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Ngo LTH, Peng Y, Denman R, Yang I, Ranasinghe I. Long-term outcomes after hospitalization for atrial fibrillation or flutter. Eur Heart J 2024:ehae204. [PMID: 38678737 DOI: 10.1093/eurheartj/ehae204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 11/24/2023] [Accepted: 03/19/2024] [Indexed: 05/01/2024] Open
Abstract
BACKGROUND AND AIMS Atrial fibrillation (AF) and flutter are common causes of hospitalizations but contemporary long-term outcomes following these episodes are uncertain. This study assessed outcomes up to 10 years after an acute AF or flutter hospitalization. METHODS Patients hospitalized acutely with a primary diagnosis of AF or flutter from 2008-17 from all public and most private hospitals in Australia and New Zealand were included. Kaplan-Meier methods and flexible parametric survival modelling were used to estimate survival and loss in life expectancy, respectively. Competing risk model accounting for death was used when estimating incidence of non-fatal outcomes. RESULTS A total of 260 492 adults (mean age 70.5 ± 14.4 years, 49.6% female) were followed up for 1 068 009 person-years (PY), during which 69 167 died (incidence rate 6.5/100 PY) with 91.2% survival at 1 year, 72.7% at 5 years, and 55.2% at 10 years. Estimated loss in life expectancy was 2.6 years, or 16.8% of expected life expectancy. Re-hospitalizations for heart failure (2.9/100 PY), stroke (1.7/100 PY), and myocardial infarction (1.1/100 PY) were common with respective cumulative incidences of 16.8%, 11.0%, and 7.1% by 10 years. Re-hospitalization for AF or flutter occurred in 21.3% by 1 year, 35.3% by 5 years, and 41.2% by 10 years (11.6/100 PY). The cumulative incidence of patients undergoing catheter ablation of AF was 6.5% at 10 years (1.2/100 PY). CONCLUSIONS Patients hospitalized for AF or flutter had high death rates with an average 2.6-year loss in life expectancy. Moreover, re-hospitalizations for AF or flutter and related outcomes such as heart failure and stroke were common with catheter ablation used infrequently for treatment, which warrant further actions.
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Affiliation(s)
- Linh Thi Hai Ngo
- Faculty of Medicine, The University of Queensland, 627 Rode Road, Chermside, Queensland 4032, Australia
- Department of Cardiology, The Prince Charles Hospital, 627 Rode Road, Chermside, Queensland 4032, Australia
| | - Yang Peng
- Faculty of Medicine, The University of Queensland, 627 Rode Road, Chermside, Queensland 4032, Australia
- Department of Cardiology, The Prince Charles Hospital, 627 Rode Road, Chermside, Queensland 4032, Australia
| | - Russell Denman
- Department of Cardiology, The Prince Charles Hospital, 627 Rode Road, Chermside, Queensland 4032, Australia
| | - Ian Yang
- Faculty of Medicine, The University of Queensland, 627 Rode Road, Chermside, Queensland 4032, Australia
- Department of Thoracic Medicine, The Prince Charles Hospital, 627 Rode Road, Chermside, Queensland 4032, Australia
| | - Isuru Ranasinghe
- Faculty of Medicine, The University of Queensland, 627 Rode Road, Chermside, Queensland 4032, Australia
- Department of Cardiology, The Prince Charles Hospital, 627 Rode Road, Chermside, Queensland 4032, Australia
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Yousuf OK, Kennedy K, Russo A, Varosy P, Lindsay BD, Steinberg B, Atwater BD, Calkins H, Spertus JA. Appropriateness of implantable cardioverter-defibrillator device implants in the United States. Heart Rhythm 2024; 21:397-407. [PMID: 38123044 DOI: 10.1016/j.hrthm.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND The appropriate use criteria (AUCs) are a diverse group of indications aimed to better evaluate the benefits of implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy. OBJECTIVE The purpose of this study was to quantify the proportion of ICD and cardiac resynchronization therapy with defibrillator (CRT-D) implants as appropriate, may be appropriate (MA), or rarely appropriate (RA) on the basis of the AUC guidelines. METHODS This is a multicenter retrospective study of patients within the National Cardiovascular Data Registry undergoing ICD implantation between April 2018 and March 2019 at >1500 US hospitals. The appropriateness of ICD implants was adjudicated using the AUC. RESULTS Of 309,318 ICDs, 241,438 were primary prevention implants (78.1%) and 67,880 secondary prevention implants (21.9%); 243,532 (79%) were mappable to the AUC. For primary prevention, 185,431 ICDs (96.4%) were appropriate, 5660 (2.9%) MA, and 1205 (0.6%) RA. For secondary prevention, 47,498 ICDs (92.7%) were appropriate, 2581 (5%) MA, and 1157 (2.3%) RA. A significant number of RA devices were implanted in patients with New York Heart Association class IV heart failure who were ineligible for advanced therapies (53.9%) and those with myocardial infarction within 40 days (18.1%). The appropriateness of the pacing lead was more variable, with 48,470 dual-chamber ICD implants (62%) being classified as appropriate, 29,209 (37.4%) MA, and 448 (0.6%) RA. Among CRT-D implants, 63,848 (82.2%) were appropriate, 9900 (12.7%) MA, and 3940 (5.1%) RA for left ventricular pacing. A total of 99,754 implants were deemed appropriate but excluded from Centers for Medicare & Medicaid Services National Coverage Determination. More than 92% of hospitals had an RA implant rate of <4%. CONCLUSION In this large national registry, 95% of mappable ICD and CRT-D implants were considered appropriate, with <2% of RA implants. Nearly 100,000 appropriate implants are excluded by Centers for Medicare & Medicaid Services National Coverage Determination.
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Affiliation(s)
- Omair K Yousuf
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; Carient Heart & Vascular, Manassas, Virginia; Inova Heart and Vascular Institute, Fairfax, Virginia; University of Virginia Health, Manassas, Virginia.
| | - Kevin Kennedy
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | | | | | | | | | - Brett D Atwater
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; Inova Heart and Vascular Institute, Fairfax, Virginia
| | - Hugh Calkins
- Johns Hopkins Medical Institution, Baltimore, Maryland
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri
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3
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Friedman DJ, Qin L, Freeman JV, Singh JP, Curtis JP, Piccini JP, Al-Khatib SM, Jackson KP. Left ventricular lead implantation failure in an unselected nationwide cohort. Heart Rhythm 2023; 20:1420-1428. [PMID: 37406870 DOI: 10.1016/j.hrthm.2023.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 06/26/2023] [Accepted: 06/29/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Left ventricular (LV) lead implantation is often the most challenging aspect of cardiac resynchronization therapy (CRT) procedures; early studies reported implant failure rates in ∼10% of cases. OBJECTIVE The purpose of this study was to define rates, reasons for, and factors independently associated with LV lead implant failure. METHODS We studied patients with left bundle branch block and ejection fraction ≤ 35% who underwent planned de novo transvenous CRT implantation (2010-2016) and were reported to the National Cardiovascular Data Registry ICD Registry. Independent predictors of LV lead implant failure were determined using logistic regression; age, sex, and variables with a univariable P value of <.15 were considered for inclusion in the model. RESULTS Of the 111,802 patients who underwent a planned CRT procedure, 3.6% of patients (n = 3979) had LV lead implant failure. Reasons for implant failure included venous access (7.5%), coronary sinus access (64.3%), tributary vein access (13.5%), coronary sinus dissection (7.6%), unacceptable threshold (4.4%), and diaphragmatic stimulation (1.7%). Significant independent predictors of LV lead implant failure included younger age (odds ratio [OR] 1.01; 95% confidence interval [CI] 0.1.01-1.02), female sex (OR 1.38; 95% CI 1.29-1.47), black race (vs white, OR 1.44; 95% CI 1.32-1.57), Hispanic ethnicity (OR 1.23; 95% CI 1.08-1.40), QRS duration (OR 1.055 per 10 ms; 95% CI 1.038-1.072 per 10 ms), obstructive sleep apnea (OR 1.14; 95% CI 1.04-1.24), and implantation by a physician without specialized training (vs electrophysiology trained, OR 1.53; 95% CI 1.34-1.76). CONCLUSION LV lead implant failure is uncommon in the current era and is most commonly due to coronary sinus access failure. Predictors of LV lead implant failure included younger age, female sex, black race, Hispanic ethnicity, increased QRS duration, sleep apnea, and absence of electrophysiology training.
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Affiliation(s)
- Daniel J Friedman
- Electrophysiology Section, Duke University Hospital, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
| | - Li Qin
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
| | - James V Freeman
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
| | - Jagmeet P Singh
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts
| | - Jeptha P Curtis
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
| | - Jonathan P Piccini
- Electrophysiology Section, Duke University Hospital, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Sana M Al-Khatib
- Electrophysiology Section, Duke University Hospital, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Kevin P Jackson
- Electrophysiology Section, Duke University Hospital, Durham, North Carolina
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Hurley NC, Dhruva SS, Desai NR, Ross JR, Ngufor CG, Masoudi F, Krumholz HM, Mortazavi BJ. Clinical Phenotyping with an Outcomes-driven Mixture of Experts for Patient Matching and Risk Estimation. ACM TRANSACTIONS ON COMPUTING FOR HEALTHCARE 2023; 4:1-18. [PMID: 37908872 PMCID: PMC10613929 DOI: 10.1145/3616021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 08/02/2023] [Indexed: 11/02/2023]
Abstract
Observational medical data present unique opportunities for analysis of medical outcomes and treatment decision making. However, because these datasets do not contain the strict pairing of randomized control trials, matching techniques are to draw comparisons among patients. A key limitation to such techniques is verification that the variables used to model treatment decision making are also relevant in identifying the risk of major adverse events. This article explores a deep mixture of experts approach to jointly learn how to match patients and model the risk of major adverse events in patients. Although trained with information regarding treatment and outcomes, after training, the proposed model is decomposable into a network that clusters patients into phenotypes from information available before treatment. This model is validated on a dataset of patients with acute myocardial infarction complicated by cardiogenic shock. The mixture of experts approach can predict the outcome of mortality with an area under the receiver operating characteristic curve of 0.85 ± 0.01 while jointly discovering five potential phenotypes of interest. The technique and interpretation allow for identifying clinically relevant phenotypes that may be used both for outcomes modeling as well as potentially evaluating individualized treatment effects.
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Nowroozilarki Z, Mortazavi BJ, Jafari R. Variational Autoencoders for Biomedical Signal Morphology Clustering and Noise Detection. IEEE J Biomed Health Inform 2023; PP:10.1109/JBHI.2023.3320585. [PMID: 37768790 PMCID: PMC10984704 DOI: 10.1109/jbhi.2023.3320585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
Accurate estimation of physiological biomarkers using raw waveform data from non-invasive wearable devices requires extensive data preprocessing. An automatic noise detection method in time-series data would offer significant utility for various domains. As data labeling is onerous, having a minimally supervised abnormality detection method for input data, as well as an estimation of the severity of the signal corruptness, is essential. We propose a model-free, time-series biomedical waveform noise detection framework using a Variational Autoencoder coupled with Gaussian Mixture Models, which can detect a range of waveform abnormalities without annotation, providing a confidence metric for each segment. Our technique operates on biomedical signals that exhibit periodicity of heart activities. This framework can be applied to any machine learning or deep learning model as an initial signal validator component. Moreover, the confidence score generated by the proposed framework can be incorporated into different models' optimization to construct confidence-aware modeling. We conduct experiments using dynamic time warping (DTW) distance of segments to validated cardiac cycle morphology. The result confirms that our approach removes noisy cardiac cycles and the remaining signals, classified as clean, exhibit a 59.92% reduction in the standard deviation of DTW distances. Using a dataset of bio-impedance data of 97885 cardiac cycles, we further demonstrate a significant improvement in the downstream task of cuffless blood pressure estimation, with an average reduction of 2.67 mmHg root mean square error (RMSE) of Diastolic Blood pressure and 2.13 mmHg RMSE of systolic blood pressure, with increases of average Pearson correlation of 0.28 and 0.08, with a statistically significant improvement of signal-to-noise ratio respectively in the presence of different synthetic noise sources. This enables burden-free validation of wearable sensor data for downstream biomedical applications.
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Uzendu A, Kennedy K, Chertow G, Amin AP, Giri JS, Rymer JA, Bangalore S, Lavin K, Anderson C, Spertus JA. Implications of a Race Term in GFR Estimates Used to Predict AKI After Coronary Intervention. JACC Cardiovasc Interv 2023; 16:2309-2320. [PMID: 37758386 DOI: 10.1016/j.jcin.2023.07.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 06/06/2023] [Accepted: 07/25/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND The prediction of mortality, bleeding, and acute kidney injury (AKI) after percutaneous coronary intervention (PCI) traditionally relied on race-based estimates of the glomerular filtration rate (GFR). Recently, race agnostic equations were developed to advance equity. OBJECTIVES The authors aimed to compare the accuracy and implications of various GFR equations when used to predict AKI after PCI. METHODS Using the National Cardiovascular Data Registry (NCDR) CathPCI data set, we identified patients undergoing PCI in 2020 and calculated their AKI risk using the 2014 NCDR AKI risk model. We created 4 AKI models per patient for each estimate of baseline renal function: the traditional GFR equation with a race term, 2 GFR equations without a race term, and serum creatinine alone. We then compared each model's performance predicting AKI. RESULTS Among 455,806 PCI encounters, the median age was 67 years, 32.2% were women, and 8.5% were Black. In Black patients, risk models without a race term were better calibrated than models incorporating an equation with a race term (intercept: -0.01 vs 0.15). Race-agnostic models reclassified 6% of Black patients into higher-risk categories, potentially prompting appropriate mitigation efforts. However, even with a race-agnostic model, AKI occurred in Black patients 18% more often than expected, which was not explained by captured patient or procedural characteristics. CONCLUSIONS Incorporating a GFR estimate without a Black race term into the NCDR AKI risk prediction model yielded more accurate prediction of AKI risk for Black patients, which has important implications for reducing disparities and benchmarking.
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Affiliation(s)
- Anezi Uzendu
- Cardiovascular Outcomes, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri Kansas City, Kansas City, Missouri, USA.
| | - Kevin Kennedy
- Cardiovascular Outcomes, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Glenn Chertow
- Department of Medicine, Stanford University, Stanford, California, USA
| | - Amit P Amin
- Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Jay S Giri
- Penn Center for Quality, Outcomes, and Evaluative Research, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer A Rymer
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Sripal Bangalore
- Department of Medicine, New York University Langone, New York, New York, USA
| | - Kimberly Lavin
- Department of Science and Quality, American College of Cardiology, Washington, DC, USA
| | - Cornelia Anderson
- Department of Science and Quality, American College of Cardiology, Washington, DC, USA
| | - John A Spertus
- Cardiovascular Outcomes, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri Kansas City, Kansas City, Missouri, USA
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7
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Uzendu A, Kennedy K, Chertow G, Amin AP, Giri JS, Rymer JA, Bangalore S, Lavin K, Anderson C, Wang TY, Curtis JP, Spertus JA. Contemporary Methods for Predicting Acute Kidney Injury After Coronary Intervention. JACC Cardiovasc Interv 2023; 16:2294-2305. [PMID: 37758384 PMCID: PMC10795198 DOI: 10.1016/j.jcin.2023.07.041] [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: 02/16/2023] [Revised: 06/06/2023] [Accepted: 07/25/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is the most common complication after percutaneous coronary intervention (PCI). Accurately estimating patients' risks not only creates a means of benchmarking performance but can also be used prospectively to inform practice. OBJECTIVES The authors sought to update the 2014 National Cardiovascular Data Registry (NCDR) AKI risk model to provide contemporary estimates of AKI risk after PCI to further improve care. METHODS Using the NCDR CathPCI Registry, we identified all 2020 PCIs, excluding those on dialysis or lacking postprocedural creatinine. The cohort was randomly split into a 70% derivation cohort and a 30% validation cohort, and logistic regression models were built to predict AKI (an absolute increase of 0.3 mg/dL in creatinine or a 50% increase from preprocedure baseline) and AKI requiring dialysis. Bedside risk scores were created to facilitate prospective use in clinical care, along with threshold contrast doses to reduce AKI. We tested model calibration and discrimination in the validation cohort. RESULTS Among 455,806 PCI procedures, the median age was 67 years (IQR: 58.0-75.0 years), 68.8% were men, and 86.8% were White. The incidence of AKI and new dialysis was 7.2% and 0.7%, respectively. Baseline renal function and variables associated with clinical instability were the strongest predictors of AKI. The final AKI model included 13 variables, with a C-statistic of 0.798 and excellent calibration (intercept = -0.03 and slope = 0.97) in the validation cohort. CONCLUSIONS The updated NCDR AKI risk model further refines AKI prediction after PCI, facilitating enhanced clinical care, benchmarking, and quality improvement.
