CONCLUSIONS In our real-life registry, women account for the minority of ICD recipients and presented with a different clinical profile. Whereas female cardiac resynchronization therapy recipients had a lower incidence of appropriate ICD therapies and all-cause death than their male counterparts, the observed rates of inappropriate shocks and early complications in all ICD recipients were comparable. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01992458.
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Affiliation(s)
- Rui Providência
- Clinique Pasteur, Toulouse, France Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Eloi Marijon
- European Georges Pompidou Hospital and Paris Descartes University, Paris, France
| | - Pier D Lambiase
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | | | | | | | - Denis Amet
- European Georges Pompidou Hospital and Paris Descartes University, Paris, France
| | | | - Daniel Gras
- Nouvelles Cliniques Nantaises, Nantes, France
| | | | | | | | | | | | | | | | - Olivier Piot
- Centre Cardiologique du Nord, Saint Denis, France
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23
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Patel NJ, Edla S, Deshmukh A, Nalluri N, Patel N, Agnihotri K, Patel A, Savani C, Patel N, Bhimani R, Thakkar B, Arora S, Asti D, Badheka AO, Parikh V, Mitrani RD, Noseworthy P, Paydak H, Viles-Gonzalez J, Friedman PA, Kowalski M. Gender, Racial, and Health Insurance Differences in the Trend of Implantable Cardioverter-Defibrillator (ICD) Utilization: A United States Experience Over the Last Decade. Clin Cardiol 2016; 39:63-71. [PMID: 26799597 DOI: 10.1002/clc.22496] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Revised: 11/01/2015] [Indexed: 12/28/2022] Open
Abstract
Prior studies have highlighted disparities in cardiac lifesaving procedure utilization, particularly among women and in minorities. Although there has been a significant increase in implantable cardioverter-defibrillator (ICD) insertion, socioeconomic disparities still exist in the trend of ICD utilization. With the use of the Nationwide Inpatient Sample from 2003 through 2011, we identified subjects with ICD insertion (procedure code 37.94) and cardiac resynchronization defibrillator (procedure code 00.50, 00.51) as codified by the International Classification of Diseases, Ninth Revision, Clinical Modification. Overall, 1 020 076 ICDs were implanted in the United States from 2003 to 2011. We observed an initial increase in ICD utilization by 51%, from 95 062 in 2003 to 143 262 in 2006, followed by a more recent decline. The majority of ICDs were implanted in men age ≥65 years. Implantation of ICDs was 2.5× more common in men than in women (402 per million vs 163 per million). Approximately 95% of the ICDs were implanted in insured patients, and 5% were used in the uninsured population. There has been a significant increase in ICD implantation in blacks, from 162 per million in 2003 to 291 per million in 2011. We found a significant difference in the volume of ICD implants between the insured and the uninsured patient populations. Racial disparities have narrowed significantly in comparison with those noted in earlier studies and are now more reflective of the population demographics at large. On the other hand, significant gender disparities continue to exist.
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Affiliation(s)
- Nileshkumar J Patel
- Department of Cardiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, Florida
| | - Sushruth Edla
- Department of Internal Medicine, St. Vincent Charity Medical Center, Cleveland, Ohio
| | | | - Nikhil Nalluri
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, New York
| | - Nilay Patel
- Department of Internal Medicine, Saint Peter's University Hospital, New Brunswick, New Jersey
| | - Kanishk Agnihotri
- Department of Internal Medicine, Saint Peter's University Hospital, New Brunswick, New Jersey
| | - Achint Patel
- Department of Public Health, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Chirag Savani
- Department of Internal Medicine, New York Medical College, Valhalla, New York
| | - Nish Patel
- Department of Cardiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, Florida
| | - Ronak Bhimani
- Department of Internal Medicine, St. Vincent Charity Medical Center, Cleveland, Ohio
| | - Badal Thakkar
- Department of Internal Medicine, Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - Shilpkumar Arora
- Department of Cardiology, Mount Sinai St. Luke's Roosevelt Hospital, New York, New York
| | - Deepak Asti
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, New York
| | - Apurva O Badheka
- Department of Cardiology, Yale School of Medicine, New Haven, Connecticut
| | - Valay Parikh
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, New York
| | - Raul D Mitrani
- Department of Cardiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, Florida
| | | | - Hakan Paydak
- Department of Cardiology, University of Arkansas for Medical Science, Little Rock, Arkansas
| | - Juan Viles-Gonzalez
- Department of Cardiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, Florida
| | | | - Marcin Kowalski
- Department of Cardiology, Staten Island University Hospital, Staten Island, New York
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24
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Abstract
Despite advances in evidence-based treatments, the morbidity and mortality of congestive heart failure remain exceedingly high. In addition, the costs associated with recurrent hospitalizations and advanced therapies, such as implantable cardiac defibrillators (ICDs), left ventricular assist devices, and heart transplantation, place a substantial financial burden on the health care system. The present criteria for risk stratification in patients with heart failure are inadequate and often prevent the allocation of appropriate treatment. Patients who have received ICDs as primary prevention for sudden cardiac death often receive no device therapy in their lifetime, whereas other patients with left ventricular dysfunction die suddenly without meeting criteria for ICD implantation.
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Manheimer ED, Gonzalez C, Turk J, Krumerman AK, Kim SG, Gross JN, Palma EC, Grushko MJ, Fisher JD, Ferrick KJ. Referral Patterns for Primary Prophylaxis Implantable Cardioverter Defibrillator Therapy for an Urban US Population. Am J Cardiol 2015; 116:1210-2. [PMID: 26320756 DOI: 10.1016/j.amjcard.2015.07.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 07/14/2015] [Accepted: 07/14/2015] [Indexed: 11/16/2022]
Abstract
Implantable cardioverter defibrillators (ICDs) have been demonstrated to improve survival for both primary and secondary prevention of sudden cardiac arrest. However, studies suggest that ICD therapy is underused in appropriate candidates. Sex and racial disparities in ICD use have been suggested. We sought to characterize the referral patterns of high-risk patients for the primary prophylaxis of sudden cardiac arrest at a tertiary academic medical center serving a diverse population in an urban US setting. Electronic hospital databases were retrospective reviewed for patients meeting criteria for prophylactic ICD implantation. We evaluated the association of gender, age, race, and primary language with the referral and subsequent implantation of an ICD. We identified 1,055 patients satisfying prophylactic ICD criteria: 600 men, mean age 62.6 years, 27.6% black, 19.3% white, 23.3% Hispanic, and 49.8% primary language of English. Of the 673 patients (63.7%) referred for ICD evaluation, 345 underwent implantation, 125 declined, and 203 had significant co-morbidities that precluded implantation. Gender, race, and primary language were not associated with referral for ICD or with decision to proceed with implantation. Patients of increased age were less likely to be referred for ICD and were more likely to refuse implantation. ICD therapy was not considered in 146 patients eligible for prophylactic implantation. In conclusion, referral rates for ICD consideration were higher at our institution than in previous reports. Nonetheless, 14% of appropriate patients were not considered. This argues for the importance of increased education for patients and referring physicians.