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Affiliation(s)
- Anezi Uzendu
- Cardiovascular Outcomes, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri Kansas City, Kansas City, Missouri, USA.
| | - Kevin Kennedy
- Cardiovascular Outcomes, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Glenn Chertow
- Department of Medicine, Stanford University, Stanford, California, USA
| | - Amit P Amin
- Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Jay S Giri
- Penn Center for Quality, Outcomes, and Evaluative Research, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer A Rymer
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Sripal Bangalore
- Department of Medicine, New York University Langone, New York, New York, USA
| | - Kimberly Lavin
- Department of Science and Quality, American College of Cardiology, Washington, DC, USA
| | - Cornelia Anderson
- Department of Science and Quality, American College of Cardiology, Washington, DC, USA
| | - Tracy Y Wang
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - John A Spertus
- Cardiovascular Outcomes, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; University of Missouri Kansas City, Kansas City, Missouri, USA
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Pundi K, Gosch KL, Perino AC, Jones PG, Desai NR, Maddox TM, Turakhia M. ACC/AHA Hypertension Guidelines and CHA2DS2-VASc Up-Scoring in Patients With Atrial Fibrillation. JAMA Netw Open 2023; 6:e2335722. [PMID: 37751209 PMCID: PMC10523168 DOI: 10.1001/jamanetworkopen.2023.35722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 08/18/2023] [Indexed: 09/27/2023] Open
Abstract
This cohort study compares rates of hypertension among nonhypertensive patients with atrial fibrillation using JNC 8 vs ACC/AHA thresholds.
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Affiliation(s)
- Krishna Pundi
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Kensey L. Gosch
- St Luke’s Mid America Heart Institute, Kansas City, Missouri
| | - Alexander C. Perino
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Philip G. Jones
- St Luke’s Mid America Heart Institute, Kansas City, Missouri
| | - Nihar R. Desai
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Thomas M. Maddox
- Division of Cardiology, Washington University School of Medicine, St Louis, Missouri
| | - Mintu Turakhia
- Department of Medicine, Stanford University School of Medicine, Stanford, California
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Houterman S, van Dullemen A, Versteegh M, Aengevaeren W, Danse P, Brinkman E, Schuurman D, van Veghel D. Data quality and auditing within the Netherlands Heart Registration: using the PCI registry as an example. Neth Heart J 2023; 31:334-339. [PMID: 36645544 PMCID: PMC10444924 DOI: 10.1007/s12471-022-01752-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2022] [Indexed: 01/17/2023] Open
Abstract
AIM The aim of this article is to present the method and results of the data quality control system and audit within the Netherlands Heart Registration (NHR) using data of patients treated with percutaneous coronary intervention (PCI) in the Netherlands as an example. METHODS The NHR is a Dutch nationwide registry of all cardiac interventions, comprising data from all 71 hospitals, of which 30 are cardiac intervention or heart centres. Each year, within the NHR, data validation and verification is performed by standard quality controls and monitoring visits (audits). For the audit in 2019, a sample of 50-100 medical records of patients treated with PCI in 2016 and 2017 were reviewed in each hospital by an independent auditor. The data received by the NHR were compared with the information in the hospitals' medical records. In total 12 patient characteristics, 5 intervention variables and 3 outcome variables were screened. The value of a variable was considered discrepant if more than 10% of the medical records reviewed regarding this variable were not consistent with the reported data received by the NHR. RESULTS For all variables together, the consistency was high, 97.6%. All variables, except multivessel disease (9.3% discrepancy in the 2622 medical records reviewed), had an accuracy above 95%. CONCLUSION The results of the audit of the PCI medical records show that the overall quality of the data is high. For variables such as multivessel disease it is important to improve knowledge of the definitions and to train all those involved in the registration process.
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Affiliation(s)
- S Houterman
- Netherlands Heart Registration, Utrecht, The Netherlands.
| | - A van Dullemen
- Netherlands Heart Registration, Utrecht, The Netherlands
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis Hospital, Amsterdam, The Netherlands
| | - M Versteegh
- Netherlands Heart Registration, Utrecht, The Netherlands
| | - W Aengevaeren
- Netherlands Heart Registration, Utrecht, The Netherlands
| | - P Danse
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - E Brinkman
- Department of Medical Informatics, Amsterdam UMC, Amsterdam, The Netherlands
| | - D Schuurman
- Netherlands Heart Registration, Utrecht, The Netherlands
| | - D van Veghel
- Netherlands Heart Registration, Utrecht, The Netherlands
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Bischoff AR, Kennedy KF, Backes CH, Sathanandam S, McNamara PJ. Percutaneous Closure of the Patent Ductus Arteriosus in Infants ≤2 kg: IMPACT Registry Insights. Pediatrics 2023; 152:e2023061460. [PMID: 37529882 DOI: 10.1542/peds.2023-061460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2023] [Indexed: 08/03/2023] Open
Abstract
OBJECTIVES Percutaneous patent ductus arteriosus (PDA) closure is becoming the standard of care for definitive closure in progressively smaller and younger neonates. The objective of this study was to assess safety and feasibility of percutaneous PDA closure in patients ≤2 kg. METHODS This was a cohort study using the IMPACT Registry (Improving Pediatric and Adult Congenital Treatments) from the American College of Cardiology Foundation's National Cardiovascular Data Registry. Patients who were ≤2 kg at the time of percutaneous PDA closure were included. The primary outcome was the composite of technical failure and/or major adverse event. RESULTS A total of 1587 attempted PDA closures were included, with a 3% incidence of technical failure and 5.5% incidence of the composite outcome. Major adverse events were observed in 3.8% of the patients; the most common events were device embolization requiring retrieval and unplanned cardiac or vascular surgery in 1.3% and 1.3% of cases, respectively. The incidence of the composite outcome was associated with the need for arterial access (P < .001) as well as annual hospital volume of percutaneous PDA closures in infants ≤2 kg (P = .001). The incidence of the composite outcome has decreased overtime, whereas median weight at the time of procedure has also diminished. CONCLUSIONS Percutaneous PDA closure appears to be safe and feasible procedures in infants ≤2 kg. The incidence of major adverse events has continued to decline over the years and seems to have a strong correlation with individual center case volumes and expertise.
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Affiliation(s)
| | | | - Carl H Backes
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Shyam Sathanandam
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Patrick J McNamara
- Department of Pediatrics, Division of Neonatology
- Department of Internal Medicine University of Iowa, Iowa City, Iowa
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Goldstein SA, Kennedy KF, Friedman DJ, Al-Khatib SM, Wang A. Utilization and Outcomes of Primary Prevention Implantable Cardioverter-Defibrillators in Patients With Hypertrophic Cardiomyopathy. J Am Heart Assoc 2023; 12:e029293. [PMID: 37586066 PMCID: PMC10492935 DOI: 10.1161/jaha.122.029293] [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: 12/22/2022] [Accepted: 06/19/2023] [Indexed: 08/18/2023]
Abstract
Background There is uncertainty about the appropriate use of primary prevention implantable cardioverter-defibrillators (ICDs) among older patients with hypertrophic cardiomyopathy. Methods and Results Patients with hypertrophic cardiomyopathy who received a primary prevention ICD between 2010 and 2016 were identified using the National Cardiovascular Data Registry ICD Registry. Trends in ICD utilization and patient characteristics were assessed over time. Using linked Centers for Medicare and Medicaid Service claims data, Cox proportional hazard models assessed factors associated with mortality and postdischarge hospitalization for cardiac arrest/ventricular arrhythmia. Of 5571 patients with hypertrophic cardiomyopathy, 1511 (27.1%) were ≥65 years old. ICD utilization increased over time in all age groups. There were no changes in the prevalence of risk factors for sudden cardiac death over time. The variables most strongly associated with postdischarge mortality were older age (adjusted hazard ratio (aHR) 1.80 [95% CI, 1.47-2.21]), New York Heart Association class (III/IV versus I/II aHR 2.17 [95% CI, 1.57-2.98]), and left ventricular ejection fraction (left ventricular ejection fraction ≤35% versus >50% aHR 2.34 [95% CI, 1.58-3.48]; left ventricular ejection fraction 36%-50% versus >50% aHR 2.98 [95% CI, 2.02-4.40]), while history of nonsustained ventricular tachycardia (aHR 2.38 [95% CI, 1.62-3.51]) and New York Heart Association class (III/IV versus I/II aHR 1.84 [95% CI, 1.22-2.78]) were strongly associated with hospitalization for ventricular arrhythmia/cardiac arrest. Conclusions Primary prevention ICD utilization in patients with hypertrophic cardiomyopathy increased over time, including among those ≥65 years old. Among older patients, the strongest risk factors for hospitalization for ventricular arrhythmia/cardiac arrest following ICD implantation were history of nonsustained ventricular tachycardia and New York Heart Association class.
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MESH Headings
- Humans
- Aged
- United States/epidemiology
- Defibrillators, Implantable/adverse effects
- Stroke Volume
- Aftercare
- Ventricular Function, Left
- Medicare
- Patient Discharge
- Cardiomyopathy, Hypertrophic/complications
- Cardiomyopathy, Hypertrophic/therapy
- Tachycardia, Ventricular
- Arrhythmias, Cardiac/complications
- Risk Factors
- Death, Sudden, Cardiac/epidemiology
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Heart Arrest/epidemiology
- Heart Arrest/therapy
- Heart Arrest/complications
- Primary Prevention
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Affiliation(s)
- Sarah A Goldstein
- Division of Cardiology, Department of Medicine Yale University School of Medicine New Haven CT USA
| | | | - Daniel J Friedman
- Division of Cardiology, Department of Medicine Duke University Medical Center Durham NC USA
- Duke Clinical Research Institute Durham NC USA
| | - Sana M Al-Khatib
- Division of Cardiology, Department of Medicine Duke University Medical Center Durham NC USA
- Duke Clinical Research Institute Durham NC USA
| | - Andrew Wang
- Division of Cardiology, Department of Medicine Duke University Medical Center Durham NC USA
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12
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Segar MW, Zhang A, Paisley RD, Badjatiya A, Lambeth KD, Mullins K, Razavi M, Molina-Razavi JE, Rasekh A, Saeed M. Risk Stratification in Patients Who Underwent Percutaneous Left Atrial Appendage Occlusion. Am J Cardiol 2023; 200:50-56. [PMID: 37295180 DOI: 10.1016/j.amjcard.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/04/2023] [Accepted: 05/13/2023] [Indexed: 06/12/2023]
Abstract
Left atrial appendage occlusion (LAAO) is effective in preventing thromboembolism. Risk stratification tools could help identify patients at risk for early mortality after LAAO. In this study, we validated and recalibrated a clinical risk score (CRS) to predict risk of all-cause mortality after LAAO. This study used data from patients who underwent LAAO in a single-center, tertiary hospital. A previously developed CRS using 5 variables (age, body mass index [BMI], diabetes, heart failure, and estimated glomerular filtration rate) was applied to each patient to assess risk of all-cause mortality at 1 and 2 years. The CRS was recalibrated to the present study cohort and compared with established atrial fibrillation-specific (CHA2DS2-VASc and HAS-BLED) and generalized (Walter index) risk scores. Cox proportional hazard models were used to assess the risk of mortality and discrimination was assessed by Harrel C-index. Among 223 patients, the 1- and 2-year mortality rates were 6.7% and 11.2%, respectively. With the original CRS, only low BMI (<23 kg/m2) was a significant predictor of all-cause mortality (hazard ratio [HR] [95% CI] 2.76 [1.03 to 7.35]; p = 0.04). With recalibration, BMI <29 kg/m2 and estimated glomerular filtration rate <60 ml/min/1.73 m2 were significantly associated with an increased risk of death (HR [95% CI] 3.24 [1.29 to 8.13] and 2.48 [1.07 to 5.74], respectively), with a trend toward significance noted for history of heart failure (HR [95% CI] 2.13 [0.97 to 4.67], p = 0.06). Recalibration improved the discriminative ability of the CRS from 0.65 to 0.70 and significantly outperformed established risk scores (CHA2DS2-VASc = 0.58, HAS-BLED = 0.55, Walter index = 0.62). In this single-center, observational study, the recalibrated CRS accurately risk stratified patients who underwent LAAO and significantly outperformed established atrial fibrillation-specific and generalized risk scores. In conclusion, clinical risk scores should be considered as an adjunct to standard of care when evaluating a patient's candidacy for LAAO.
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Affiliation(s)
- Matthew W Segar
- Department of Cardiology, Texas Heart Institute, Houston, Texas.
| | - Allan Zhang
- School of Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Anish Badjatiya
- Department of Cardiology, Texas Heart Institute, Houston, Texas
| | - Kaleb D Lambeth
- Department of Cardiology, Texas Heart Institute, Houston, Texas
| | - Karen Mullins
- Quality CV Service Line, Baylor St. Luke's Medical Center, Houston, Texas
| | - Mehdi Razavi
- Department of Cardiology, Texas Heart Institute, Houston, Texas
| | | | - Abdi Rasekh
- Department of Cardiology, Texas Heart Institute, Houston, Texas
| | - Mohammad Saeed
- Department of Cardiology, Texas Heart Institute, Houston, Texas
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13
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Malekrah A, Shafiee A, Heidari A, Vasheghani‐Farahani A, Bozorgi A, Sadeghian S, Yaminisharif A. Predictors of mortality and clinical outcomes following implantable cardioverter-defibrillator therapy in elderly patients: A retrospective single-center cohort study. Health Sci Rep 2023; 6:e1432. [PMID: 37492274 PMCID: PMC10363787 DOI: 10.1002/hsr2.1432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 06/30/2023] [Accepted: 07/05/2023] [Indexed: 07/27/2023] Open
Abstract
Background and aims Implantable cardioverter-defibrillators (ICDs) are frequently used to prevent sudden cardiac death in patients with high-risk arrhythmias. However, the use of ICD therapy in elderly patients beyond the predicted age of life expectancy is still controversial. We aimed to evaluate the predictors of mortality and clinical outcomes following ICD implantation in elderly patients. Methods We conducted a retrospective analysis of 145 elderly patients aged 72 years and older who received ICD implantation between January 2010 and August 2015. We collected and analyzed baseline data, including clinical, demographic, and medical history, the reason for ICD therapy, procedural data, and echocardiography results. Follow-up data included the development of complications and mortality. The predictors of mortality were identified using the univariate and multivariable Cox regression models. Results During the median follow-up duration of 30.5 [18.0-48.0] months, 141 cases completed follow-up (mean age = 76.0 ± 3.7 years). Forty-four patients experienced at least one episode of ICD therapy. Inappropriate shock, recurrent shock, and device-related infection were the most frequent complications observed in our study. Of the 145 patients, 42 died during the follow-up period, with an average survival time of 22.4 months after ICD implantation. Among these patients, 11 received ICD for primary prevention, and 31 received it for secondary prevention. Cardiovascular problems were the leading cause of death. We found that a low baseline ejection fraction (EF) was an independent predictor of mortality (hazard ratio = 0.93, 95% confidence interval: 0.90-0.98; p = 0.008). Conclusion Our study suggests that ICD therapy is a valuable treatment option for elderly patients beyond their predicted age of life expectancy. The study highlights the importance of baseline EF as a significant predictor of mortality in these patients.