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Affiliation(s)
- Eric D Manheimer
- Arrhythmia Service, Department of Cardiology, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, New York.
| | - Christian Gonzalez
- Arrhythmia Service, Department of Cardiology, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, New York
| | - Jordan Turk
- Arrhythmia Service, Department of Cardiology, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, New York
| | - Andrew K Krumerman
- Arrhythmia Service, Department of Cardiology, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, New York
| | - Soo G Kim
- Arrhythmia Service, Department of Cardiology, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, New York
| | - Jay N Gross
- Arrhythmia Service, Department of Cardiology, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, New York
| | - Eugen C Palma
- Arrhythmia Service, Department of Cardiology, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, New York
| | - Michael J Grushko
- Arrhythmia Service, Department of Cardiology, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, New York
| | - John D Fisher
- Arrhythmia Service, Department of Cardiology, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, New York
| | - Kevin J Ferrick
- Arrhythmia Service, Department of Cardiology, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx, New York
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Mehta NK, Abraham WT, Maytin M. ICD and CRT use in ischemic heart disease in women. Curr Atheroscler Rep 2015; 17:512. [PMID: 25921310 DOI: 10.1007/s11883-015-0512-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Although the role of implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy (CRT) in improving outcomes in ischemic cardiomyopathy (ICM) has been described, the data regarding gender-based survival outcomes are limited. There is a higher preponderance of non-ischemic cardiomyopathy (NICM) in women, and most of the ICM literature is derived from sub-study analysis. This review summarizes the current body of literature on prognosis, pathophysiology, and the present clinical practice for device implantation in women with ICM.
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Affiliation(s)
- Nishaki Kiran Mehta
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, 43220, USA,
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Gracieux J, Sanders GD, Pokorney SD, Lopes RD, Thomas K, Al-Khatib SM. Incidence and predictors of appropriate therapies delivered by the implantable cardioverter defibrillator in patients with ischemic cardiomyopathy: A systematic review. Int J Cardiol 2014; 177:990-4. [DOI: 10.1016/j.ijcard.2014.09.170] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 09/27/2014] [Indexed: 12/17/2022]
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Borne RT, Peterson PN, Greenlee R, Heidenreich PA, Wang Y, Curtis JP, Tzou WS, Varosy PD, Kremers MS, Masoudi FA. 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. Circulation 2014; 130:845-53. [PMID: 25095884 DOI: 10.1161/circulationaha.114.008653] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Ryan T Borne
- From the University of Colorado Anschutz Medical Campus, Aurora, CO (R.T.B., P.N.P., W.S.T., P.D.V., F.A.M.); the Department of Medicine, Denver Health and Hospital Authority, Denver, CO (P.N.P.); Colorado Cardiovascular Outcomes Research (C-COR) Consortium, Denver, CO (P.N.P., P.D.V., F.A.M.); Marshfield Clinic Research Foundation, Marshfield, WI (R.G.); VA Palo Alto Health Care System, Palo Alto, Stanford University, Stanford, CA (P.A.H.); the Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.P.C.); VA Eastern Colorado Healthcare System, Denver, CO (P.D.V.); and Novant Heart and Vascular Institute, Charlotte, NC (M.S.K.).
| | - Pamela N Peterson
- From the University of Colorado Anschutz Medical Campus, Aurora, CO (R.T.B., P.N.P., W.S.T., P.D.V., F.A.M.); the Department of Medicine, Denver Health and Hospital Authority, Denver, CO (P.N.P.); Colorado Cardiovascular Outcomes Research (C-COR) Consortium, Denver, CO (P.N.P., P.D.V., F.A.M.); Marshfield Clinic Research Foundation, Marshfield, WI (R.G.); VA Palo Alto Health Care System, Palo Alto, Stanford University, Stanford, CA (P.A.H.); the Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.P.C.); VA Eastern Colorado Healthcare System, Denver, CO (P.D.V.); and Novant Heart and Vascular Institute, Charlotte, NC (M.S.K.)
| | - Robert Greenlee
- From the University of Colorado Anschutz Medical Campus, Aurora, CO (R.T.B., P.N.P., W.S.T., P.D.V., F.A.M.); the Department of Medicine, Denver Health and Hospital Authority, Denver, CO (P.N.P.); Colorado Cardiovascular Outcomes Research (C-COR) Consortium, Denver, CO (P.N.P., P.D.V., F.A.M.); Marshfield Clinic Research Foundation, Marshfield, WI (R.G.); VA Palo Alto Health Care System, Palo Alto, Stanford University, Stanford, CA (P.A.H.); the Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.P.C.); VA Eastern Colorado Healthcare System, Denver, CO (P.D.V.); and Novant Heart and Vascular Institute, Charlotte, NC (M.S.K.)
| | - Paul A Heidenreich
- From the University of Colorado Anschutz Medical Campus, Aurora, CO (R.T.B., P.N.P., W.S.T., P.D.V., F.A.M.); the Department of Medicine, Denver Health and Hospital Authority, Denver, CO (P.N.P.); Colorado Cardiovascular Outcomes Research (C-COR) Consortium, Denver, CO (P.N.P., P.D.V., F.A.M.); Marshfield Clinic Research Foundation, Marshfield, WI (R.G.); VA Palo Alto Health Care System, Palo Alto, Stanford University, Stanford, CA (P.A.H.); the Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.P.C.); VA Eastern Colorado Healthcare System, Denver, CO (P.D.V.); and Novant Heart and Vascular Institute, Charlotte, NC (M.S.K.)
| | - Yongfei Wang
- From the University of Colorado Anschutz Medical Campus, Aurora, CO (R.T.B., P.N.P., W.S.T., P.D.V., F.A.M.); the Department of Medicine, Denver Health and Hospital Authority, Denver, CO (P.N.P.); Colorado Cardiovascular Outcomes Research (C-COR) Consortium, Denver, CO (P.N.P., P.D.V., F.A.M.); Marshfield Clinic Research Foundation, Marshfield, WI (R.G.); VA Palo Alto Health Care System, Palo Alto, Stanford University, Stanford, CA (P.A.H.); the Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.P.C.); VA Eastern Colorado Healthcare System, Denver, CO (P.D.V.); and Novant Heart and Vascular Institute, Charlotte, NC (M.S.K.)
| | - Jeptha P Curtis
- From the University of Colorado Anschutz Medical Campus, Aurora, CO (R.T.B., P.N.P., W.S.T., P.D.V., F.A.M.); the Department of Medicine, Denver Health and Hospital Authority, Denver, CO (P.N.P.); Colorado Cardiovascular Outcomes Research (C-COR) Consortium, Denver, CO (P.N.P., P.D.V., F.A.M.); Marshfield Clinic Research Foundation, Marshfield, WI (R.G.); VA Palo Alto Health Care System, Palo Alto, Stanford University, Stanford, CA (P.A.H.); the Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.P.C.); VA Eastern Colorado Healthcare System, Denver, CO (P.D.V.); and Novant Heart and Vascular Institute, Charlotte, NC (M.S.K.)
| | - Wendy S Tzou
- From the University of Colorado Anschutz Medical Campus, Aurora, CO (R.T.B., P.N.P., W.S.T., P.D.V., F.A.M.); the Department of Medicine, Denver Health and Hospital Authority, Denver, CO (P.N.P.); Colorado Cardiovascular Outcomes Research (C-COR) Consortium, Denver, CO (P.N.P., P.D.V., F.A.M.); Marshfield Clinic Research Foundation, Marshfield, WI (R.G.); VA Palo Alto Health Care System, Palo Alto, Stanford University, Stanford, CA (P.A.H.); the Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.P.C.); VA Eastern Colorado Healthcare System, Denver, CO (P.D.V.); and Novant Heart and Vascular Institute, Charlotte, NC (M.S.K.)
| | - Paul D Varosy
- From the University of Colorado Anschutz Medical Campus, Aurora, CO (R.T.B., P.N.P., W.S.T., P.D.V., F.A.M.); the Department of Medicine, Denver Health and Hospital Authority, Denver, CO (P.N.P.); Colorado Cardiovascular Outcomes Research (C-COR) Consortium, Denver, CO (P.N.P., P.D.V., F.A.M.); Marshfield Clinic Research Foundation, Marshfield, WI (R.G.); VA Palo Alto Health Care System, Palo Alto, Stanford University, Stanford, CA (P.A.H.); the Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.P.C.); VA Eastern Colorado Healthcare System, Denver, CO (P.D.V.); and Novant Heart and Vascular Institute, Charlotte, NC (M.S.K.)
| | - Mark S Kremers
- From the University of Colorado Anschutz Medical Campus, Aurora, CO (R.T.B., P.N.P., W.S.T., P.D.V., F.A.M.); the Department of Medicine, Denver Health and Hospital Authority, Denver, CO (P.N.P.); Colorado Cardiovascular Outcomes Research (C-COR) Consortium, Denver, CO (P.N.P., P.D.V., F.A.M.); Marshfield Clinic Research Foundation, Marshfield, WI (R.G.); VA Palo Alto Health Care System, Palo Alto, Stanford University, Stanford, CA (P.A.H.); the Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.P.C.); VA Eastern Colorado Healthcare System, Denver, CO (P.D.V.); and Novant Heart and Vascular Institute, Charlotte, NC (M.S.K.)
| | - Frederick A Masoudi
- From the University of Colorado Anschutz Medical Campus, Aurora, CO (R.T.B., P.N.P., W.S.T., P.D.V., F.A.M.); the Department of Medicine, Denver Health and Hospital Authority, Denver, CO (P.N.P.); Colorado Cardiovascular Outcomes Research (C-COR) Consortium, Denver, CO (P.N.P., P.D.V., F.A.M.); Marshfield Clinic Research Foundation, Marshfield, WI (R.G.); VA Palo Alto Health Care System, Palo Alto, Stanford University, Stanford, CA (P.A.H.); the Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (Y.W., J.P.C.); VA Eastern Colorado Healthcare System, Denver, CO (P.D.V.); and Novant Heart and Vascular Institute, Charlotte, NC (M.S.K.)
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Gender Bias Trends in Implantable Cardioverter-Defibrillator Therapy. CURRENT CARDIOVASCULAR RISK REPORTS 2014. [DOI: 10.1007/s12170-014-0375-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Matchett M, Sears SF, Hazelton G, Kirian K, Wilson E, Nekkanti R. The implantable cardioverter defibrillator: its history, current psychological impact and future. Expert Rev Med Devices 2014; 6:43-50. [DOI: 10.1586/17434440.6.1.43] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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van der Heijden AC, Thijssen J, Borleffs CJW, van Rees JB, Höke U, van der Velde ET, van Erven L, Schalij MJ. Gender-specific differences in clinical outcome of primary prevention implantable cardioverter defibrillator recipients. Heart 2013; 99:1244-9. [PMID: 23723448 DOI: 10.1136/heartjnl-2013-304013] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To assess differences in clinical outcome of implantable cardioverter-defibrillator (ICD) treatment in men and women. DESIGN Prospective cohort study. SETTING University Medical Center. PATIENTS 1946 primary prevention ICD recipients (1528 (79%) men and 418 (21%) women). Patients with congenital heart disease were excluded for this analysis. MAIN OUTCOME MEASURES All-cause mortality, ICD therapy (antitachycardia pacing and shock) and ICD shock. RESULTS During a median follow-up of 3.3 years (25th-75th percentile 1.4-5.4), 387 (25%) men and 76 (18%) women died. The estimated 5-year cumulative incidence for all-cause mortality was 20% (95% CI 18% to 23%) for men and 14% (95% CI 9% to 19%) for women (log rank p<0.01). After adjustment for potential confounding covariates all-cause mortality was lower in women (HR 0.65; 95% CI 0.49 to 0.84; p<0.01). The 5-year cumulative incidence for appropriate therapy in men was 24% (95% CI 21% to 28%) as compared with 20% (95% CI 14% to 26%) in women (log rank p=0.07). After adjustment, a non-significant trend remained (HR 0.82; 95% CI 0.64 to 1.06; p=0.13). CONCLUSIONS In clinical practice, 21% of primary prevention ICD recipients are women. Women have lower mortality and tend to experience less appropriate ICD therapy as compared with their male peers.
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MEHRA MANDEEPR, ALBERT NANCYM, CURTIS ANNEB, GHEORGHIADE MIHAI, HEYWOOD JTHOMAS, LIU YANG, O’CONNOR CHRISTOPHERM, REYNOLDS DWIGHT, WALSH MARYNORINE, YANCY CLYDEW, FONAROW GREGGC. Factors Associated with Improvement in Guideline-Based Use of ICDs in Eligible Heart Failure Patients. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2011; 35:135-45. [DOI: 10.1111/j.1540-8159.2011.03279.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Tsai V, Goldstein MK, Hsia HH, Wang Y, Curtis J, Heidenreich PA. Influence of age on perioperative complications among patients undergoing implantable cardioverter-defibrillators for primary prevention in the United States. Circ Cardiovasc Qual Outcomes 2011; 4:549-56. [PMID: 21878667 DOI: 10.1161/circoutcomes.110.959205] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND- The majority of current implantable cardioverter-defibrillator (ICD) recipients are significantly older than those in the ICD trials. Data on periprocedural complications among the elderly are insufficient. We evaluated the influence of age on perioperative complications among primary prevention ICD recipients in the United States. METHODS AND RESULTS- Using the National Cardiovascular Data's ICD Registry, we identified 150 264 primary prevention patients who received ICDs from January 2006 to December 2008. The primary end point was any adverse event or in-hospital mortality. Secondary end points included major adverse events, minor adverse events, and length of stay. Of 150 264 patients, 61% (n=91 863) were 65 years and older. A higher proportion of patients ≥65 years had diabetes, congestive heart failure, atrial fibrillation, renal disease, and coronary artery disease. Approximately 3.4% of the entire cohort had any complication, including death, after ICD implant. Any adverse event or death occurred in 2.8% of patients under 65 years old; 3.1% of 65- to 69-year-olds; 3.5% of 70- to 74-year-olds; 3.9% of 75- to 79-year-olds, 4.5% of 80- to 84-year-olds; and 4.5% of patients 85 years and older. After adjustment for clinical covariates, multivariate analysis found an increased odds of any adverse event or death among 75- to 79-year-olds (1.14 [95% confidence interval, 1.03 to 1.25], 80-to 84-year-olds (1.22 [95% confidence interval, 1.10 to 1.36], and patients 85 years and older (1.15 [95% confidence interval, 1.01 to 1.32], compared with patients under 65 years old. CONCLUSIONS- Older patients had a modestly increased-but acceptably safe-risk of periprocedural complications and in-hospital mortality, driven mostly by increased comorbidity.