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Affiliation(s)
- Alireza Malekrah
- Department of Electrophysiology, Tehran Heart Center, Cardiovascular Diseases Research InstituteTehran University of Medical SciencesTehranIran
- Cardiovascular Research CenterMazandaran University of Medical ScienceSariIran
| | - Akbar Shafiee
- Department of Cardiovascular Research, Tehran Heart Center, Cardiovascular Diseases Research InstituteTehran University of Medical SciencesTehranIran
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research InstituteTehran University of Medical SciencesTehranIran
| | - Amirhossein Heidari
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research InstituteTehran University of Medical SciencesTehranIran
- Faculty of Medicine, Tehran Medical SciencesIslamic Azad UniversityTehranIran
| | - Ali Vasheghani‐Farahani
- Department of Electrophysiology, Tehran Heart Center, Cardiovascular Diseases Research InstituteTehran University of Medical SciencesTehranIran
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research InstituteTehran University of Medical SciencesTehranIran
| | - Ali Bozorgi
- Department of Electrophysiology, Tehran Heart Center, Cardiovascular Diseases Research InstituteTehran University of Medical SciencesTehranIran
| | - Saeed Sadeghian
- Department of Electrophysiology, Tehran Heart Center, Cardiovascular Diseases Research InstituteTehran University of Medical SciencesTehranIran
| | - Ahmad Yaminisharif
- Department of Electrophysiology, Tehran Heart Center, Cardiovascular Diseases Research InstituteTehran University of Medical SciencesTehranIran
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14
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Mahtta D, Manandhar P, Wegermann ZK, Wojdyla D, Megaly M, Kochar A, Virani SS, Rao SV, Elgendy IY. Outcomes and Institutional Variation in Arterial Access Among Patients With AMI and Cardiogenic Shock Undergoing PCI. JACC Cardiovasc Interv 2023; 16:1517-1528. [PMID: 37380235 DOI: 10.1016/j.jcin.2023.03.043] [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] [Received: 02/03/2023] [Revised: 03/22/2023] [Accepted: 03/24/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Contemporary data comparing the outcomes of transradial access (TRA) vs transfemoral access (TFA) among patients presenting with acute myocardial infarction and cardiogenic shock (AMI-CS) undergoing percutaneous coronary intervention (PCI) are limited. OBJECTIVES This study examines in-hospital outcomes and institutional variation among patients with AMI-CS undergoing TRA-PCI vs TFA-PCI. METHODS Patients admitted with AMI-CS from the NCDR CathPCI registry between April 2018 and June 2021 were included. Multivariable logistic regression and inverse probability weighting models were used to assess the association between access site and in-hospital outcomes. A falsification analysis using non-access site-related bleeding was performed. RESULTS Among 35,944 patients with AMI-CS undergoing PCI, 25.6% were performed with TRA. The proportion of TRA-PCI increased over the study period (22.0% in the second quarter of 2018 vs 29.1% in the second quarter of 2021; P-trend <0.001). Significant institutional-level variability in the use of TRA-PCI was also observed: 20.9% of all sites using TRA in <2% of PCIs (low utilization) vs 1.9% of all sites using TRA in >80% of PCIs (high utilization). Patients undergoing TRA-PCI had a significantly lower adjusted incidence of major bleeding (odds ratio [OR]: 0.71; 95% confidence interval [CI]: 0.67-0.76), mortality (OR: 0.73; 95% CI: 0.69-0.78), vascular complications (OR: 0.67; 95% CI: 0.54-0.84), and new dialysis (OR: 0.86; 95% CI: 0.77-0.97). There was no difference in non-access site related bleeding (OR: 0.93; 95% CI: 0.84-1.03). Sensitivity analyses revealed similar benefit with TRA-PCI among patients without arterial cross-over. There were no significant interactions observed between TRA-PCI with mechanical circulatory support and in-hospital outcomes. CONCLUSIONS In this large nationwide contemporary analysis of patients with AMI-CS, about quarter of PCIs were performed via TRA with wide variability across US institutions. TRA-PCI was associated with significantly lower incidence of in-hospital major bleeding, mortality, vascular complications, and new dialysis. This benefit was observed irrespective of mechanical circulatory support use.
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Affiliation(s)
- Dhruv Mahtta
- Division of Cardiovascular Medicine, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | | | - Zachary K Wegermann
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Daniel Wojdyla
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Michael Megaly
- Willis Knighton Heart Institute, Shreveport, Louisiana, USA
| | - Ajar Kochar
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA; Richard and Susan Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Salim S Virani
- Division of Cardiovascular Medicine, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | - Sunil V Rao
- NYU Langone Health System, New York, New York, USA
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, Gill Heart and Vascular Institute, University of Kentucky HealthCare, Lexington, Kentucky, USA.
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15
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Julien HM, Wang Y, Curtis JP, Johnston-Cox H, Eberly LA, Wang GJ, Nathan AS, Fanaroff AC, Khatana SAM, Groeneveld PW, Secemsky EA, Eneanya ND, Vora AN, Kobayashi T, Barbery C, Chery G, Kohi M, Kirksey L, Armstrong EJ, Jaff MR, Giri J. Racial Differences in Presentation and Outcomes After Peripheral Arterial Interventions: Insights From the NCDR-PVI Registry. Circ Cardiovasc Interv 2023; 16:e011485. [PMID: 37339237 DOI: 10.1161/circinterventions.121.011485] [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] [Received: 10/09/2021] [Accepted: 05/03/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND We assess the rates of device use and outcomes by race among patients undergoing lower extremity peripheral arterial intervention using the American College of Cardiology National Cardiovascular Data Registry-Peripheral Vascular Intervention (PVI) registry. METHODS Patients who underwent PVI between April 2014 and March 2019 were included. Socioeconomic status was evaluated using the Distressed Community Index score for patients' zip codes. Multivariable logistic regression was used to assess factors associated with utilization of drug-eluting technologies, intravascular imaging, and atherectomy. Among patients with Centers for Medicare and Medicaid Services data, we compared 1-year mortality, rates of amputation, and repeat revascularizations. RESULTS Of 63 150 study cases, 55 719 (88.2%) were performed in White patients and 7431 (11.8%) in Black patients. Black patients were younger (67.9 versus 70.0 years), had higher rates of hypertension (94.4% versus 89.5%), diabetes (63.0% versus 46.2%), less likely to be able to walk 200 m (29.1% versus 24.8%), and higher Distressed Community Index scores (65.1 versus 50.6). Black patients were provided drug-eluting technologies at a higher rate (adjusted odds ratio, 1.14 [95% CI, 1.06-1.23]) with no difference in atherectomy (adjusted odds ratio, 0.98 [95% CI, 0.91-1.05]) or intravascular imaging (adjusted odds ratio, 1.03 [95% CI, 0.88-1.22]) use. Black patients experienced a lower rate of acute kidney injury (adjusted odds ratio, 0.79 [95% CI, 0.72-0.88]). In Centers for Medicare and Medicaid Services-linked analyses of 7429 cases (11.8%), Black patients were significantly less likely to have surgical (adjusted hazard ratio, 0.40 [95% CI, 0.17-0.96]) or repeat PVI revascularization (adjusted hazard ratio, 0.42 [95% CI, 0.30-0.59]) at 1 year compared with White patients. There was no difference in mortality (adjusted hazard ratio [0.8-1.4]) or major amputation (adjusted hazard ratio, 2.5 [95% CI, 0.8-7.6]) between Black and White patients. CONCLUSIONS Black patients presenting for PVI were younger, had higher prevalence of comorbidities and lower socioeconomic status. After adjustment, Black patients were less likely to have surgical or repeat PVI revascularization after the index PVI procedure.
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Affiliation(s)
- Howard M Julien
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
- Center for Health Equity Research and Promotion, Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA (H.M.J., P.W.G., S.A.M.K.)
- Penn Cardiovascular Center for Health Equity and Social Justice, Philadelphia (H.M.J., L.A.E.)
| | - Yongfei Wang
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (Y.W., J.P.C.)
- Center of Outcome Research and Evaluation Yale New Haven Health System, CT (Y.W., J.P.C.)
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (Y.W., J.P.C.)
- Center of Outcome Research and Evaluation Yale New Haven Health System, CT (Y.W., J.P.C.)
| | - Hillary Johnston-Cox
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
| | - Lauren A Eberly
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
- Penn Cardiovascular Center for Health Equity and Social Justice, Philadelphia (H.M.J., L.A.E.)
| | - Grace J Wang
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
| | - Ashwin S Nathan
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
| | - Alexander C Fanaroff
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
| | - Sameed Ahmed M Khatana
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
- Center for Health Equity Research and Promotion, Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA (H.M.J., P.W.G., S.A.M.K.)
| | - Peter W Groeneveld
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
- Center for Health Equity Research and Promotion, Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA (H.M.J., P.W.G., S.A.M.K.)
| | - Eric A Secemsky
- Department of Medicine, Harvard Medical School, Boston, MA (E.A.S.)
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (E.A.S.)
| | - Nwamaka D Eneanya
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia (N.D.E.)
- Palliative and Advanced Illness Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (N.D.E.)
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (N.D.E.)
| | - Amit N Vora
- University of Pittsburgh Medical Center-Pinnacle, Wormleysburg, PA (A.N.V.)
| | - Taisei Kobayashi
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
| | - Carlos Barbery
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
| | - Godefroy Chery
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., H.J.-C., L.A.E., A.S.N., A.C.F., S.A.M.K., T.K., C.B., G.C., J.C.)
| | - Maureen Kohi
- Department of Radiology, University of North Carolina School of Medicine, Chapel Hill (M.K.)
| | - Lee Kirksey
- Division of Vascular Surgery, Cleveland Clinic, OH (L.K.)
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO (E.J.A.)
- University of Colorado School of Medicine, Aurora (E.J.A.)
| | - Michael R Jaff
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston (M.R.J.)
| | - Jay Giri
- Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.G., T.K., J.G.)
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (H.M.J., L.A.E., G.J.W., A.S.N., A.C.F., S.A.M.K., P.W.G., J.G.)
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16
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Darden D, Aldaas O, Du C, Munir MB, Feld GK, Pothineni NVK, Gopinathannair R, Lakkireddy D, Curtis JP, Freeman JV, Akar JG, Hsu JC. In-hospital complications associated with pulmonary vein isolation with adjunctive lesions: the NCDR AFib Ablation Registry. Europace 2023; 25:euad124. [PMID: 37184436 PMCID: PMC10228609 DOI: 10.1093/europace/euad124] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 03/29/2023] [Indexed: 05/16/2023] Open
Abstract
AIMS No prior study has been adequately powered to evaluate real-world safety outcomes in those receiving adjunctive ablation lesions beyond pulmonary vein isolation (PVI). We sought to evaluate characteristics and in-hospital complications among patients undergoing PVI with and without adjunctive lesions. METHODS AND RESULTS Patients in the National Cardiovascular Data Registry AFib Ablation Registry undergoing first-time atrial fibrillation (AF) ablation between 2016 and 2020 were identified and stratified into paroxysmal (PAF) and persistent AF, and separated into PVI only, PVI + cavotricuspid isthmus (CTI) ablation, and PVI + adjunctive (superior vena cava isolation, coronary sinus, vein of Marshall, atypical atrial flutter lines, other). Adjusted odds of adverse events were calculated using multivariable logistic regression. A total of 50 937 patients [PAF: 30 551 (60%), persistent AF: 20 386 (40%)] were included. Among those with PAF, there were no differences in the adjusted odds of complications between PVI + CTI or PVI + adjunctive when compared with PVI only. Among persistent AF, PVI + adjunctive was associated with a higher risk of any complication [3.0 vs. 4.5%, odds ratio (OR) 1.30, 95% confidence interval (CI) 1.07-1.58] and major complication (0.8 vs. 1.4%, OR 1.56, 95% CI 1.10-2.21), while no differences were observed in PVI + CTI compared with PVI only. Overall, there was high heterogeneity in adjunctive lesion type, and those receiving adjunctive lesions had a higher comorbidity burden. CONCLUSION Additional CTI ablation was common without an increased risk of complications. Adjunctive lesions other than CTI are commonly performed in those with more comorbidities and were associated with an increased risk of complications in persistent AF, although the current analysis is limited by high heterogeneity in adjunctive lesion set type.
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Affiliation(s)
- Douglas Darden
- Kansas City Heart Rhythm Institute, 5100 W 110th St, Suite 200, Overland Park, KS, USA
| | - Omar Aldaas
- Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, CA 92037, USA
| | - Chengan Du
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - Muhammad Bilal Munir
- Division of Cardiology, Department of Medicine, University of California Davis, Sacramento, CA, USA
| | - Gregory K Feld
- Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, CA 92037, USA
| | | | - Rakesh Gopinathannair
- Kansas City Heart Rhythm Institute, 5100 W 110th St, Suite 200, Overland Park, KS, USA
| | - Dhanunjaya Lakkireddy
- Kansas City Heart Rhythm Institute, 5100 W 110th St, Suite 200, Overland Park, KS, USA
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - James V Freeman
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - Joseph G Akar
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - Jonathan C Hsu
- Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, CA 92037, USA
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17
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Nguyen MT, Ali A, Ngo L, Ellis C, Psaltis PJ, Ranasinghe I. Thirty-Day Unplanned Readmissions Following Elective and Acute Percutaneous Coronary Intervention. Heart Lung Circ 2023; 32:619-628. [PMID: 37003938 DOI: 10.1016/j.hlc.2023.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 12/04/2022] [Accepted: 02/28/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Prior studies have reported a high rate of unplanned readmissions following acute percutaneous coronary intervention (PCI). Data outside the USA comparing 30-day unplanned readmissions following elective PCI to those who undergo acute PCI remain limited. METHODS Patients who underwent a PCI procedure in Australia and New Zealand between 2010 and 2015 were included. We determined the rates, causes and predictors of 30-day unplanned readmissions, as well as rates of repeat revascularisation procedures, for patients who underwent an elective or acute PCI. Predictors of readmissions were identified using logistic regression. RESULTS A total of 199,686 PCI encounters were included, of which 74,890 (37.5%) were elective and 124,796 (62.5%) were acute procedures. Overall, 10.6% of patients had at least one unplanned readmission within 30 days of discharge with lower rates following elective PCI (7.0%) compared to acute PCI (12.7%) (p<0.01). Non-specific chest pain was the commonest cause of readmission after elective and acute PCI, accounting for 20.7% and 21.5% of readmission diagnoses, respectively. Readmissions for acute myocardial infarction (13.0% vs 4.6%, p<0.01) and heart failure (6.5% vs 3.3%, p<0.01) were higher following acute PCI compared to elective PCI. Among readmitted patients, 16.7% had a coronary catheterisation, 12.2% had a PCI and 0.7% had coronary artery bypass surgery. Multivariable predictors of 30-day unplanned readmission included female sex and comorbidities such as heart failure, metastatic disease, chronic lung disease and renal failure (p<0.0001 for all). CONCLUSIONS Unplanned readmissions following elective or acute PCI are high. Clinical and quality-control measures are required to prevent avoidable readmissions in both settings.
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Affiliation(s)
- Mau T Nguyen
- Vascular Research Centre, Lifelong Health Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia; Department of Cardiology, Central Adelaide Local Health Network, Adelaide, SA, Australia; Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia.
| | - Anna Ali
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia; Royal Australasian College of Surgeons, Adelaide, SA, Australia
| | - Linh Ngo
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Qld, Australia; School of Clinical Medicine, The University of Queensland, Brisbane, Qld, Australia
| | - Chris Ellis
- Cardiology Department, Auckland City Hospital, Auckland, New Zealand
| | - Peter J Psaltis
- Vascular Research Centre, Lifelong Health Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia; Department of Cardiology, Central Adelaide Local Health Network, Adelaide, SA, Australia; Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Isuru Ranasinghe
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Qld, Australia; School of Clinical Medicine, The University of Queensland, Brisbane, Qld, Australia
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18
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Mszar R, Friedman DJ, Ong E, Du C, Wang Y, Zeitler EP, Cunningham SD, Akar J, Curtis JP, Freeman JV. Sex-based differences in atrial fibrillation ablation adverse events. Heart 2023; 109:595-605. [PMID: 36104219 DOI: 10.1136/heartjnl-2022-321192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 08/24/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Older, relatively small studies identified female sex as a risk factor for adverse events after catheter ablation for atrial fibrillation (AF). We aimed to assess contemporary sex-based differences in baseline and procedural characteristics, adverse events, and quality of life among adults undergoing catheter ablation for AF. METHODS In this observational cohort study, we evaluated those enrolled in the National Cardiovascular Data Registry AFib Ablation Registry between January 2016 and September 2020. Using logistic regression, we analysed the association between patient sex and in-hospital adverse events. RESULTS Among 58 960 adults (34.6% women) from 150 centres undergoing AF ablation by 706 physicians, women were older (68 vs 64 years, p<0.001), had more comorbidities, and had lower AF-related quality of life at the time of ablation (mean Atrial Fibrillation Effect on QualiTy-of-life Questionnaire) score: 51.8 vs 62.2, p<0.001). Women had a higher risk of hospitalisation >1 day (adjusted OR (aOR) 1.41 (95% CI 1.33 to 1.49)), major adverse event (aOR 1.60 (95% CI 1.33 to 1.92)) and any adverse event (aOR 1.57 (95% CI 1.41 to 1.75)). Women had a higher risk of bradycardia requiring pacemaker, phrenic nerve damage, pericardial effusion, bleeding and vascular injury, but had no differences in death or acute pulmonary vein isolation. CONCLUSIONS Among almost 60 000 patients in the largest prospective registry of AF ablation procedures, female sex was independently associated with a higher risk of hospitalisation >1 day, adverse events, and reduced quality of life, although there were no differences in death or acute pulmonary vein isolation.