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Affiliation(s)
- Vivian Tsai
- Stanford University School of Medicine, CA, USA.
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Al-Khatib SM, Sanders GD, O'Brien SM, Matlock D, Zimmer LO, Masoudi FA, Peterson E. Do physicians' attitudes toward implantable cardioverter defibrillator therapy vary by patient age, gender, or race? Ann Noninvasive Electrocardiol 2011; 16:77-84. [PMID: 21251138 DOI: 10.1111/j.1542-474x.2010.00412.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Implantable cardioverter defibrillator (ICD) therapy improves survival of patients with systolic heart failure. We assessed whether physicians' recommendation for ICD therapy varies as a function of patient age, gender, race, and physician's specialty. METHODS We surveyed a random sample (n = 9969) of U.S. physicians who are active members of the American College of Cardiology (ACC). We asked participants about their likelihood to recommend ICD therapy in 4 clinical scenarios that randomly varied patient age, gender, race, and ICD indication (guideline Class I, Class IIa, Class III, and Class I in a noncompliant patient). RESULTS Responses were received from 1210 physicians (response rate 12%), of whom 1127 met the study inclusion criteria. Responders and nonresponders had similar demographics. In responding to hypothetical clinical scenarios, physicians were less likely to recommend an ICD to older patients (≥80 vs 50 years) (P < 0.01) but were unaffected by gender or race for all class indications. Compared with non-electrophysiologists (EPs), EPs were significantly more likely to recommend an ICD for a Class I indication (92.4% vs 81.4%; P < 0.01), but they were not more likely to offer an ICD for a Class III indication (0.4% vs 0.6%; P = 0.95). CONCLUSIONS Based on survey responses, physicians were equally willing to offer an ICD to men and women and to whites and blacks, but were less likely to offer an ICD to an older patient even when indicated by practice guidelines. Electrophysiologists (EPs) more often adhered to practice guideline recommendations on ICD therapy compared with non-EPs.
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Affiliation(s)
- Sana M Al-Khatib
- Duke Cardiovascular Center for Education and Research on Therapeutics, Duke Clinical Research Institute, Durham, NC, USA.
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Gravelin LM, Yuhas J, Remetz M, Radford M, Foley J, Lampert R. Use of a Screening Tool Improves Appropriate Referral to an Electrophysiologist for Implantable Cardioverter-Defibrillators for Primary Prevention of Sudden Cardiac Death. Circ Cardiovasc Qual Outcomes 2011; 4:152-6. [DOI: 10.1161/circoutcomes.110.956987] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Laura M. Gravelin
- From the Brown University School of Medicine (L.M.G.), Providence, RI; Yale University School of Medicine (J.Y., M. Remetz, J.F., R.L.), New Haven, CT; New York University School of Medicine (M. Radford), New York, NY; and Norwich Cardiology Associates (J.F.), Norwich, CT
| | - Jennifer Yuhas
- From the Brown University School of Medicine (L.M.G.), Providence, RI; Yale University School of Medicine (J.Y., M. Remetz, J.F., R.L.), New Haven, CT; New York University School of Medicine (M. Radford), New York, NY; and Norwich Cardiology Associates (J.F.), Norwich, CT
| | - Michael Remetz
- From the Brown University School of Medicine (L.M.G.), Providence, RI; Yale University School of Medicine (J.Y., M. Remetz, J.F., R.L.), New Haven, CT; New York University School of Medicine (M. Radford), New York, NY; and Norwich Cardiology Associates (J.F.), Norwich, CT
| | - Martha Radford
- From the Brown University School of Medicine (L.M.G.), Providence, RI; Yale University School of Medicine (J.Y., M. Remetz, J.F., R.L.), New Haven, CT; New York University School of Medicine (M. Radford), New York, NY; and Norwich Cardiology Associates (J.F.), Norwich, CT
| | - John Foley
- From the Brown University School of Medicine (L.M.G.), Providence, RI; Yale University School of Medicine (J.Y., M. Remetz, J.F., R.L.), New Haven, CT; New York University School of Medicine (M. Radford), New York, NY; and Norwich Cardiology Associates (J.F.), Norwich, CT
| | - Rachel Lampert
- From the Brown University School of Medicine (L.M.G.), Providence, RI; Yale University School of Medicine (J.Y., M. Remetz, J.F., R.L.), New Haven, CT; New York University School of Medicine (M. Radford), New York, NY; and Norwich Cardiology Associates (J.F.), Norwich, CT
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Allen LaPointe NM, Al-Khatib SM, Piccini JP, Atwater BD, Honeycutt E, Thomas K, Shah BR, Zimmer LO, Sanders G, Peterson ED. Extent of and Reasons for Nonuse of Implantable Cardioverter Defibrillator Devices in Clinical Practice Among Eligible Patients With Left Ventricular Systolic Dysfunction. Circ Cardiovasc Qual Outcomes 2011; 4:146-51. [DOI: 10.1161/circoutcomes.110.958603] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Several studies that used claims and registry data have reported that 40% to 80% of patients eligible for an implantable cardioverter defibrillator (ICD) fail to receive one in clinical practice, and the rates are especially high among women and blacks. The extent and documented reasons for nonuse of ICDs among patients with left ventricular systolic dysfunction are unknown.