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Affiliation(s)
- Reed Mszar
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Daniel J Friedman
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Emily Ong
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Chengan Du
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Yongfei Wang
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Emily P Zeitler
- Department of Medicine, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
- Dartmouth-Hitchcock Medical Center, Lebanon, Pennsylvania, USA
| | - Shayna D Cunningham
- Department of Public Health Sciences, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Joseph Akar
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jeptha P Curtis
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - James V Freeman
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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19
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Chui PW, Lan Z, Freeman JV, Enriquez AD, Khera R, Akar JG, Masoudi FA, Ong EL, Curtis JP. Variation in hospital use of cardiac resynchronization therapy-defibrillator among eligible patients and association with clinical outcomes. Heart Rhythm 2023:S1547-5271(23)00293-X. [PMID: 36963741 DOI: 10.1016/j.hrthm.2023.03.022] [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] [Received: 11/14/2022] [Revised: 02/23/2023] [Accepted: 03/14/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND Despite strong guideline recommendations for cardiac resynchronization therapy-defibrillator (CRT-D) In select patients, this therapy is underutilized with substantial variation among hospitals, and the association of this variation with outcomes is unknown. OBJECTIVE To assess if facility variation in CRT-D utilization is associated with differences in hospital-level outcomes METHODS: We linked Medicare claims data with the NCDR ICD Registry from 2010 to 2015. We assessed the intraclass correlation coefficient to quantify the degree of variation in patient-level CRT usage that can be explained by interfacility variation on a hospital level. To quantify the degree of hospital variation in patient-level outcomes (all-cause mortality, readmissions, and cardiac readmissions) that can be attributed to variations in CRT-D usage, we utilized multi-level modeling. RESULTS The study included 30,134 patients across 1,377 hospitals. The median rate of CRT-D implantation among those meeting guideline indications was 89%, but there was a wide variation across hospitals. After adjustment, most of the variation (74%) in hospital rates of CRT-D utilization was attributable to the hospital in which the patient was treated. Differences in hospital CRT-D utilization was associated with 8.76%, 5.26%, and 4.71% of differences in hospital mortality, readmissions, and cardiac readmission rates, respectively (p<0.001 for all outcomes). CONCLUSIONS There is wide variation in the use of CRT-D across hospitals that was not explained by case mix. Hospital-level variation in CRT-D utilization was associated with clinically significant differences in outcomes. A measure of CRT-D utilization in eligible patients may serve as a useful metric for quality improvement efforts.
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Affiliation(s)
- Philip W Chui
- Kaiser Permanente Los Angeles Medical Center; Department of Cardiology, Los Angeles, CA 90027; Yale School of Medicine; Department of Cardiology, New Haven, CT 06510.
| | - Zhou Lan
- Brigham and Women's Hospital; Department of Radiology, Boston 02115
| | - James V Freeman
- Yale School of Medicine; Department of Cardiology, New Haven, CT 06510
| | - Alan D Enriquez
- Yale School of Medicine; Department of Cardiology, New Haven, CT 06510
| | - Rohan Khera
- Yale School of Medicine; Department of Cardiology, New Haven, CT 06510
| | - Joseph G Akar
- Yale School of Medicine; Department of Cardiology, New Haven, CT 06510
| | - Fred A Masoudi
- University of Colorado School of Medicine; Aurora CO, 80045
| | - Emily L Ong
- Yale School of Medicine; Department of Cardiology, New Haven, CT 06510
| | - Jeptha P Curtis
- Yale School of Medicine; Department of Cardiology, New Haven, CT 06510
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20
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Shweikh Y, Sekimitsu S, Boland MV, Zebardast N. The Growing Need for Ophthalmic Data Standardization. OPHTHALMOLOGY SCIENCE 2023; 3:100262. [PMID: 36691643 PMCID: PMC9860145 DOI: 10.1016/j.xops.2022.100262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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21
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Iwata J, Inohara T, Shiraishi Y, Nakamaru R, Niimi N, Ueda I, Suzuki M, Noma S, Numasawa Y, Fukuda K, Kohsaka S. Standard modifiable cardiovascular risk factors in patients with acute coronary syndrome: A report from multicenter percutaneous coronary intervention registry. J Cardiol 2023; 81:571-576. [PMID: 36758671 DOI: 10.1016/j.jjcc.2023.01.009] [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] [Received: 10/18/2022] [Revised: 01/03/2023] [Accepted: 01/08/2023] [Indexed: 02/09/2023]
Abstract
BACKGROUND High mortality in patients with acute coronary syndrome (ACS) without standard modifiable cardiovascular risk factors [SMuRFs (e.g. diabetes, hypertension, smoking, and dyslipidemia)] has been reported. However, details regarding their acute presentation and reasons for the excess risk remain unclear. METHOD Patient-level data were extracted from a multicenter procedure-based registry (KiCS-PCI). We analyzed consecutive patients with ACS who underwent de novo percutaneous coronary intervention (PCI) between 2009 and 2020. The primary outcome of interest was the in-hospital mortality. RESULTS Among the 10,523 patients with ACS, 7775 met the inclusion criteria. Patients without SMuRFs who underwent PCI [n = 529 (6.8 %)] were older [median 71 (IQR: 63-79) vs. 68 (59-76) years, p < 0.001] and more often presented with cardiogenic shock or cardiopulmonary arrest (14.6 % vs. 8.6 %, p < 0.001; 12.7 % vs. 5.3 %, p < 0.001, respectively). In patients with ST-elevation myocardial infarction (STEMI), median door-to-balloon time was significantly longer in SMuRF-less patients (90 min vs 82 min). In-hospital death was significantly higher in SMuRF-less patients [10.2 % vs. 4.1 %, p < 0.001, adjusted odds ratio, 1.81 (95%CI, 1.26-2.59); p = 0.001], whereas the rate of procedural complications showed no significant difference. When stratified by the ACS presentation pattern, the findings were consistent, although the association between SMuRF-less and the increased risk of in-hospital mortality was not statistically significant in patients with non-ST-elevation- (NSTE)-ACS. CONCLUSIONS SMuRF-less ACS patients frequently presented with cardiopulmonary arrest and/or cardiogenic shock, leading to high in-hospital mortality. When stratified by the ACS presentation pattern, the association of SMuRF-less and the increased risk of mortality was more prominent in STEMI patients and it was not statistically significant in NSTE-ACS patients. Almost half of these patients had amendable left main trunk or left anterior descending artery disease and treating clinicians should be aware of this paradox to avoid the delay in treatment.
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Affiliation(s)
- Juri Iwata
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Taku Inohara
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Yasuyuki Shiraishi
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Ryo Nakamaru
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan; Department of Healthcare Quality Assessment, The University of Tokyo, Tokyo, Japan
| | - Nozomi Niimi
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Ikuko Ueda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Masahiro Suzuki
- Department of Cardiology National Hospital Organization Saitama Hospital, Saitama, Japan
| | - Shigetaka Noma
- Department of Cardiology, Saiseikai Utsunomiya Hospital, Tochigi, Japan
| | - Yohei Numasawa
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Tochigi, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan.
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22
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Janson CM, Shah MJ, Kennedy KF, Iyer VR, Behere S, Sweeten TL, O'Byrne ML. Association of Weight With Ablation Outcomes in Pediatric Wolff-Parkinson-White: Analysis of the NCDR IMPACT Registry. JACC Clin Electrophysiol 2023; 9:73-84. [PMID: 36697203 DOI: 10.1016/j.jacep.2022.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Guidelines for electrophysiology study (EPS) and catheter ablation in Wolff-Parkinson-White (WPW) are age based, but size may be a more relevant factor in determination of outcomes. OBJECTIVES The goal of this study was to evaluate the association of patient weight with outcomes of catheter ablation for pediatric WPW. METHODS A multicenter retrospective cohort study was performed on children aged 1 to 21 years with WPW and first-time EPS from April 2016 to December 2019 recorded in the IMPACT (Improving Pediatric and Adult Congenital Treatment) registry, excluding those with congenital heart disease, cardiomyopathy, and >1 ablation target. A weight threshold of 30 kg was selected, representing 1 SD below the cohort mean. The primary outcome was major adverse events (MAEs); additional outcomes included deferred ablation, use of cryoablation, and ablation success. RESULTS A total of 4,456 subjects from 84 centers were evaluated, with 14% weighing <30 kg. Subjects weighing <30 kg were more likely to have preprocedural supraventricular tachycardia (45% vs 29%; P < 0.001) and less likely to have right septal accessory pathways (25% vs 33%; P < 0.001). MAEs were rare, although with higher incidence in the <30 kg cohort (0.3% vs 0.05%; P = 0.04). No difference was seen in likelihood of deferred ablation (9% vs 12%; P = 0.07) or use of cryoablation (11% vs 11%; P = 0.70). Success was higher in the <30 kg cohort: 95% vs 92% (P = 0.009). This effect persisted after adjusting for covariates (odds ratio: 1.6; 95% CI: 1.01-2.70; P = 0.046). CONCLUSIONS Weight <30 kg was associated with a small but elevated risk of MAEs. Rates of deferred ablation and cryoablation were similar. Adjusting for factors (including accessory pathway type and location), weight <30 kg remained an independent predictor of acute success.
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Affiliation(s)
- Christopher M Janson
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Maully J Shah
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kevin F Kennedy
- Mid America Heart Institute and St. Luke's Health System, Kansas City, Missouri, USA
| | - V Ramesh Iyer
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shashank Behere
- Division of Cardiology, University of Oklahoma, Oklahoma City, Oklahoma, USA
| | - Tammy L Sweeten
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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23
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Friedman DJ, Pierre D, Wang Y, Gambone L, Koutras C, Segawa C, Farb A, Vemulapalli S, Varosy PD, Masoudi FA, Lansky A, Curtis JP, Freeman JV. Development and validation of an automated algorithm for end point adjudication for a large U.S. national registry. Am Heart J 2022; 254:102-111. [PMID: 36007567 DOI: 10.1016/j.ahj.2022.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 08/14/2022] [Accepted: 08/17/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Clinical events committee (CEC) evaluation is the standard approach for end point adjudication in clinical trials. Due to resource constraints, large registries typically rely on site-reported end points without further confirmation, which may preclude use for regulatory oversight. METHODS We developed a novel automated adjudication algorithm (AAA) for end point adjudication in the National Cardiovascular Data Registry Left Atrial Appendage Occlusion (LAAO) Registry using an iterative process using CEC adjudication as the "gold standard." A ≥80% agreement rate between automated algorithm adjudication and CEC adjudication was prespecified as clinically acceptable. Agreement rates were calculated. RESULTS A total of 92 in-hospital and 127 post-discharge end points were evaluated between January 1, 2016 and June 30, 2019 using AAA and CEC. Agreement for neurologic events was >90%. Percent agreement for in-hospital and post-discharge events was as follows: ischemic stroke 95.7% and 94.5%, hemorrhagic stroke 97.8% and 96.1%, undetermined stroke 97.8% and 99.2%, transient ischemic attack 98.9% and 98.4% and intracranial hemorrhage 100.0% and 94.5%. Agreement was >80% for major bleeding (83.7% and 90.6%) and major vascular complication (89.1% and 97.6%). With this approach, <1% of site reported end points require CEC adjudication. Agreement remained very good during the period after algorithm derivation. CONCLUSIONS An AAA-guided approach for end point adjudication was successfully developed and validated for the LAAO Registry. With this approach, the need for formal CEC adjudication was substantially reduced, with accuracy maintained above an 80% agreement threshold. After application specific validation, these methods could be applied to large registries and clinical trials to reduce the cost of event adjudication while preserving scientific validity.
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Affiliation(s)
- Daniel J Friedman
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT; Duke Clinical Research Institute, Durham, NC
| | - Dominique Pierre
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT
| | - Yongfei Wang
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT; Yale Cardiovascular Research Group, Yale University School of Medicine, New Haven, CT
| | - Louise Gambone
- Yale Cardiovascular Research Group, Yale University School of Medicine, New Haven, CT
| | | | | | - Andrew Farb
- U.S. Food and Drug Administration, Silver Spring, MD
| | | | - Paul D Varosy
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO; VA Eastern Colorado Health Care System, Aurora, CO
| | - Frederick A Masoudi
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO; Ascension Health, St. Louis, MO
| | - Alexandra Lansky
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT; Yale Cardiovascular Research Group, Yale University School of Medicine, New Haven, CT
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT
| | - James V Freeman
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT.
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24
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Sandhu A, Varosy PD, Du C, Aleong RG, Tumolo AZ, West JJ, Tzou WS, Curtis JP, Freeman JV, Friedman DJ, Hess PL. Device-Sizing and Associated Complications With Left Atrial Appendage Occlusion: Findings From the NCDR LAAO Registry. Circ Cardiovasc Interv 2022; 15:e012183. [PMID: 36472194 DOI: 10.1161/circinterventions.122.012183] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Left atrial appendage occlusion is an important alternative to anticoagulation in select patients with nonvalvular atrial fibrillation. Trends in real-world device sizing and associated short-term complications have not been characterized. METHODS Using the National Cardiovascular Data Left Atrial Appendage Occlusion (NCDR LAAO) Registry, patients who underwent left atrial appendage occlusion with a Watchman 2.5 device from January 1, 2016, to June 30, 2020, were identified. Patients were stratified by device size based on left atrial appendage orifice size, and categorized as receiving a device that was undersized, oversized, or per manufacturer recommendation. Relationships between device sizing and short-term outcomes, including pericardial effusion, device embolism, and significant leak, were assessed. RESULTS Of the 68 456 patients, 6539 (10.5%) of patients received undersized devices, 17 791 (26.0%) according to manufacturer recommendations, and 44 126 (64.4%) received an oversized device. The 27-mm device was most commonly deployed [21 736 (31.8%)], whereas the smallest and largest devices (21 and 33 mm) were least commonly deployed [7695 (11.2%) and 9077 (13.3%), respectively]. Compared with manufacturer recommended sizing, there was no difference in the odds of pericardial effusion for either undersized (1.048 [95% CI' 0.801-1.372]; P=0.733) or oversized (1.101 [95% CI' 0.933-1.298]; P=0.254) devices. Similarly, relative to manufacturer recommended sizing, the odds of a composite adverse outcome of device migration or embolization and significant peridevice leak at 45 days were similar among undersized devices (1.030 [95% CI' 0.735-1.444]; P=0.863) and favorable for oversized devices (0.701 [95% CI' 0.561-0.876]; P=0.002) devices, primarily driven by lower odds of leak. Selection of oversized devices increased significantly over the study period (from 60.3% in 2016 to 66.0% in 2020; P<0.001). CONCLUSIONS Among patients undergoing left atrial appendage occlusion with the first-generation Watchman device, receipt of oversized devices was common and increased over time. The high prevalence of oversizing was associated with lower odds of significant leak or device embolization without increased odds of other adverse events.
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Affiliation(s)
- Amneet Sandhu
- Section of Cardiology, Rocky Mountain Regional VA Medical Center, Aurora, CO (A.S., P.D.V., P.L.H.).,Section of Electrophysiology, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora (A.S., P.D.V., R.G.A., A.Z.T., J.J.W., W.S.T.)
| | - Paul D Varosy
- Section of Cardiology, Rocky Mountain Regional VA Medical Center, Aurora, CO (A.S., P.D.V., P.L.H.).,Section of Electrophysiology, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora (A.S., P.D.V., R.G.A., A.Z.T., J.J.W., W.S.T.)
| | - Chengan Du
- Section of Cardiovascular Medicine, Yale University School of Medicine' Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (C.D., J.P.C., J.V.F.)
| | - Ryan G Aleong
- Section of Electrophysiology, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora (A.S., P.D.V., R.G.A., A.Z.T., J.J.W., W.S.T.)
| | - Alexis Z Tumolo
- Section of Electrophysiology, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora (A.S., P.D.V., R.G.A., A.Z.T., J.J.W., W.S.T.)
| | - J Jason West
- Section of Electrophysiology, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora (A.S., P.D.V., R.G.A., A.Z.T., J.J.W., W.S.T.)
| | - Wendy S Tzou
- Section of Electrophysiology, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora (A.S., P.D.V., R.G.A., A.Z.T., J.J.W., W.S.T.)
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Yale University School of Medicine' Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (C.D., J.P.C., J.V.F.)
| | - James V Freeman
- Section of Cardiovascular Medicine, Yale University School of Medicine' Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, CT (C.D., J.P.C., J.V.F.)
| | - Daniel J Friedman
- Section of Electrophysiology, Division of Cardiology, Duke University Hospital, Durham, NC (D.J.F.)
| | - Paul L Hess
- Section of Cardiology, Rocky Mountain Regional VA Medical Center, Aurora, CO (A.S., P.D.V., P.L.H.).,Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora (P.L.H.)
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25
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Price MJ, Friedman DJ, Du C, Wang Y, Lin Z, Curtis JP, Freeman JV. Comparative Safety of Transcatheter LAAO With the First-Generation Watchman and Next-Generation Watchman FLX Devices. JACC Cardiovasc Interv 2022; 15:2115-2123. [DOI: 10.1016/j.jcin.2022.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 09/02/2022] [Accepted: 09/06/2022] [Indexed: 11/09/2022]
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26
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Azizi Z, Ward AT, Lee DJ, Gad SS, Bhasin K, Beetel RJ, Ferreira T, Shankar S, Rumsfeld JS, Harrington RA, Virani SS, Gluckman TJ, Dash R, Rodriguez F. Sociodemographic Determinants of Oral Anticoagulant Prescription in Patients with Atrial Fibrillations: Findings from the PINNACLE Registry Using Machine Learning. Heart Rhythm O2 2022; 4:158-168. [PMID: 36993910 PMCID: PMC10041076 DOI: 10.1016/j.hroo.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background Current risk scores that are solely based on clinical factors have shown modest predictive ability for understanding of factors associated with gaps in real-world prescription of oral anticoagulation (OAC) in patients with atrial fibrillation (AF). Objective In this study, we sought to identify the role of social and geographic determinants, beyond clinical factors associated with variation in OAC prescriptions using a large national registry of ambulatory patients with AF. Methods Between January 2017 and June 2018, we identified patients with AF from the American College of Cardiology PINNACLE (Practice Innovation and Clinical Excellence) Registry. We examined associations between patient and site-of-care factors and prescription of OAC across U.S. counties. Several machine learning (ML) methods were used to identify factors associated with OAC prescription. Results Among 864,339 patients with AF, 586,560 (68%) were prescribed OAC. County OAC prescription rates ranged from 26.8% to 93%, with higher OAC use in the Western United States. Supervised ML analysis in predicting likelihood of OAC prescriptions and identified a rank order of patient features associated with OAC prescription. In the ML models, in addition to clinical factors, medication use (aspirin, antihypertensives, antiarrhythmic agents, lipid modifying agents), and age, household income, clinic size, and U.S. region were among the most important predictors of an OAC prescription. Conclusion In a contemporary, national cohort of patients with AF underuse of OAC remains high, with notable geographic variation. Our results demonstrated the role of several important demographic and socioeconomic factors in underutilization of OAC in patients with AF.
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Daimee UA, Wang Y, Masoudi FA, Varosy PD, Friedman DJ, Du C, Koutras C, Reddy VY, Saw J, Price MJ, Kusumoto FM, Curtis JP, Freeman JV. Indications for Left Atrial Appendage Occlusion in the United States and Associated In-Hospital Outcomes: Results From the NCDR LAAO Registry. Circ Cardiovasc Qual Outcomes 2022; 15:e008418. [PMID: 35959677 PMCID: PMC9388561 DOI: 10.1161/circoutcomes.121.008418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Food and Drug Administration approved left atrial appendage occlusion with the Watchman device for patients who are at increased stroke risk and are suitable for oral anticoagulation but who have an appropriate reason to seek a nondrug alternative. These broad criteria raise the question of their interpretation in clinical practice. There is a lack of studies comprehensively evaluating the indications for Watchman implantation among a large series of patients from contemporary, real-world practice in the United States. METHODS We used the National Cardiovascular Data Registry Left Atrial Appendage Occlusion Registry to identify Watchman procedures performed between 2016 and 2018. We assessed procedural indications for Watchman implantation in the United States and evaluated the association between procedural indications and in-hospital adverse events. RESULTS A total of 38 314 procedures were included. The mean patient age was 76.1±8.1 years, and 58.9% were men. The mean CHA2DS2-VASc score was 4.8±1.5, whereas the mean hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol (HAS-BLED) score was 3.0±1.1. Prior stroke or transient ischemic attack was reported in 40.2% and prior bleeding in 70.1%, with gastrointestinal bleeding being most common (41.9%). The most common site-reported procedural indications for Watchman implantation were increased thromboembolic risk (64.8%) and history of major bleed (64.3%), followed by high fall risk (35.5%). Most (71.9%) had ≥2 procedural indications. Patients with high fall risk had increased risk of in-hospital adverse events (adjusted OR, 1.12; P=0.025), but no other differences were found in the risk of in-hospital adverse events by procedural indication. CONCLUSIONS Among patients in the National Cardiovascular Data Registry Left Atrial Appendage Occlusion Registry, the most common procedural indications for Watchman implantation were increased thromboembolic risk, history of major bleed, and high fall risk. A majority of patients had multiple procedural indications. High fall risk conferred a modestly increased risk of in-hospital adverse events.
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Affiliation(s)
- Usama A. Daimee
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Yongfei Wang
- Center for Outcomes Research and Evaluation, Yale University School of Medicine, New Haven, CT
| | - Frederick A. Masoudi
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Paul D. Varosy
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Daniel J. Friedman
- Center for Outcomes Research and Evaluation, Yale University School of Medicine, New Haven, CT
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Chengan Du
- Center for Outcomes Research and Evaluation, Yale University School of Medicine, New Haven, CT
| | | | | | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia
| | - Matthew J. Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California
| | - Fred M. Kusumoto
- Department of Cardiovascular Disease, Mayo Clinic, Jacksonville, Florida
| | - Jeptha P. Curtis
- Center for Outcomes Research and Evaluation, Yale University School of Medicine, New Haven, CT
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - James V. Freeman
- Center for Outcomes Research and Evaluation, Yale University School of Medicine, New Haven, CT
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
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Darden D, Peterson PN, Xin X, Munir MB, Minges KE, Goldenberg I, Poole JE, Feld GK, Birgersdotter-Green U, Curtis JP, Hsu JC. Temporal trends and long-term outcomes among recipients of cardiac resynchronization therapy with defibrillator in the United States, 2011-2015: Insights from the National Cardiovascular Data Registry. Heart Rhythm O2 2022; 3:405-414. [PMID: 36097450 PMCID: PMC9463686 DOI: 10.1016/j.hroo.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Contemporary data on national trends and outcomes in cardiac resynchronization therapy with defibrillator (CRT-D) recipients following the 2012 updated guidelines has not been studied. Objectives This study assessed the trends in long-term outcomes among CRT-D Medicare-aged recipients implanted in 2011-2015. Methods Patients aged ≥65 years undergoing de novo CRT-D implantation in the National Cardiovascular Data Implantable Cardiac Defibrillator Registry from 2011-2015 with follow-up through 2017 using Medicare data were included and stratified by year of implant. Patient characteristics, in-hospital outcomes, and outcomes up to 2 years following implant were evaluated. Results Among 53,174 patients (aged 75.6-6.4 years, 29.7% women) implanted with CRT-D from 2011 to 2015, there was an increase in implantations based on guideline-concordant recommendations (81.0% to 84.7%, P < .001). Compared to 2011, in-hospital procedural complications decreased in 2015 (3.9% vs 2.9%; adjusted odds ratio, 0.76, 95% confidence interval, 0.66-0.88, P < .001), driven in part by decreased lead dislodgement (1.4% vs 1.0%). After multivariable adjustment, there was a lower risk of all-cause hospitalization, cardiovascular hospitalization, and mortality at 2-year follow-up in 2015 as compared to 2011, while there were no differences in heart failure hospitalizations at follow-up. Conclusion Among Medicare beneficiaries receiving CRT-D from 2011 to 2015, there was an increase in implantations based on guideline-concordant recommendations. Furthermore, there has been a reduction in in-hospital complications and long-term outcomes, including cardiovascular hospitalization, all-cause hospitalization, and mortality; however, there has been no difference in the risk of heart failure hospitalization after adjustment.
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Affiliation(s)
- Douglas Darden
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Pamela N. Peterson
- Division of Cardiology, Denver Health Medical Center, Denver, Colorado
- University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Xin Xin
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Muhammad Bilal Munir
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Karl E. Minges
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Ilan Goldenberg
- Division of Cardiology, University of Rochester Medical Center, Rochester, New York
- Clinical Cardiovascular Research Center, University of Rochester, Rochester, New York
| | - Jeanne E. Poole
- University of Washington School of Medicine, Seattle, Washington
| | - Gregory K. Feld
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Ulrika Birgersdotter-Green
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Jeptha P. Curtis
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jonathan C. Hsu
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California
- Address reprint requests and correspondence: Dr Jonathan C. Hsu, Associate Professor of Medicine, University of California San Diego, 9452 Medical Center Dr, MC7411, La Jolla, CA 92037.
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Batra G, Aktaa S, Wallentin L, Maggioni AP, Ludman P, Erlinge D, Casadei B, Gale CP. Data standards for acute coronary syndrome and percutaneous coronary intervention: the European Unified Registries for Heart Care Evaluation and Randomised Trials (EuroHeart). Eur Heart J 2022; 43:2269-2285. [PMID: 35380662 PMCID: PMC9209007 DOI: 10.1093/eurheartj/ehac133] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 02/14/2022] [Accepted: 03/01/2022] [Indexed: 11/14/2022] Open
Abstract
Standardized data definitions are essential for monitoring and benchmarking the quality of care and patient outcomes in observational studies and randomized controlled trials. There are no contemporary pan-European data standards for the acute coronary syndrome (ACS) and percutaneous coronary intervention (PCI). The European Unified Registries for Heart Care Evaluation and Randomised Trials (EuroHeart) project of the European Society of Cardiology (ESC) aimed to develop such data standards for ACS and PCI. Following a systematic review of the literature on ACS and PCI data standards and evaluation of contemporary ACS and PCI registries, we undertook a modified Delphi process involving clinical and registry experts from 11 European countries, as well as representatives from relevant ESC Associations, including the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and Acute CardioVascular Care (ACVC). This resulted in final sets of 68 and 84 'mandatory' variables and several catalogues of optional variables for ACS and PCI, respectively. Data definitions were provided for these variables, which have been programmed as the basis for continuous registration of individual patient data in the online EuroHeart IT platform. By means of a structured process and the interaction with major stakeholders, internationally harmonized data standards for ACS and PCI have been developed. In the context of the EuroHeart project, this will facilitate country-level quality of care improvement, international observational research, registry-based randomized trials, and post-marketing surveillance of devices and pharmacotherapies.
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Affiliation(s)
- Gorav Batra
- Department of Medical Sciences Cardiology and Uppsala Clinical Research Center Uppsala UniversityUppsalaSweden
| | - Suleman Aktaa
- Leeds Institute of Cardiovascular and Metabolic Medicine University of LeedsLeedsUK
- Leeds Institute for Data Analytics University of LeedsLeedsUK
- Department of Cardiology Leeds Teaching Hospitals NHS TrustLeedsUK
| | - Lars Wallentin
- Department of Medical Sciences Cardiology and Uppsala Clinical Research Center Uppsala UniversityUppsalaSweden
| | - Aldo P Maggioni
- Italian Association of Hospital Cardiologists Research Center (ANMCO)FlorenceItaly
| | - Peter Ludman
- Institute of Cardiovascular Sciences University of BirminghamBirminghamUK
| | - David Erlinge
- Department of Cardiology Skåne University Hospital Lund UniversityLundSweden
| | - Barbara Casadei
- Division of Cardiovascular Medicine NIHR Oxford Biomedical Research Centre University of OxfordOxfordUK
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine University of LeedsLeedsUK
- Leeds Institute for Data Analytics University of LeedsLeedsUK
- Department of Cardiology Leeds Teaching Hospitals NHS TrustLeedsUK
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Hussain A, Virani SS, Zheng L, Gluckman TJ, Borden WB, Masoudi FA, Maddox TM. Potential Impact of 2017 American College of Cardiology/American Heart Association Hypertension Guideline on Contemporary Practice: A Cross-Sectional Analysis From NCDR PINNACLE Registry. J Am Heart Assoc 2022; 11:e024107. [PMID: 35656989 PMCID: PMC9238704 DOI: 10.1161/jaha.121.024107] [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 Clinical implications of change in the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guideline on the diagnosis and management of hypertension, compared with recommendations by 2014 expert panel and Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7), are not known. Methods and Results Using data from the NCDR (National Cardiovascular Data Registry) PINNACLE (Practice Innovation and Clinical Excellence) Registry (January 2013‐Decemver 2016), we compared the proportion and clinical characteristics of patients seen in cardiology practices diagnosed with hypertension, recommended antihypertensive treatment, and achieving blood pressure (BP) goals per each guideline document. In addition, we evaluated the proportion of patients at the level of practices meeting BP targets defined by each guideline. Of 6 042 630 patients evaluated, 5 027 961 (83.2%) were diagnosed with hypertension per the 2017 ACC/AHA guideline, compared with 4 521 272 (74.8%) per the 2014 panel and 4 545 976 (75.2%) per JNC7. The largest increase in hypertension prevalence was seen in younger ages, women, and those with lower cardiovascular risk. Antihypertensive medication was recommended to 70.6% of patients per the ACC/AHA guideline compared with 61.8% and 65.9% per the 2014 panel and JNC7, respectively. Among those on antihypertensive agents, 41.2% achieved BP targets per the ACC/AHA guideline, compared with 79.4% per the 2014 panel and 64.3% per JNC7. Lower proportions of women, non‐White (Black and "other") races, and those at higher cardiovascular risk achieved BP goals. Median practice‐level proportion of patients meeting BP targets per the 2014 panel but not the ACC/AHA guideline was 37.8% (interquartile range, 34.8%–40.7%) and per JNC7 but not the ACC/AHA guideline was 22.9% (interquartile range, 19.8%–25.9%). Conclusions Following publication of the 2017 guideline, significantly more people, particularly younger people and those with lower cardiovascular risk, will be diagnosed with hypertension and need antihypertensive treatment compared with previous recommendations. Significant practice‐level variation in BP control also exists. Efforts are needed to improve guideline‐concordant hypertension management in an effort to improve outcomes.
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Affiliation(s)
- Aliza Hussain
- Section of Cardiology Department of Medicine Baylor College of Medicine Houston TX
| | - Salim S Virani
- Section of Cardiology Department of Medicine Baylor College of Medicine Houston TX.,Section of Cardiology Michael E. DeBakey Veterans Affairs Hospital Houston TX
| | - Luke Zheng
- BAIM Institute for Clinical Research Boston MA
| | - Ty J Gluckman
- Center for Cardiovascular Analytics, Research and Data Science Providence Heart InstituteProvidence St Joseph Health Portland OR
| | - William B Borden
- Department of Medicine George Washington University Washington DC
| | - Frederick A Masoudi
- Division of Cardiology University of Colorado Anschutz Medical Campus Aurora CO
| | - Thomas M Maddox
- Division of Cardiology Washington University School of Medicine St. Louis MO
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Freeman JV, Higgins AY, Wang Y, Du C, Friedman DJ, Daimee UA, Minges KE, Pereira L, Goldsweig AM, Price MJ, Reddy VY, Gibson D, Doshi SK, Varosy PD, Masoudi FA, Curtis JP. Antithrombotic Therapy After Left Atrial Appendage Occlusion in Patients With Atrial Fibrillation. J Am Coll Cardiol 2022; 79:1785-1798. [PMID: 35512858 PMCID: PMC9097170 DOI: 10.1016/j.jacc.2022.02.047] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 01/21/2022] [Accepted: 02/15/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Pivotal trials of percutaneous left atrial appendage occlusion (LAAO) used specific postprocedure treatment protocols. OBJECTIVES This study sought to evaluate patterns of postprocedure care after LAAO with the Watchman device in clinical practice and compare the risk of adverse events for different discharge antithrombotic strategies. METHODS We evaluated patients in the LAAO Registry of the National Cardiovascular Data Registry who underwent LAAO with the Watchman device between 2016 and 2018. We assessed adherence to the full postprocedure trial protocol including standardized follow-up, imaging, and antithrombotic agents and then evaluated the most commonly used antithrombotic strategies and compared the rates and risk of adverse events at 45 days and 6 months by means of multivariable COX frailty regression. RESULTS Among 31,994 patients undergoing successful LAAO, only 12.2% received the full postprocedure treatment protocol studied in pivotal trials; the most common protocol deviations were with discharge antithrombotic medications. The most common discharge medication strategies were warfarin and aspirin (36.9%), direct oral anticoagulant (DOAC) and aspirin (20.8%), warfarin only (13.5%), DOAC only (12.3%), and dual antiplatelet therapy (5.0%). In multivariable Cox frailty regression, the adjusted risk of any adverse event through the 45-day follow-up visit were significantly lower for discharge on warfarin alone (HR: 0.692; 95% CI: 0.569-0.841) and DOAC alone (HR: 0.731; 95% CI: 0.574-0.930) compared with warfarin and aspirin. Warfarin alone retained lower risk at the 6-month follow-up. CONCLUSIONS In contemporary U.S. practice, practitioners rarely used the full U.S. Food and Drug Administration-approved postprocedure treatment protocols studied in pivotal trials of the Watchman device. Discharge after implantation on warfarin or DOAC without concomitant aspirin was associated with lower risk of adverse outcomes.