Methods and Results—
Using hospital claims and clinical data, we identified patients hospitalized with a heart failure diagnosis and left ventricular ejection fraction ≤30% between January 1, 2007, and August 30, 2007, at a tertiary-care center. Using claims data, we determined placement of an ICD or cardiac resynchronization therapy with defibrillation device at any time up to 1 year after hospitalization. Medical records for patients without an ICD were abstracted to determine reasons for nonuse. Patients with an ICD were compared with patients without an ICD and also with patients without an ICD who did not have any contraindication for an ICD as identified through chart abstraction. Of the 542 potentially eligible patients identified, 224 (41%) did not have an ICD. In the initial adjusted analysis, female sex (odds ratio=1.90; 95% CI, 1.28 to 2.81) and increasing age (odds ratio=1.07; 95% CI, 1.04 to 1.11) were associated with a higher likelihood of not having an ICD. After detailed chart review, of the 224 patients without an ICD, 117 (52%) were ineligible for the device and 38 (17%) patients refused the device, resulting in only 69 (13%) patients eligible for an ICD who failed to receive one. In this subsequent adjusted analysis, remaining factors associated with a higher likelihood of not having an ICD were absence of ventricular arrhythmias (odds ratio=4.93; 95% CI, 2.56 to 9.50), noncardiology hospital service (odds ratio=3.73; 95% CI, 1.98 to 7.04), and lack of health insurance (odds ratio=3.10; 95% CI, 1.48 to 6.46).
Conclusions—
On the basis of a detailed chart review, the true rate of ICD underuse may be substantially lower than previous estimates. In addition, after accounting for ICD eligibility criteria, patient sex and age disparities in ICD therapy were no longer present.
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Affiliation(s)
- Nancy M. Allen LaPointe
- From Duke University Medical Center (N.M.A.L., S.M.A., J.P.P., B.D.A., K.T., B.R.S., G.S., E.D.P.), Duke Clinical Research Institute (N.M.A.L., S.M.A., J.P.P., E.H., K.T., B.R.S., L.O.Z., G.S., E.D.P.), and Duke Center for Education and Research on Therapeutics (N.M.A.L., S.M.A., K.T., L.O.Z., G.S., E.D.P.), Durham, NC
| | - Sana M. Al-Khatib
- From Duke University Medical Center (N.M.A.L., S.M.A., J.P.P., B.D.A., K.T., B.R.S., G.S., E.D.P.), Duke Clinical Research Institute (N.M.A.L., S.M.A., J.P.P., E.H., K.T., B.R.S., L.O.Z., G.S., E.D.P.), and Duke Center for Education and Research on Therapeutics (N.M.A.L., S.M.A., K.T., L.O.Z., G.S., E.D.P.), Durham, NC
| | - Jonathan P. Piccini
- From Duke University Medical Center (N.M.A.L., S.M.A., J.P.P., B.D.A., K.T., B.R.S., G.S., E.D.P.), Duke Clinical Research Institute (N.M.A.L., S.M.A., J.P.P., E.H., K.T., B.R.S., L.O.Z., G.S., E.D.P.), and Duke Center for Education and Research on Therapeutics (N.M.A.L., S.M.A., K.T., L.O.Z., G.S., E.D.P.), Durham, NC
| | - Brett D. Atwater
- From Duke University Medical Center (N.M.A.L., S.M.A., J.P.P., B.D.A., K.T., B.R.S., G.S., E.D.P.), Duke Clinical Research Institute (N.M.A.L., S.M.A., J.P.P., E.H., K.T., B.R.S., L.O.Z., G.S., E.D.P.), and Duke Center for Education and Research on Therapeutics (N.M.A.L., S.M.A., K.T., L.O.Z., G.S., E.D.P.), Durham, NC
| | - Emily Honeycutt
- From Duke University Medical Center (N.M.A.L., S.M.A., J.P.P., B.D.A., K.T., B.R.S., G.S., E.D.P.), Duke Clinical Research Institute (N.M.A.L., S.M.A., J.P.P., E.H., K.T., B.R.S., L.O.Z., G.S., E.D.P.), and Duke Center for Education and Research on Therapeutics (N.M.A.L., S.M.A., K.T., L.O.Z., G.S., E.D.P.), Durham, NC
| | - Kevin Thomas
- From Duke University Medical Center (N.M.A.L., S.M.A., J.P.P., B.D.A., K.T., B.R.S., G.S., E.D.P.), Duke Clinical Research Institute (N.M.A.L., S.M.A., J.P.P., E.H., K.T., B.R.S., L.O.Z., G.S., E.D.P.), and Duke Center for Education and Research on Therapeutics (N.M.A.L., S.M.A., K.T., L.O.Z., G.S., E.D.P.), Durham, NC
| | - Bimal R. Shah
- From Duke University Medical Center (N.M.A.L., S.M.A., J.P.P., B.D.A., K.T., B.R.S., G.S., E.D.P.), Duke Clinical Research Institute (N.M.A.L., S.M.A., J.P.P., E.H., K.T., B.R.S., L.O.Z., G.S., E.D.P.), and Duke Center for Education and Research on Therapeutics (N.M.A.L., S.M.A., K.T., L.O.Z., G.S., E.D.P.), Durham, NC
| | - Louise O. Zimmer
- From Duke University Medical Center (N.M.A.L., S.M.A., J.P.P., B.D.A., K.T., B.R.S., G.S., E.D.P.), Duke Clinical Research Institute (N.M.A.L., S.M.A., J.P.P., E.H., K.T., B.R.S., L.O.Z., G.S., E.D.P.), and Duke Center for Education and Research on Therapeutics (N.M.A.L., S.M.A., K.T., L.O.Z., G.S., E.D.P.), Durham, NC
| | - Gillian Sanders
- From Duke University Medical Center (N.M.A.L., S.M.A., J.P.P., B.D.A., K.T., B.R.S., G.S., E.D.P.), Duke Clinical Research Institute (N.M.A.L., S.M.A., J.P.P., E.H., K.T., B.R.S., L.O.Z., G.S., E.D.P.), and Duke Center for Education and Research on Therapeutics (N.M.A.L., S.M.A., K.T., L.O.Z., G.S., E.D.P.), Durham, NC
| | - Eric D. Peterson
- From Duke University Medical Center (N.M.A.L., S.M.A., J.P.P., B.D.A., K.T., B.R.S., G.S., E.D.P.), Duke Clinical Research Institute (N.M.A.L., S.M.A., J.P.P., E.H., K.T., B.R.S., L.O.Z., G.S., E.D.P.), and Duke Center for Education and Research on Therapeutics (N.M.A.L., S.M.A., K.T., L.O.Z., G.S., E.D.P.), Durham, NC
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Kong MH, Peterson ED, Fonarow GC, Sanders GD, Yancy CW, Russo AM, Curtis AB, Sears SF, Thomas KL, Campbell S, Carlson MD, Chiames C, Cook NL, Hayes DL, LaRue M, Hernandez AF, Lyons EL, Al-Khatib SM. Addressing disparities in sudden cardiac arrest care and the underutilization of effective therapies. Am Heart J 2010; 160:605-18. [PMID: 20934553 PMCID: PMC2956019 DOI: 10.1016/j.ahj.2010.07.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Accepted: 07/09/2010] [Indexed: 02/06/2023]
Abstract
Sudden cardiac arrest (SCA) is the most common cause of death in the Unites States. Despite its major impact on public health, significant challenges exist at the patient, provider, public, and policy levels with respect to raising more widespread awareness and understanding of SCA risks, identifying patients at risk for SCA, addressing barriers to SCA care, and eliminating disparities in SCA care and outcomes. To address many of these challenges, the Duke Center for the Prevention of Sudden Cardiac Death at the Duke Clinical Research Institute (Durham, NC) held a think tank meeting on December 7, 2009, convening experts on this issue from clinical cardiology, cardiac electrophysiology, health policy and economics, the US Food and Drug Administration, the Centers for Medicare and Medicaid Services, the Agency for Health Care Research and Quality, and device and pharmaceutical manufacturers. The specific goals of the meeting were to examine existing educational tools on SCA for patients, health care providers, and the public and explore ways to enhance and disseminate these tools; to propose a framework for improved identification of patients at risk of SCA; and to review the latest data on disparities in SCA care and explore ways to reduce these disparities. This article summarizes the discussions that occurred at the meeting.