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Affiliation(s)
- James V Freeman
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut, USA.
| | | | - Yongfei Wang
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut, USA
| | - Chengan Du
- Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut, USA
| | - Daniel J Friedman
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Usama A Daimee
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Karl E Minges
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut, USA
| | - Lucy Pereira
- Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut, USA
| | - Andrew M Goldsweig
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California, USA
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Douglas Gibson
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California, USA
| | - Shephal K Doshi
- Division of Cardiology, St John's Health Center, Pacific Heart Institute, Santa Monica, California, USA
| | - Paul D Varosy
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA; Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado, USA
| | | | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut, USA
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Friedman DJ, Du C, Wang Y, Agarwal V, Varosy PD, Masoudi FA, Holmes DR, Reddy VY, Price MJ, Curtis JP, Freeman JV. Patient-Level Analysis of Watchman Left Atrial Appendage Occlusion in Practice Versus Clinical Trials. JACC Cardiovasc Interv 2022; 15:950-961. [PMID: 35512918 PMCID: PMC9370831 DOI: 10.1016/j.jcin.2022.02.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 01/28/2022] [Accepted: 02/15/2022] [Indexed: 01/24/2023]
Abstract
OBJECTIVES The aim of this study was to compare outcomes among patients from the PROTECT-AF (WATCHMAN Left Atrial Appendage System for Embolic PROTECTion in Patients With Atrial Fibrillation) and PREVAIL (Evaluation of the WATCHMAN Left Atrial Appendage [LAA] Closure Device in Patients With Atrial Fibrillation Versus Long Term Warfarin Therapy) left atrial appendage occlusion (LAAO) trials with matched patients from the National Cardiovascular Data Registry LAAO Registry using patient-level data. BACKGROUND Patients undergoing LAAO in clinical practice generally have more comorbidities than trial participants. METHODS Propensity-matched analyses, with up to 3 registry patients matched to each trial patient, were performed using Cox proportional hazards and Fine-Gray models. RESULTS A total of 1,904 registry patients were matched to 667 trial LAAO patients; 1,010 registry patients were matched to 348 warfarin patients. Compared with registry patients, trial LAAO patients experienced more pericardial effusion requiring intervention (3.8% vs 0.6%, P < 0.001), periprocedural ischemic stroke (0.9% vs 0.2%, P = 0.005), and failed device implantation (7.5% vs 3.6%, P < 0.001). The 425-day risk of ischemic stroke in trial LAAO patients was higher than in registry patients (2.70% vs 1.21%; HR: 1.951; P = 0.03); warfarin patients had comparable rates of ischemic stroke compared with registry patients (1.15% vs 1.29%; HR: 0.728; P = 0.57). Hemorrhagic stroke risk was similar among trial LAAO and registry patients (P = 0.88). Hemorrhagic stroke risk was greater among warfarin patients versus registry patients (1.44% vs 0.20%; HR: 5.871, P = 0.03). Mortality was lower in trial LAAO patients than in registry patients (2.92% vs 6.23%; HR: 0.477; P = 0.004), a difference attributable to noncardiovascular deaths. Mortality was similar (P = 0.44) among trial warfarin (4.48%) and registry (5.86%) patients. CONCLUSION In clinical practice, patients who meet trial criteria and undergo LAAO experience a lower risk of ischemic stroke, a similar risk of hemorrhagic stroke, and a higher risk of death after implant versus LAAO trial patients. (WATCHMAN Left Atrial Appendage System for Embolic PROTECTion in Patients With Atrial Fibrillation [PROTECT-AF], NCT00129545; Evaluation of the WATCHMAN Left Atrial Appendage [LAA] Closure Device in Patients With Atrial Fibrillation Versus Long Term Warfarin Therapy [PREVAIL], NCT01182441).
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Affiliation(s)
- Daniel J Friedman
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Chengan Du
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut, USA
| | - Yongfei Wang
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut, USA
| | - Vratika Agarwal
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut, USA
| | - Paul D Varosy
- Division of Cardiology, University of Colorado School of Medicine, Denver, Colorado, USA; Cardiology Section, VA Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Frederick A Masoudi
- Division of Cardiology, University of Colorado School of Medicine, Denver, Colorado, USA
| | - David R Holmes
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Vivek Y Reddy
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California, USA
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut, USA
| | - James V Freeman
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut, USA. https://twitter.com/JFreeMD
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The National Cardiovascular Data Registry Data Quality Program 2020: JACC State-of-the-Art Review. J Am Coll Cardiol 2022; 79:1704-1712. [PMID: 35483759 DOI: 10.1016/j.jacc.2022.02.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 01/25/2022] [Accepted: 02/01/2022] [Indexed: 11/21/2022]
Abstract
The National Cardiovascular Data Registry is a group of registries maintained by the American College of Cardiology Foundation. These registries are used by a diverse constituency to improve the quality and outcomes of cardiovascular care, to assess the safety and effectiveness of new therapies, and for research. To achieve these goals, registry data must be complete and reliable. In this article, we review the process of National Cardiovascular Data Registry data collection, assess data completeness and integrity, and report on the current state of the data. Registry data are complete. Accuracy is very good but variable, and there is room for improvement. Knowledge of the quality of data is essential to ensuring its appropriate use.
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Zeitouni M, Marquis-Gravel G, Smilowitz NR, Zakroysky P, Wojdyla DM, Amit AP, Rao SV, Wang TY. Prophylactic Mechanical Circulatory Support Use in Elective Percutaneous Coronary Intervention for Patients With Stable Coronary Artery Disease. Circ Cardiovasc Interv 2022; 15:e011534. [PMID: 35580202 DOI: 10.1161/circinterventions.121.011534] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Mechanical circulatory support (MCS) devices can be used in high-risk percutaneous coronary intervention (PCI). Our objective was to describe trends and outcomes of prophylactic MCS use in elective PCI for patients with stable coronary artery disease in the American College of Cardiology National Cardiovascular Data Registry's CathPCI registry. METHODS Among 2 108 715 consecutive patients with stable coronary artery disease undergoing elective PCI in the CathPCI registry between 2009 and 2018, we examined patterns of prophylactic use of MCS. Propensity score models with inverse probability of treatment weighting compared effectiveness (in-hospital death, cardiogenic shock, or new heart failure) and safety (stroke, tamponade, major bleeding, or vascular complication requiring treatment) between patients treated with intra-aortic balloon pump versus other MCS (Impella or extracorporeal membrane oxygenation). RESULTS Overall, 6905 (0.3%) patients underwent elective PCI with prophylactic MCS. MCS use trended up from 0.2% of elective PCIs in 2009 to 0.6% in 2018 (P<0.0001), driven by other MCS (P<0.0001), whereas intra-aortic balloon pump use remained low and constant (P=0.12). In-hospital major adverse cardiac events and cardiovascular complications occurred in 7.1% and 18.8% of elective PCI patients with prophylactic MCS use and 0.5% and 2.3% of patients without prophylactic MCS use. Intra-aortic balloon pump use was associated with a higher risk of major adverse cardiac events (9.6% versus 6.0%, adjusted odds ratio, 1.59 [95% CI, 1.32-1.91]) but lower risk of complications (18.2% versus 19.1%, adjusted odds ratio, 0.88 [95% CI, 0.77-0.99]) than use of other MCS. CONCLUSIONS The use of prophylactic MCS has increased over time for elective PCI in patients with stable coronary artery disease. Intra-aortic balloon pump was associated with higher major adverse cardiac events but lower risk of procedural complications compared with other MCS.
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Affiliation(s)
- Michel Zeitouni
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.Z., G.M.G., P.Z., D.M.W., S.V.R., T.Y.W.)
| | - Guillaume Marquis-Gravel
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.Z., G.M.G., P.Z., D.M.W., S.V.R., T.Y.W.)
| | - Nathaniel R Smilowitz
- Division of Cardiology, Department of Medicine, NYU Langone Medical Center' New York (N.R.S.)
| | - Pearl Zakroysky
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.Z., G.M.G., P.Z., D.M.W., S.V.R., T.Y.W.)
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.Z., G.M.G., P.Z., D.M.W., S.V.R., T.Y.W.)
| | - Amin P Amit
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, MO (A.P.A.)
| | - Sunil V Rao
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.Z., G.M.G., P.Z., D.M.W., S.V.R., T.Y.W.)
| | - Tracy Y Wang
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.Z., G.M.G., P.Z., D.M.W., S.V.R., T.Y.W.)
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Patel A, Ngo L, Woodman RJ, Aliprandi-Costa B, Bennetts J, Psaltis PJ, Ranasinghe I. Institutional variation in early mortality following isolated coronary artery bypass graft surgery. Int J Cardiol 2022; 362:35-41. [PMID: 35504451 DOI: 10.1016/j.ijcard.2022.04.080] [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] [Received: 11/29/2021] [Revised: 04/04/2022] [Accepted: 04/27/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Thirty-day mortality following coronary artery bypass grafting (CABG) is a widely accepted marker for quality of care. Although surgical mortality has declined, the utility of this measure to profile quality has not been questioned. We assessed the institutional variation in risk-standardised mortality rates (RSMR) following isolated CABG within Australia and New Zealand (ANZ). METHODS We used an administrative dataset from all public and most private hospitals across ANZ to capture all isolated CABG procedures recorded between 2010 and 2015. The primary outcome was all-cause death occurring in-hospital or within 30-days of discharge. Hospital-specific RSMRs and 95% CI were estimated using a hierarchical generalised linear model accounting for differences in patient characteristics. RESULTS Overall, 60,953 patients (mean age 66.1 ± 10.1y, 18.7% female) underwent an isolated CABG across 47 hospitals. The observed early mortality rate was 1.69% (n = 1029) with 81.8% of deaths recorded in-hospital. The risk-adjustment model was developed with good discrimination (C-statistic = 0.81). Following risk-adjustment, a 3.9-fold variation was observed in RSMRs among hospitals (median:1.72%, range:0.84-3.29%). Four hospitals had RSMRs significantly higher than average, and one hospital had RSMR lower than average. When in-hospital mortality alone was considered, the median in-hospital RSMR was 1.40% with a 5.6-fold variation across institutions (range:0.57-3.19%). CONCLUSIONS Average mortality following isolated CABG is low across ANZ. Nevertheless, in-hospital and 30-day mortality vary among hospitals, highlighting potential disparities in care quality and the enduring usefulness of 30-day mortality as an outcome measure. Clinical and policy intervention, including participating in clinical quality registries, are needed to standardise CABG care.
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Affiliation(s)
- Aayush Patel
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia
| | - Linh Ngo
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia; School of Clinical Medicine, The University of Queensland, Brisbane, Australia; Cardiovascular Centre, E Hospital, Hanoi, Viet Nam
| | - Richard J Woodman
- Flinders Centre for Epidemiology and Biostatistics, Flinders University, South Australia, Australia
| | | | - Jayme Bennetts
- Department of Cardiothoracic Surgery, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, Australia; Department of Surgery, College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Peter J Psaltis
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia.; Department of Cardiology, Central Adelaide Local Health Network, Adelaide, Australia; Vascular Research Centre, Heart and Vascular Program, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Isuru Ranasinghe
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia; School of Clinical Medicine, The University of Queensland, Brisbane, Australia.
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Price MJ, Slotwiner D, Du C, Freeman JV, Turi Z, Rammohan C, Kusumoto FM, Kavinsky C, Akar J, Varosy PD, Koutras C, Curtis JP, Masoudi FA. Clinical Outcomes at 1 Year Following Transcatheter Left Atrial Appendage Occlusion in the United States. JACC Cardiovasc Interv 2022; 15:741-750. [PMID: 35393108 DOI: 10.1016/j.jcin.2022.02.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The aim of this study was to report 1-year clinical outcomes following commercial transcatheter left atrial appendage occlusion (LAAO) in the United States. BACKGROUND The National Cardiovascular Data Registry LAAO Registry was initiated to meet a condition of Medicare coverage and allow the assessment of clinical outcomes. The 1-year rates of thromboembolic events after transcatheter LAAO in such a large cohort of "real-world" patients have not been previously reported. METHODS Patients entered into the National Cardiovascular Data Registry LAAO Registry for a Watchman procedure between January 1, 2016, and December 31, 2018, were included. The primary endpoint was ischemic stroke. Key secondary endpoints included the rate of ischemic stroke or systemic embolism, mortality, and major bleeding. Major bleeding was defined as any bleeding requiring hospitalization, and/or causing a decrease in hemoglobin level > 2g/dL, and/or requiring blood transfusion that was not hemorrhagic stroke. The Kaplan-Meier method was used for 1-year estimates of cumulative event rates. RESULTS The study population consisted of 36,681 patients. The mean age was 76.0 ± 8.1 years, the mean CHA2DS2-VASc score was 4.8 ± 1.5, and the mean HAS-BLED score was 3.0 ± 1.1. Prior stroke was present in 25.5%, clinically relevant bleeding in 69.5%, and intracranial bleeding in 11.9%. Median follow-up was 374 days (IQR: 212-425 days). The Kaplan-Meier-estimated 1-year rate of ischemic stroke was 1.53% (95% CI: 1.39%-1.69%), the rate of ischemic stroke or systemic embolism was 2.19% (95% CI: 2.01%-2.38%), and the rate of mortality was 8.52% (95% CI: 8.19%-8.87%). The 1-year estimated rate of major bleeding was 6.93% (95% CI: 6.65%-7.21%). Most bleeding events occurred between discharge and 45 days following the procedure. CONCLUSIONS This study characterizes important outcomes in a national cohort of patients undergoing transcatheter LAAO in the United States. Clinicians and patients can integrate these data in shared decision making when considering this therapy.
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Affiliation(s)
- Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California, USA.
| | - David Slotwiner
- Division of Cardiology, New York Presbyterian Queens, Weill Cornell Medical College, New York, New York, USA
| | - Chengan Du
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - James V Freeman
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA; Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Zoltan Turi
- Center for Structural and Congenital Heart Disease, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Chidambaram Rammohan
- Division of Cardiovascular Medicine, Palo Alto Medical Foundation, El Camino Hospital, Mountain View, California
| | - Fred M Kusumoto
- Department of Cardiovascular Disease, Mayo Clinic, Jacksonville, Florida, USA
| | - Clifford Kavinsky
- Division of Cardiovascular Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Joseph Akar
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA; Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Paul D Varosy
- VA Eastern Colorado Health Care System and University of Colorado, Aurora, Colorado, USA
| | - Christina Koutras
- American College of Cardiology Foundation, Washington, District of Columbia, USA
| | - Jeptha P Curtis
- Division of Cardiology, New York Presbyterian Queens, Weill Cornell Medical College, New York, New York, USA; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
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Borden WB, Wang J, Jones P, Tang Y, Contreras J, Daugherty SL, Desai NR, Virani SS, Wasfy JH, Maddox TM. Reducing Cardiovascular Risk in the Medicare Million Hearts Risk Reduction Model: Insights From the National Cardiovascular Data Registry PINNACLE Registry. Circ Cardiovasc Qual Outcomes 2022; 15:e007908. [PMID: 35272505 PMCID: PMC9187962 DOI: 10.1161/circoutcomes.121.007908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND The Million Hearts Cardiovascular Disease Risk Reduction Model provides financial incentives for practices to lower 10-year atherosclerotic cardiovascular disease (ASCVD) risk for high-risk (ASCVD ≥30%) Medicare patients. To estimate average practice-level ASCVD risk reduction, we applied optimal trial outcomes to a real-world population with high ASCVD risk. METHODS This study uses observational registry data from the National Cardiovascular Data Registry Practice Innovation and Clinical Excellence Registry from January 2013 to June 2016. We modeled ASCVD risk reductions using historical clinical trial data (reducing cholesterol by 26.5%, reducing systolic blood pressure by 10.9%, reducing smoking rates by 21.8%) the average reduction in ASCVD risk associated with individual and combined risk factor modifications, and then percentage of practices achieving the various incentive thresholds for the Million Hearts Model. RESULTS The final study population included 135 166 patients, with 16 248 (12.0%) with 10-year ASCVD risk of ≥30%, but without existing ASCVD. The mean 10-year ASCVD risk was 41.9% (±1 SD of 11.6). Using risk factor reductions from clinical trials, lowering cholesterol, blood pressure, and smoking rates reduced 10-year ASCVD risk by 3.3% (±3.1), 6.3% (±1.1) and 0.5% (±1.3), respectively. Combining all 3 reductions resulted in a 9.7% (±3.6) reduction, with 67 (27.0%) of practices achieving a patient-level average 10-year ASCVD risk reduction of ≥10%, 181 (73.0%) achieving a 2 to 10% reduction, and no practice achieving <2% reduction. CONCLUSIONS In cardiology practices, about 1 out of 8 patients have a 10-year ASCVD risk ≥30% and qualify as high risk in the Million Hearts Model. If practices target the three main modifiable risk factors and achieve reductions similar to clinical trial results, ASCVD risk could be substantially lowered and all practices could receive incentive payments. These findings support the potential benefit of the Million Hearts Model and provide guidance to participating practices.
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Affiliation(s)
| | - Jingyan Wang
- University of Texas Health Science Center, Houston (J.W.)
| | - Philip Jones
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City School of Medicine, Kansas City (P.J.)
| | | | | | | | | | - Salim S Virani
- Michael E. DeBakey Veterans Affairs Medical Center & Baylor College of Medicine, Houston, TX (S.S.V.)
| | | | - Thomas M Maddox
- Washington University School of Medicine, St. Louis, MO (T.M.M.)
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Higgins AY, Annapureddy AR, Wang Y, Minges KE, Bellumkonda L, Lampert R, Rosenfeld LE, Jacoby DL, Curtis JP, Miller EJ, Freeman JV. Risk and predictors of mortality after implantable cardioverter-defibrillator implantation in patients with sarcoid cardiomyopathy. Am Heart J 2022; 246:21-31. [PMID: 34968442 DOI: 10.1016/j.ahj.2021.12.011] [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] [Received: 09/09/2020] [Revised: 12/19/2021] [Accepted: 12/21/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Implantable cardioverter-defibrillators (ICDs) are recommended for patients with cardiac sarcoidosis (CS) with an indication for pacing, prior ventricular arrhythmias, cardiac arrest, or left ventricular ejection fraction <35%, but data on outcomes are limited. METHODS Using data from the National Cardiovascular Data Registry ICD Registry between April 1, 2010 and December 31, 2015, we evaluated a propensity matched cohort of CS patients implanted with ICDs versus non-ischemic cardiomyopathies (NICM). We compared mortality using Kaplan-Meier survival curves and Cox proportional hazards models. RESULTS We identified 1,638 patients with CS and 8,190 propensity matched patients with NICM. The rate of death at 1 and 2 years was similar in patients with CS and patients with NICM (5.2% vs 5.4%, P = 0.75 and 9.0% vs 9.3%, P = 0.72, respectively). After adjusting for other covariates, patients with CS had similar mortality at 2 years after ICD implantations compared with NICM patients (RR 1.03, 95% CI 0.87-1.23). Among patients with CS, multivariable logistic regression identified 6 factors significantly associated with increased 2-year mortality: presence of heart failure (HR 1.92, 95% CI 1.44-3.22), New York Heart Association (NYHA) Class III heart failure (HR 1.68, 95% CI 1.16-2.45), NYHA Class IV heart failure (HR 3.08, 95% CI 1.49-6.39), atrial fibrillation/flutter (HR 1.66, 95% CI 1.17-2.35), chronic lung disease (HR 1.64, 95% CI 1.17-2.29), creatinine >2.0 mg/dL (HR 4.07, 95% CI 2.63-6.30), and paced rhythm (HR 2.66, 95% CI 1.07-6.59). CONCLUSION Mortality following ICD implantation was similar in CS patients compared with propensity matched NICM patients. Presence of heart failure, NYHA class, atrial fibrillation/flutter, chronic lung disease, renal dysfunction, and paced rhythm at time of implantation were all predictors of increased 2-year mortality among CS patients with ICDs.
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Friedman DJ, Qin L, Parzynski C, Heist EK, Russo AM, Ranasinghe I, Zeitler EP, Minges KE, Akar JG, Freeman JV, Curtis JP, Al-Khatib SM. Longitudinal Outcomes of Subcutaneous or Transvenous Implantable Cardioverter-Defibrillators in Older Patients. J Am Coll Cardiol 2022; 79:1050-1059. [PMID: 35300816 DOI: 10.1016/j.jacc.2021.12.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/15/2021] [Accepted: 12/20/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The subcutaneous (S-) implantable cardioverter-defibrillator (ICD) is an alternative to the transvenous (TV-) ICD that is increasingly implanted in younger patients; data on the safety and effectiveness of the S-ICD in older patients are lacking. OBJECTIVES The purpose of this study was to compare outcomes among older patients who received an S- or TV-ICD. METHODS The authors compared S-ICD and single-chamber TV-ICD implants in Fee-For-Service Medicare beneficiaries using the National Cardiovascular Data Registry ICD Registry. Outcomes were ascertained from Medicare claims data. Cox regression or competing-risk models (with TV-ICD as reference) with overlap weights were used to compare death and nonfatal outcomes (device reoperation, device removal for infection, device reoperation without infection, and cardiovascular admission), respectively. Recurrent all-cause readmissions were compared using Anderson-Gill models. RESULTS A total of 16,063 patients were studied (age 72.6 ± 5.9 years, 28.4% women, ejection fraction 28.3 ± 8.9%). Compared with TV-ICD patients (n = 15,072), S-ICD patients (n = 991, 6.2% overall) were more often Black, younger, and dialysis dependent and less likely to have history of atrial fibrillation or flutter. In adjusted analyses, there were no differences between device type and risk of all-cause mortality (HR: 1.020; 95% CI: 0.819-1.270), device reoperation (subdistribution [s] HR: 0.976; 95% CI: 0.645-1.479), device removal for infection (sHR: 0.614; 95% CI: 0.138-2.736), device reoperation without infection (sHR: 0.975; 95% CI: 0.632-1.506), cardiovascular readmission (sHR: 1.087; 95% CI: 0.912-1.295), or recurrent all-cause readmission (HR: 1.072; 95% CI: 0.990-1.161). CONCLUSIONS In a large representative national cohort of older patients undergoing ICD implantation, risk of death, device reoperation, device removal for infection, device reoperation without infection, and cardiovascular and all-cause readmission were similar among S- and TV-ICD recipients.
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Affiliation(s)
- Daniel J Friedman
- Electrophysiology Section, Duke University Hospital, Durham North Carolina, USA; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.
| | - Li Qin
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut, USA
| | - Craig Parzynski
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut, USA
| | - E Kevin Heist
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Andrea M Russo
- Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Isuru Ranasinghe
- Department of Cardiology, The Prince Charles Hospital and University of Queensland, Chermside, Queensland, Australia
| | - Emily P Zeitler
- Division of Cardiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA; The Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Karl E Minges
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut, USA; Department of Health Administration and Policy, University of New Haven, New Haven, Connecticut, USA
| | - Joseph G Akar
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut, USA
| | - James V Freeman
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut, USA
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut, USA
| | - Sana M Al-Khatib
- Electrophysiology Section, Duke University Hospital, Durham North Carolina, USA
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Borne RT, Varosy P, Lan Z, Masoudi FA, Curtis JP, Matlock DD, Peterson PN. Trends in Use of Single- vs Dual-Chamber Implantable Cardioverter-Defibrillators Among Patients Without a Pacing Indication, 2010-2018. JAMA Netw Open 2022; 5:e223429. [PMID: 35315917 PMCID: PMC8941353 DOI: 10.1001/jamanetworkopen.2022.3429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Use of dual-chamber implantable cardioverter-defibrillator (ICD) systems among patients without a pacing indication is an example of low-value care given higher procedural risks, higher costs, and little evidence for benefit from an atrial lead. However, variation in the use of dual-chamber systems was present among patients without a pacing indication. OBJECTIVE To examine the temporal trends and hospital variation in use of single- and dual-chamber ICD implantation among patients without a pacing indication undergoing first-time ICD implantation. DESIGN, SETTING, AND PARTICIPANTS A multicenter cross-sectional study was conducted using the US National Cardiovascular Data Registry ICD Registry. A total of 266 182 patients undergoing initial implantation of a single- or dual-chamber transvenous ICD without a bradycardia pacing indication, class I or II cardiac resynchronization therapy indication, or history of atrial fibrillation or atrial flutter were included. The study was conducted from April 1, 2010, to December 31, 2018; data analysis was performed from October 19, 2020, to January 5, 2022. EXPOSURES Implantation of a single- or dual-chamber ICD. MAIN OUTCOMES AND MEASURES Temporal trends among patients undergoing single- vs dual-chamber ICDs were determined using the Cochran-Armitage trend test, and hospital-level variation using adjusted hospital median odds ratios was examined. RESULTS A total of 266 182 patients (single-chamber ICD, 134 925; dual-chamber ICD, 131 257) were included in this analysis; mean (SD) age was 58.0 (14.0) years and 91 990 patients (68.2%) were men. The use of dual-chamber ICDs decreased from 64.7% (n = 15 694) in 2010 to 42.2% (n = 9762) in 2018 (P < .001). Adjusted for patient characteristics, the median hospital-level proportion of single-chamber ICDs increased from 42.9% (95% CI, 42.6%-45.0%) in 2010 to 50.0% (95% CI, 47.8%-51.0%) in 2018. The median odds ratio for the use of dual-chamber ICDs, adjusted for patient characteristics, was 1.6 (95% CI, 1.6-1.8) in 2010 and 1.5 (95% CI, 1.5-1.8) in 2018, indicating decreasing but persistent variation in use. CONCLUSIONS AND RELEVANCE In this national study of US patients undergoing first-time ICD implantation without a clinical indication for an atrial lead, the use of dual-chamber devices decreased. However, institutional variability in the use of atrial leads persists, suggesting differences in individual or institutional cultures of real-world practice and opportunity to reduce this low-value practice.
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Affiliation(s)
- Ryan T. Borne
- Division of Cardiology, University of Colorado Health, Colorado Springs
| | - Paul Varosy
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
- Cardiology Section, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado
| | - Zhou Lan
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut
| | - Frederick A. Masoudi
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
- Research and Analytics, Ascension Health, St Louis, Missouri
| | - Jeptha P. Curtis
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut
- Division of Cardiology, Yale University School of Medicine, New Haven, Connecticut
| | - Daniel D. Matlock
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora
- Veterans Affairs Eastern Colorado Geriatric Research Education and Clinical Center, Denver
| | - Pamela N. Peterson
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
- Division of Cardiology, Denver Health Hospital, Denver, Colorado
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Castro-Dominguez YS, Curtis JP, Masoudi FA, Wang Y, Messenger JC, Desai NR, Slattery LE, Dehmer GJ, Minges KE. Hospital Characteristics and Early Enrollment Trends in the American College of Cardiology Voluntary Public Reporting Program. JAMA Netw Open 2022; 5:e2147903. [PMID: 35142829 PMCID: PMC8832180 DOI: 10.1001/jamanetworkopen.2021.47903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
IMPORTANCE Limited data exist regarding the characteristics of hospitals that do and do not participate in voluntary public reporting programs. OBJECTIVE To describe hospital characteristics and trends associated with early participation in the American College of Cardiology (ACC) voluntary reporting program for cardiac catheterization-percutaneous coronary intervention (CathPCI) and implantable cardioverter-defibrillator (ICD) registries. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study analyzed enrollment trends and characteristics of hospitals that did and did not participate in the ACC voluntary public reporting program. All hospitals reporting procedure data to the National Cardiovascular Data Registry (NCDR) CathPCI or ICD registries that were eligible for the public reporting program from July 2014 (ie, program launch date) to May 2017 were included. Stepwise logistic regression was used to identify hospital characteristics associated with voluntary participation. Enrollment trends were evaluated considering the date US News & World Report (USNWR) announced that it would credit participating hospitals. Data analysis was performed from March 2017 to January 2018. MAIN OUTCOMES AND MEASURES Hospital characteristics and participation in the public reporting program. RESULTS By May 2017, 561 of 1747 eligible hospitals (32.1%) had opted to participate in the program. Enrollment increased from 240 to 376 hospitals (56.7%) 1 month after the USNWR announcement that program participation would be considered as a component of national hospital rankings. Compared with hospitals that did not enroll, program participants had increased median (IQR) procedural volumes for PCI (481 [280-764] procedures vs 332 [186-569] procedures; P < .001) and ICD (114 [56-220] procedures vs 62 [25-124] procedures; P < .001). Compared with nonparticipating hospitals, an increased mean (SD) proportion of participating hospitals adhered to composite discharge medications after PCI (0.96 [0.03] vs 0.92 [0.07]; P < .001) and ICD (0.88 [0.10] vs 0.81 [0.12]; P < .001). Hospital factors associated with enrollment included participation in 5 or more NCDR registries (odds ratio [OR],1.98; 95% CI, 1.24-3.19; P = .005), membership in a larger hospital system (ie, 3-20 hospitals vs ≤2 hospitals in the system: OR, 2.29; 95% CI, 1.65-3.17; P = .001), participation in an NCDR pilot public reporting program of PCI 30-day readmissions (OR, 2.93; 95% CI, 2.19-3.91; P < .001), university affiliation (vs government affiliation: OR, 3.85, 95% CI, 1.03-14.29; P = .045; vs private affiliation: OR, 2.22; 95% CI, 1.35-3.57; P < .001), Midwest location (vs South: OR, 1.47; 95% CI, 1.06-2.08; P = .02), and increased comprehensive quality ranking (4 vs 1-2 performance stars in CathPCI: OR, 8.08; 95% CI, 5.07-12.87; P < .001; 4 vs 1 performance star in ICD: OR, 2.26; 95% CI, 1.48-3.44; P < .001) (C statistic = 0.829). CONCLUSIONS AND RELEVANCE This study found that one-third of eligible hospitals participated in the ACC voluntary public reporting program and that enrollment increased after the announcement that program participation would be considered by USNWR for hospital rankings. Several hospital characteristics, experience with public reporting, and quality of care were associated with increased odds of participation.
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Affiliation(s)
- Yulanka S. Castro-Dominguez
- Harrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jeptha P. Curtis
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Frederick A. Masoudi
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora
| | - Yongfei Wang
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - John C. Messenger
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora
| | - Nihar R. Desai
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Lara E. Slattery
- American College of Cardiology, Washington, District of Columbia
| | - Gregory J. Dehmer
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Karl E. Minges
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Department of Health Administration and Policy, University of New Haven, West Haven, Connecticut
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Haghighat L, Reinhardt SW, Saly DL, Lu D, Matsouaka RA, Wang TY, Desai NR. Comfort Measures Only in Myocardial Infarction: Prevalence of This Status, Change Over Time, and Predictors From a Nationwide Study. Circ Cardiovasc Qual Outcomes 2022; 15:e007610. [PMID: 35041476 DOI: 10.1161/circoutcomes.120.007610] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients hospitalized with acute myocardial infarction (AMI) have a high mortality rate. Despite increasing recognition of the role for comfort focused care, little is known about the prevalence of comfort measures only (CMO) care among patients with AMI. The objective of this study was to investigate patient- and hospital-level patterns and predictors of CMO care among patients admitted with AMI. METHODS This retrospective cohort study used the National Cardiovascular Data Registry Chest Pain-MI Registry, which contains data on patients admitted with AMI. Data were analyzed in 6-month increments from January 2015 to June 2018. RESULTS Among 483 696 patients with AMI across 827 hospitals, 13 955 (2.9%) had CMO status at discharge (2.6% non-ST-segment-elevation myocardial infarction and 3.4% ST-segment-elevation myocardial infarction). There was a modest decline in CMO rates over time (3.0% to 2.8%). Independent patient characteristics associated with CMO status included male gender, White race, nonprivate insurance, frailty, and higher estimated bleeding and mortality risks. There was substantial variation in CMO rates across hospitals, with the proportion of CMO patients ranging from 0% to 17.1% and a median odds ratio of 1.59 (95% CI, 1.56-1.62). Among the 13 955 patients who were CMO by discharge, 8134 (58.3%) underwent diagnostic catheterization. This is despite significantly elevated risks predicted using precatheterization models, specifically the ACTION Registry GWTG in-hospital major bleeding and mortality risk scores. Patients who were initially managed invasively but later made CMO experienced high rates of procedural complications, including cardiogenic shock (38.3%), dialysis (10.1%), and bleeding (33.3%). CONCLUSIONS Most patients with AMI who were CMO by discharge had aggressive initial management and became CMO following in-hospital complications of their care. Early identification of high-risk patients and appropriate transition of such patients to CMO, if aligned with their values, remain important areas for future quality programs in AMI.