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López L, Wilper AP, Cervantes MC, Betancourt JR, Green AR. Racial and sex differences in emergency department triage assessment and test ordering for chest pain, 1997-2006. Acad Emerg Med 2010; 17:801-8. [PMID: 20670316 DOI: 10.1111/j.1553-2712.2010.00823.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES This study assessed whether sociodemographic differences exist in triage assignment and whether these differences affect initial diagnostic testing in the emergency department (ED) for patients presenting with chest pain. METHODS A nationally representative ED data sample for all adults (>or=18 years) was obtained from the National Hospital Ambulatory Health Care Survey of EDs for 1997-2006. Weighted logistic regression was used to examine the associations between race and presenting symptom, triage assignment, and test ordering, adjusting for patient and hospital characteristics. RESULTS Over 10 years, an estimated 78 million visits to the ED presented with a complaint of chest pain. Of those presenting with chest pain, African Americans (odds ratio [OR] = 0.70; 99% confidence interval [CI] = 0.53 to 0.92), Hispanics (OR = 0.74; 99% CI = 0.51 to 0.99), Medicaid patients (OR = 0.72; 99% CI = 0.54 to 0.94), and uninsured patients (OR = 0.65; 99% CI = 0.51 to 0.84) were less likely to be triaged emergently. African Americans (OR = 0.86; 99% CI = 0.70 to 0.99), Medicaid patients (OR = 0.70; 99% CI = 0.55 to 0.88), and uninsured patients (OR = 0.70; 99% CI = 0.55 to 0.89) were less likely to have an electrocardiogram (ECG) ordered. African Americans (OR = 0.69; 99% CI = 0.49 to 0.97), Medicaid patients (OR = 0.67; 99% CI = 0.47 to 0.95), and uninsured patients (OR = 0.66; 99% CI = 0.44 to 0.96) were less likely to have cardiac enzymes ordered. Similarly, African Americans and Hispanics were less likely to have a cardiac monitor and pulse oximetry ordered, and Medicaid and uninsured patients were less likely to have a cardiac monitor ordered. CONCLUSIONS Persistent racial, sex, and insurance differences in triage categorization and basic cardiac testing exist. Eliminating triage disparities may affect "downstream" clinical care and help eliminate observed disparities in cardiac outcomes.
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Affiliation(s)
- Lenny López
- Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, MA, USA.
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Racial disparities in revascularization rates among patients with similar insurance coverage. J Natl Med Assoc 2010; 101:1132-9. [PMID: 19998642 DOI: 10.1016/s0027-9684(15)31109-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Racial disparities in coronary revascularization--percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG)--have been extensively documented. However, it is unclear whether disparities are consistent among patients with similar health insurance coverage. Our objective was to assess racial disparities in coronary revascularization among white, black, and Hispanic patients with similar insurance coverage hospitalized with acute myocardial infarction (AMI). METHODS We used 2000-2005 state inpatient data for 9 states to identify white, black, and Hispanic patients hospitalized with AMI. Patients were grouped into 3 health insurance cohorts: (1) Medicare, (2) private insurance, and (3) Medicaid/uninsured. We examined use of revascularization (PCI or CABG) among blacks and Hispanics as compared to whites in each of the 3 insurance cohorts. RESULTS The 418 study hospitals admitted 430509 AMI patients with Medicare, 238956 with private insurance, and 74926 patients who were uninsured/Medicaid. In unadjusted analyses, black and Hispanic patients were significantly less likely to receive in-hospital revascularization among the Medicare cohort (38.9% vs 44.9% vs 47.3%, P < .001), privately insured cohort (62.9% vs 69.7% vs 74.2%, P < .001), and uninsured/Medicaid cohort (55.2% vs 61.0% vs 68.4%, P <.001). In Cox models adjusting for patient demographics, comorbidity, and clustering of patients within hospitals, blacks were approximately 25% less likely and Hispanics 5% less likely to receive revascularization as compared to whites with similar insurance. CONCLUSIONS Blacks hospitalized with AMI are significantly less likely to receive revascularization when compared to whites and Hispanics with similar health insurance. Our data suggest that patients' ability to pay for costly procedures is unlikely to explain racial disparities.
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Chan PS, Birkmeyer JD, Krumholz HM, Spertus JA, Nallamothu BK. Racial and gender trends in the use of implantable cardioverter-defibrillators among Medicare beneficiaries between 1997 and 2003. ACTA ACUST UNITED AC 2009; 15:51-7. [PMID: 19379450 DOI: 10.1111/j.1751-7133.2009.00060.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Differences in the use of implantable cardioverter-defibrillators (ICDs) have been reported, but the extent to which they have widened after the publication of major clinical trials supporting their use is unclear. Using data on Medicare beneficiaries, the authors determined annual age-standardized population-based utilization rates of ICDs for white men, black men, white women, and black women from 1997 to 2003. During the study period, overall use of ICDs increased most for white men (81.7-254.7 procedures per 100,000 from 1997 to 2003) and black men (38.0-151.7 procedures per 100,000), with white women (28.9-98.4 procedures per 100,000) and black women (18.2-77.3 procedures per 100,000) showing smaller increases in comparison. After adjustment with multivariable regression models, differences in utilization rates between whites and men widened compared with blacks and women between 1997 and 2003, a period when indications for ICD therapy have expanded.
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Affiliation(s)
- Paul S Chan
- Department of Cardiovascular Research, Mid-America Heart Institute, University of Missouri-Kansas City, Kansas City, MO 64111, USA.
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Daugherty SL, Peterson PN, Wang Y, Curtis JP, Heidenreich PA, Lindenfeld J, Vidaillet HJ, Masoudi FA. Use of implantable cardioverter defibrillators for primary prevention in the community: do women and men equally meet trial enrollment criteria? Am Heart J 2009; 158:224-9. [PMID: 19619698 DOI: 10.1016/j.ahj.2009.05.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2008] [Accepted: 05/12/2009] [Indexed: 12/31/2022]
Abstract
BACKGROUND Fewer women than men undergo implantable cardioverter defibrillator (ICD) implantation for the primary prevention of sudden cardiac death. The criteria used to select patients for ICD implantation may be more permissive among men than for women. We hypothesized that women who undergo primary prevention ICD implantation more often meet strict trial enrollment criteria for this therapy. METHODS We studied 59,812 patients in the National Cardiovascular Data Registry ICD registry undergoing initial primary prevention ICD placement between January 2005 and April 2007. Patients were classified as meeting or not meeting enrollment criteria of either the MADIT-II or SCD-HeFT trials. Multivariable analyses assessed the association between gender and concordance with trial criteria adjusting for demographic, clinical, and system characteristics. RESULTS Among the cohort, 27% (n = 16,072) were women. Overall, 85.2% of women and 84.5% of men met enrollment criteria of either trial (P = .05). In multivariable analyses, women were equally likely to meet trial criteria (OR 1.04, 95% CI 0.99-1.10) than men. Significantly more women than men met the trial enrollment criteria among patients older than age 65 (86.6% of women vs 85.3% of men, OR 1.11, 95% CI 1.03-1.19), but this difference was not found among younger patients (82.5% of women vs 83.0% of men, OR 0.97, 95% CI 0.89-1.07). CONCLUSIONS In a national cohort undergoing primary prevention ICD implantation, older women were only slightly more likely then men to meet the enrollment criteria for MADIT II or SCD-HeFT. Relative overutilization in men is not an important explanation for gender differences in ICD implantation.
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Affiliation(s)
- Stacie L Daugherty
- University of Colorado Denver, Division of Cardiology, 12631 E. 17th Ave., Mailstop B130, PO Box 6511, Aurora, CO 80045, USA.
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MacFadden DR, Tu JV, Chong A, Austin PC, Lee DS. Evaluating sex differences in population-based utilization of implantable cardioverter-defibrillators: role of cardiac conditions and noncardiac comorbidities. Heart Rhythm 2009; 6:1289-96. [PMID: 19695966 DOI: 10.1016/j.hrthm.2009.05.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2009] [Accepted: 05/14/2009] [Indexed: 11/30/2022]
Abstract
BACKGROUND The influence of age and comorbidities on sex-specific implantable cardioverter-defibrillator (ICD) use for primary or secondary prevention is undefined. OBJECTIVE The purpose of this study was to investigate the influence of age and comorbidities on sex-specific ICD use. METHODS Sex disparities and sex-specific trends in ICD implantation according to indication in patients with cardiac arrest (1998-2007) in Ontario, Canada, were examined. Use of ICDs for primary prevention in patients with myocardial infarction (2002-2007) or heart failure (2005-2007) also was examined. RESULTS Among 9,246 eligible secondary prevention patients (age 66.3 +/- 14.3 years; 3,577 women [39%]) with cardiac arrest, men were more likely to undergo ICD implantation, with an age-, comorbidity-, and arrhythmia-adjusted hazard ratio (HR) of 1.92 (95% confidence interval [CI]: 1.66-2.23). Among 105,516 patients with myocardial infarction (age 68.3 +/- 12.7 years; 42,987 women [41%]), men were threefold more likely to undergo ICD implantation, with an adjusted HR of 3.00 (95% CI: 2.53-3.55). Among 61,160 patients with heart failure (age 76.2 +/- 12.0 years; 31,575 women [52%]), ICD implantation was more likely in men, with an adjusted HR of 3.01 (95% CI: 2.59-3.50). The odds of ICD implant for secondary prevention increased over time by 21% (95% CI: 13%-30%) in women and by 6% (95% CI: 2%-11%) in men, but rates of ICD use in men for primary prevention indications were persistently higher. CONCLUSION Men were more likely to undergo defibrillator implant than were women for primary and secondary prevention. Age and comorbidities did not account for the observed sex differences. Although sex differences in secondary prevention are declining over time, disparities in primary prevention persist.
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Affiliation(s)
- Derek R MacFadden
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Yancy CW, Fonarow GC, Albert NM, Curtis AB, Stough WG, Gheorghiade M, Heywood JT, McBride ML, Mehra MR, O'Connor CM, Reynolds D, Walsh MN. Influence of patient age and sex on delivery of guideline-recommended heart failure care in the outpatient cardiology practice setting: findings from IMPROVE HF. Am Heart J 2009; 157:754-62.e2. [PMID: 19332206 DOI: 10.1016/j.ahj.2008.12.016] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2008] [Accepted: 12/29/2008] [Indexed: 01/14/2023]
Abstract
BACKGROUND The influence of patient age and sex on delivery of guideline-recommended heart failure (HF) therapies in contemporary outpatient settings has not been well studied. The Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF) is a prospective cohort study designed to characterize current management of outpatients with chronic HF and left ventricular ejection fraction < or =35%. METHODS Baseline data for eligible patients with systolic HF in a national registry of 167 US outpatient cardiology practices were collected by trained chart abstractors. Data were stratified and analyzed as male/female and by age tertiles with generalized estimating equation models constructed for 7 care measures. RESULTS A total of 15,381 patients were enrolled, with 8,770 (71.1%) of these male. Median age of female patients was 72.0 and 70.0 for males. Use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, aldosterone inhibitors, and cardiac resynchronization therapy was not significantly different between male and female patients, but rates for implantable cardioverter defibrillators, anticoagulation therapy for atrial fibrillation, and HF education were significantly lower for females. After adjusting for patient and practice characteristics, 3 of 7 measures significantly differed by patient sex, and 6 of 7 measures by age. Older patients, particularly older women, were significantly less likely to receive guideline-indicated HF therapies. CONCLUSIONS Patient age and sex were independently associated with reduced rates of some, but not all, HF therapies in outpatient cardiology practices. Older women are especially at risk. Further research is needed to understand the causes and consequences of these age- and sex-related differences in care.
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Al-Khatib SM, Sanders GD, Carlson M, Cicic A, Curtis A, Fonarow GC, Groeneveld PW, Hayes D, Heidenreich P, Mark D, Peterson E, Prystowsky EN, Sager P, Salive ME, Thomas K, Yancy CW, Zareba W, Zipes D. Preventing tomorrow's sudden cardiac death today: dissemination of effective therapies for sudden cardiac death prevention. Am Heart J 2008; 156:613-22. [PMID: 18926144 DOI: 10.1016/j.ahj.2008.05.027] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2008] [Accepted: 05/23/2008] [Indexed: 10/21/2022]
Abstract
Because the burden of sudden cardiac death (SCD) is substantial, it is important to use all guideline-driven therapies to prevent SCD. Among those therapies is the implantable cardioverter defibrillator (ICD). When indicated, ICD use is beneficial and cost-effective. Unfortunately, studies suggest that most patients who have indications for this therapy for primary or secondary prevention of SCD are not receiving it. To explore potential reasons for this underuse and to propose potential facilitators for ICD dissemination, the Duke Center for the Prevention of SCD at the Duke Clinical Research Institute (Durham, NC) organized a think tank meeting of experts on this issue. The meeting took place on December 12 and 13, 2007, and it included representatives of clinical cardiology, cardiac electrophysiology, general internal medicine, economics, health policy, the US Food and Drug Administration, the Centers for Medicare and Medicaid Services, the Agency for Health care Research and Quality, and the device and pharmaceutical industry. Although the meeting was funded by industry participants, this article summarizing the presentations and discussions that occurred at the meeting presents the expert opinion of the authors.
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Age and gender trends in implantable cardioverter defibrillator utilization: a population based study. J Interv Card Electrophysiol 2008; 22:65-70. [PMID: 18324458 DOI: 10.1007/s10840-008-9213-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2007] [Accepted: 01/24/2008] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Implantable cardioverter-defibrillators improve mortality in selected high risk patients, yet population based data regarding utilization of these devices, particularly in the elderly, are limited. METHODS To address this, we reviewed all ICD implantations performed in Olmsted County, MN, a geographically defined population, between December 1989 and December 2004. RESULTS The study population comprised 179 patients (147 male, 82%, mean age 65 +/- 14 years). Baseline ejection fraction and creatinine were 35% +/- 16% and 1.38 +/- 1.08 mg/dl, respectively. Over the study period, the incidence of congestive heart failure in patients undergoing ICD implantation and referrals for primary prevention ICDs increased, while baseline ejection fraction and etiology of cardiomyopathy remained unchanged. The incidence of ICD implantations increased significantly in the elderly (p < 0.001) and especially in male patients when compared to female patients (p < 0.001). CONCLUSIONS Age of patients undergoing ICD implantation is increasing. However, fewer females compared to males are undergoing ICD implantation, suggesting a gender bias in ICD therapy and utilization.
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Mitchell JE, Hellkamp AS, Mark DB, Anderson J, Poole JE, Lee KL, Bardy GH. Outcome in African Americans and other minorities in the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT). Am Heart J 2008; 155:501-6. [PMID: 18294487 DOI: 10.1016/j.ahj.2007.10.022] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2007] [Accepted: 10/14/2007] [Indexed: 11/24/2022]
Abstract
BACKGROUND The SCD-HeFT demonstrated that implantable cardioverter/defibrillator (ICD) therapy significantly improved survival compared to medical therapy alone in stable moderately symptomatic heart failure patients with an ejection fraction < or = 35%. The purpose of this report is to describe the outcomes in African Americans (AAs) and other minorities. METHODS Of 2521 patients enrolled, 23% were minorities and 17% were AAs. Baseline demographic, clinical variables, socioeconomic status, and long-term outcomes were compared according to race. Two major prespecified subgroups were examined: heart failure cause (ischemic vs nonischemic) and New York Heart Association class (II vs III). RESULTS At baseline, compared to whites, AAs were younger and had more nonischemic heart failure, lower ejection fractions, worse New York Heart Association functional class, and higher prevalence of a history of nonsustained ventricular tachycardia. Comparable percentages of whites and AAs held paid jobs, but whites had a significantly higher educational level and household income (P = .001). Compliance with ICD implantation and medical therapy was comparable in both subgroups. No significant difference was observed in the rate of ICD discharge among whites and AAs. Adjusted mortality risk was significantly higher in AAs compared to whites (hazard ratio 1.27, P = .038). Mortality was equally reduced in both race groups receiving ICD therapy compared to placebo (hazard ratio 0.65 in AAs and 0.73 in whites). CONCLUSIONS Survival benefits from ICD therapy in SCD-HeFT were not dependent on race. In addition, in this clinical trial setting, there was no evidence that AAs were less willing to accept ICD therapy than whites.
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Davis AM, Vinci LM, Okwuosa TM, Chase AR, Huang ES. Cardiovascular health disparities: a systematic review of health care interventions. Med Care Res Rev 2007; 64:29S-100S. [PMID: 17881625 PMCID: PMC2367222 DOI: 10.1177/1077558707305416] [Citation(s) in RCA: 148] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Racial and ethnic disparities in cardiovascular health care are well documented. Promising approaches to disparity reduction are increasingly described in literature published since 1995, but reports are fragmented by risk, condition, population, and setting. The authors conducted a systematic review of clinically oriented studies in communities of color that addressed hypertension, hyperlipidemia, physical inactivity, tobacco, and two major cardiovascular conditions, coronary artery disease and heart failure. Virtually no literature specifically addressed disparity reduction. The greatest focus has been African American populations, with relatively little work in Hispanic, Asian, and Native American populations. The authors found 62 interventions, 27 addressing hypertension, 9 lipids, 18 tobacco use, 8 physical inactivity, and 7 heart failure. Only 1 study specifically addressed postmyocardial infarction care. Data supporting the value of registries, multidisciplinary teams, and community outreach were found across several conditions. Interventions addressing care transitions, using telephonic outreach, and promoting medication access and adherence merit further exploration.
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Race and gender equality in health care: are we there yet? Heart Rhythm 2007; 4:1427-9. [PMID: 17954402 DOI: 10.1016/j.hrthm.2007.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2007] [Indexed: 11/23/2022]
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Thomas KL, Al-Khatib SM, Kelsey RC, Bush H, Brosius L, Velazquez EJ, Peterson ED, Gilliam FR. Racial disparity in the utilization of implantable-cardioverter defibrillators among patients with prior myocardial infarction and an ejection fraction of <or=35%. Am J Cardiol 2007; 100:924-9. [PMID: 17826371 DOI: 10.1016/j.amjcard.2007.04.024] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2007] [Revised: 04/13/2007] [Accepted: 04/13/2007] [Indexed: 10/23/2022]
Abstract
Age-adjusted sudden cardiac death rates are highest for black patients compared with other racial groups. The prophylactic implantation of an implantable cardioverter-defibrillator (ICD) provides a significant reduction in sudden cardiac death and overall mortality in patients after myocardial infarctions with significant left ventricular systolic dysfunction. The purpose of this study was to determine whether black patients with left ventricular systolic dysfunction were less likely than white patients to receive ICDs for the primary prevention of sudden cardiac death. Data from the National Registry to Advance Heart Health (ADVANCENT) were analyzed to determine which patients with histories of myocardial infarctions and ejection fractions<or=35% received ICDs for the primary prevention of sudden cardiac death. Multivariate logistic regression was used to evaluate the association of patients' race with ICD implantation. Overall, 7,830 patients were identified as eligible candidates for ICDs. Black patients (n=660) were younger, more often women, had less education, had more co-morbidities, and had a lower mean ejection fraction compared with white patients (n=7,170). More than 90% of the study population were insured, and approximately 88% of participants in the registry were enrolled by cardiologists. Blacks were significantly less likely than whites to receive ICDs (30% vs 41%, p<0.001). This difference in ICD use persisted after adjusting for demographics, clinical characteristics, and socioeconomic factors (odds ratio 0.62, 95% confidence interval 0.50 to 0.75, p<0.001). In conclusion, among patients at an increased risk for sudden cardiac death, blacks were significantly less likely to receive ICDs than whites.
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Affiliation(s)
- Kevin L Thomas
- Duke University Medical Center, Durham, North Carolina, USA.
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