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Affiliation(s)
- Leila Haghighat
- Division of Cardiology, University of California, San Francisco (UCSF), CA (L.H.)
| | - Samuel W Reinhardt
- Section of Cardiovascular Medicine, Department of Internal Medicine (S.W.R., N.R.D.), Yale New Haven Hospital, New Haven, CT
| | - Danielle L Saly
- Department of Nephrology, Brigham and Women's Hospital, Boston, MA (D.L.S.)
| | - Di Lu
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (D.L., T.Y.W.)
| | - Roland A Matsouaka
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC (R.A.M.)
| | - Tracy Y Wang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (D.L., T.Y.W.)
| | - Nihar R Desai
- Section of Cardiovascular Medicine, Department of Internal Medicine (S.W.R., N.R.D.), Yale New Haven Hospital, New Haven, CT.,Center for Outcomes Research and Evaluation (N.R.D.), Yale New Haven Hospital, New Haven, CT
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Gandhi S, Garratt KN, Li S, Wang TY, Bhatt DL, Davis LL, Zeitouni M, Kontos MC. Ten-Year Trends in Patient Characteristics, Treatments, and Outcomes in Myocardial Infarction From National Cardiovascular Data Registry Chest Pain-MI Registry. Circ Cardiovasc Qual Outcomes 2022; 15:e008112. [PMID: 35041478 DOI: 10.1161/circoutcomes.121.008112] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The Chest Pain-MI registry affords a 10-year perspective of the acute myocardial infarction (MI) patient characteristics, management, and clinical outcomes in the United States. We report the changes in the treatment and cardiovascular outcomes of acute MI patients over 10 years. METHODS Annual trends in patient characteristics, in-hospital treatment, and outcomes of 604 936 ST-segment-elevation MI (STEMI) and 933 755 non-ST-segment-elevation MI (NSTEMI) patients at 1230 hospitals from 2009 to 2018 were analyzed. Using the validated Acute Coronary Intervention and Outcomes Network mortality risk model, trends in in-hospital risk-adjusted mortality rates were tested between 2011 and 2018. RESULTS Over 10 years, the prevalence of diabetes (22.8%-28.3% [STEMI] and 35.7%-41.3% [NSTEMI]) and atrial fibrillation (4.1%-6.1% and 9.4%-11.7%) increased, whereas the prevalence of smoking decreased (43.5%-37.9% and 30.2%-27.5%, P<0.001 for all) in patients with STEMI and NSTEMI, respectively. Among eligible patients with STEMI, primary percutaneous coronary intervention use increased (82.3%-96.0%) with shorter median first medical contact to device time (90 to 82 minutes, P<0.001). Among patients with NSTEMI, percutaneous coronary intervention use increased significantly (43.9%-54.5%, P<0.001). Adherence to guideline-directed medical therapies improved in both groups. From 2011 to 2018, risk-adjusted mortality rate (2.8%-2.7%, P=0.46) was stable in STEMI and declined significantly in patients with NSTEMI (1.9%-1.3%, P=0.0001). CONCLUSIONS Risk factors of patients presenting with acute MI have changed modestly while treatment improved over time. Risk-adjusted mortality rates remained stable for patients with STEMI and declined significantly for patients with NSTEMI.
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Affiliation(s)
- Sanjay Gandhi
- Case Western Reserve University- MetroHealth Hospital, Cleveland, OH (S.G.)
| | | | - Shuang Li
- DCRI, Durham, NC (S.L., T.Y.W., M.Z.)
| | | | - Deepak L Bhatt
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA (D.L.B.)
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Berger DA, Yiadom MYAB. ECG to Activation: Not an Appropriate Physician Metric, but a Worthy Process Metric. J Emerg Med 2022; 62:129-130. [PMID: 35090729 DOI: 10.1016/j.jemermed.2021.07.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/05/2021] [Indexed: 12/28/2022]
Affiliation(s)
- David A Berger
- Department of Emergency Medicine, Beaumont Health, Royal Oak, Michigan.
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45
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Lima FV, Manandhar P, Wojdyla D, Wang T, Aronow HD, Kadiyala V, Weissler EH, Madan N, Gilchrist IC, Grines C, Abbott JD. Percutaneous Coronary Intervention Following Diagnostic Angiography by Noninterventional Versus Interventional Cardiologists: Insights From the CathPCI Registry. Circ Cardiovasc Interv 2021; 15:e011086. [PMID: 34933569 DOI: 10.1161/circinterventions.121.011086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There are limited contemporary, national data describing diagnostic cardiac catheterization with subsequent percutaneous coronary intervention (ad hoc percutaneous coronary intervention [PCI]) performed by an invasive-diagnostic and interventional (Dx/IC) operator team versus solo interventional operator (solo-IC). Using the CathPCI Registry, this study aimed at analyzing trends and outcomes in ad hoc PCI among Dx/IC versus solo-IC operators. METHODS Quarterly rates (January 2012 to March 2018) of ad hoc PCI cases by Dx/IC and solo-IC operators were obtained. Odds of inhospital major adverse cardiovascular events, net adverse cardiovascular events (ie, composite major adverse cardiovascular event+bleeding), and rarely appropriate PCI were estimated using multivariable regression. RESULTS From 1077 sites, 1 262 948 patients were included. The number of invasive-diagnostic operators and cases performed by Dx/IC teams decreased from nearly 9% to 5% during the study period. Patients treated by Dx/IC teams were more often White and had fewer comorbidities compared with patients treated by solo-IC operators. Considerable variation existed across sites, and over two-fifths of sites had 0% ad hoc PCI performed by Dx/IC. In adjusted analyses, ad hoc performed by Dx/IC had similar risks of major adverse cardiovascular event (OR, 1.04 [95% CI, 0.97-1.11]) and net adverse cardiovascular events (OR, 0.98 [95% CI, 0.94-1.03]) compared with solo-IC. Rarely appropriate PCI, although low overall (2.1% versus 1.9%) occurred more often by Dx/IC compared with solo-IC (OR, 1.20 [95% CI, 1.13-1.26]). CONCLUSIONS Contemporary, nationwide data from the CathPCI Registry demonstrates the number of Dx/IC operator teams and cases has decreased but that case volume is stable among operators. Outcomes were independent of operator type, which supports current practice patterns. The finding of a higher risk of rarely appropriate PCI in Dx/IC teams should be further studied.
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Affiliation(s)
- Fabio V Lima
- Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, RI (F.V.L., H.D.A., V.K., J.D.A.)
| | - Pratik Manandhar
- Duke Clinical Research Institute, Durham, NC (P.M., D.W., T.W., E.H.W.)
| | - Daniel Wojdyla
- Duke Clinical Research Institute, Durham, NC (P.M., D.W., T.W., E.H.W.)
| | - Tracy Wang
- Duke Clinical Research Institute, Durham, NC (P.M., D.W., T.W., E.H.W.)
| | - Herbert D Aronow
- Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, RI (F.V.L., H.D.A., V.K., J.D.A.)
| | - Vishnu Kadiyala
- Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, RI (F.V.L., H.D.A., V.K., J.D.A.)
| | - E Hope Weissler
- Duke Clinical Research Institute, Durham, NC (P.M., D.W., T.W., E.H.W.)
| | - Nidhi Madan
- Department of Cardiovascular Diseases, Rush University Medical Center, Chicago, IL (N.M.)
| | - Ian C Gilchrist
- Penn State Heart and Vascular Institute, Hershey, PA (I.C.G.)
| | - Cindy Grines
- Northside Hospital Cardiovascular Institute, Atlanta, GA (C.G.)
| | - J Dawn Abbott
- Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, RI (F.V.L., H.D.A., V.K., J.D.A.)
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Peacock WF, Levy PD, Diercks DB, Li S, Wang TY, McCord J, Newby LK, Osborne A, Ross M, Winchester DE, Kontos MC, Deitelzweig S, Bhatt DL. The Impact of American College of Cardiology Chest Pain Center Accreditation on Guideline Recommended Acute Myocardial Infarction Management. Crit Pathw Cardiol 2021; 20:173-178. [PMID: 34494982 DOI: 10.1097/hpc.0000000000000266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Whether American College of Cardiology (ACC) Chest Pain Center (CPC) accreditation alters guidelines adherence rates is unclear. METHODS We analyzed patient-level, hospital-reported, quality metrics for myocardial infarction (MI) patients from 644 hospitals collected in the ACC's Chest Pain-MI Registry from January 1, 2019, to December 31, 2020, stratified by CPC accreditation for >1 year. RESULTS Of 192,374 MI patients, 67,462 (35.1%) received care at an accredited hospital. In general, differences in guideline adherence rates between accredited and nonaccredited hospitals were numerically small, although frequently significant. Patients at accredited hospitals were more likely to undergo coronary angiography (98.6% vs. 97.9%, P < 0.0001), percutaneous coronary intervention for NSTEMI (55.4% vs. 52.3%, P < 0.0001), have overall revascularization for NSTEMI (63.5% vs. 61.0%, P < 0.0001), and receive P2Y12 inhibitor on arrival (63.5% vs. 60.2%, P < 0.0001). Nonaccredited hospitals more ECG within 10 minutes (62.3% vs. 60.4%, P < 0.0001) and first medical contact to device activation ≤90 minutes (66.8% vs. 64.8%, P < 0.0001). Accredited hospitals had uniformly higher discharge medication guideline adherence, with patients more likely receiving aspirin (97.8% vs. 97.4%, P < 0.0001), angiotensin-converting enzyme inhibitor (46.7% vs. 45.3%, P < 0.0001), beta blocker (96.6% vs. 96.2%, P < 0.0001), P2Y12 inhibitor (90.3% vs. 89.2%, P < 0.0001), and statin (97.8% vs. 97.5%, P < 0.0001). Interaction by accredited status was significant only for length of stay, which was slightly shorter at accredited facilities for specific subgroups. CONCLUSIONS ACC CPC accreditation was associated with small consistent improvement in adherence to guideline-based treatment recommendations of catheter-based care (catheterization and PCI) for NSTEMI and discharge medications, and shorter hospital stays.
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Affiliation(s)
| | | | | | - Shuang Li
- Duke University/Duke Clinical Research Institute
| | - Tracy Y Wang
- Duke University/Duke Clinical Research Institute
| | | | - L Kristin Newby
- Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, NC
| | | | - Michael Ross
- Emory University School of Medicine, Atlanta, GA
| | | | | | | | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA
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47
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Villablanca PA, Vemulapalli S, Stebbins A, Dai D, So CY, Eng MH, Wang DD, Frisoli TM, Lee JC, Kang G, Szerlip M, Ibrahim H, Staniloae C, Gaba P, Lemor A, Finn M, Ramakrishna H, Williams MR, Leon MB, O'Neill WW, Shah B. Sex-Based Differences in Outcomes With Percutaneous Transcatheter Repair of Mitral Regurgitation With the MitraClip System: Transcatheter Valve Therapy Registry From 2011 to 2017. Circ Cardiovasc Interv 2021; 14:e009374. [PMID: 34784236 DOI: 10.1161/circinterventions.120.009374] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Women have a higher rate of adverse events after mitral valve surgery. We sought to evaluate whether outcomes after transcatheter edge-to-edge repair intervention by sex have similar trends to mitral valve surgery. METHODS The primary outcome was 1-year major adverse events defined as a composite of all-cause mortality, stroke, and any bleeding in the overall study cohort. Patients who underwent transcatheter edge-to-edge repair for mitral regurgitation with the MitraClip system in the Society of Thoracic Surgery/American College of Cardiology Transcatheter Valve Therapy registry were evaluated. Linked administrative claims from the Centers for Medicare and Medicaid Services were used to evaluate 1-year clinical outcomes. Associations between sex and outcomes were evaluated using a multivariable logistic regression model for in-hospital outcomes and Cox model for 1-year outcomes. RESULTS From November 2013 to March 2017, 5295 patients, 47.6% (n=2523) of whom were female, underwent transcatheter edge-to-edge repair. Females were less likely to have >1 clip implanted (P<0.001) and had a lower adjusted odds ratio of device success (adjusted odds ratio, 0.78 [95% CI, 0.67-0.90]), driven by lower odds of residual mitral gradient <5 mm Hg (adjusted odds ratio, 0.54 [CI, 0.46-0.63]) when compared with males. At 1-year follow-up, the primary outcome did not differ by sex. Female sex was associated with lower adjusted 1-year risk of all-cause mortality (adjusted hazard ratio, 0.80 [CI, 0.68-0.94]), but the adjusted 1-year risk of stroke and any bleeding did not differ by sex. CONCLUSIONS No difference in composite outcome of all-cause mortality, stroke, and any bleeding was observed between females and males. Adjusted 1-year all-cause mortality was lower in females compared with males.
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Affiliation(s)
- Pedro A Villablanca
- Department of Medicine, Division of Cardiology, Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI (P.A.V., C.-y.S., M.H.E., D.D.W., T.M.F., J.C.L., G.K., A.L., W.W.O.)
| | | | - Amanda Stebbins
- Duke Clinical Research Institute, Durham, NC (S.V., A.S., D.D.)
| | - Dadi Dai
- Duke Clinical Research Institute, Durham, NC (S.V., A.S., D.D.)
| | - Chak-Yu So
- Department of Medicine, Division of Cardiology, Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI (P.A.V., C.-y.S., M.H.E., D.D.W., T.M.F., J.C.L., G.K., A.L., W.W.O.)
| | - Marvin H Eng
- Department of Medicine, Division of Cardiology, Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI (P.A.V., C.-y.S., M.H.E., D.D.W., T.M.F., J.C.L., G.K., A.L., W.W.O.)
| | - Dee Dee Wang
- Department of Medicine, Division of Cardiology, Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI (P.A.V., C.-y.S., M.H.E., D.D.W., T.M.F., J.C.L., G.K., A.L., W.W.O.)
| | - Tiberio M Frisoli
- Department of Medicine, Division of Cardiology, Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI (P.A.V., C.-y.S., M.H.E., D.D.W., T.M.F., J.C.L., G.K., A.L., W.W.O.)
| | - James C Lee
- Department of Medicine, Division of Cardiology, Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI (P.A.V., C.-y.S., M.H.E., D.D.W., T.M.F., J.C.L., G.K., A.L., W.W.O.)
| | - Guson Kang
- Department of Medicine, Division of Cardiology, Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI (P.A.V., C.-y.S., M.H.E., D.D.W., T.M.F., J.C.L., G.K., A.L., W.W.O.)
| | | | - Homam Ibrahim
- Division of Cardiology, NYU Grossman School of Medicine (H.I., C.S., M.R.W., B.S.)
| | - Cezar Staniloae
- Division of Cardiology, NYU Grossman School of Medicine (H.I., C.S., M.R.W., B.S.)
| | - Prakriti Gaba
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, NY (P.G., M.F., M.B.L.)
| | - Alejandro Lemor
- Department of Medicine, Division of Cardiology, Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI (P.A.V., C.-y.S., M.H.E., D.D.W., T.M.F., J.C.L., G.K., A.L., W.W.O.)
| | - Matthew Finn
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, NY (P.G., M.F., M.B.L.)
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN (H.R.)
| | - Mathew R Williams
- Division of Cardiology, NYU Grossman School of Medicine (H.I., C.S., M.R.W., B.S.)
| | - Martin B Leon
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, NY (P.G., M.F., M.B.L.).,Cardiovascular Research Foundation, New York, NY (M.B.L.)
| | - William W O'Neill
- Department of Medicine, Division of Cardiology, Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI (P.A.V., C.-y.S., M.H.E., D.D.W., T.M.F., J.C.L., G.K., A.L., W.W.O.)
| | - Binita Shah
- Division of Cardiology, NYU Grossman School of Medicine (H.I., C.S., M.R.W., B.S.).,Division of Cardiology, VA New York Harbor Healthcare System (B.S.)
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Data quality methods through remote source data verification auditing: results from the Congenital Cardiac Research Collaborative. Cardiol Young 2021; 31:1829-1834. [PMID: 33726868 DOI: 10.1017/s1047951121000974] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Multicentre research databases can provide insights into healthcare processes to improve outcomes and make practice recommendations for novel approaches. Effective audits can establish a framework for reporting research efforts, ensuring accurate reporting, and spearheading quality improvement. Although a variety of data auditing models and standards exist, barriers to effective auditing including costs, regulatory requirements, travel, and design complexity must be considered. MATERIALS AND METHODS The Congenital Cardiac Research Collaborative conducted a virtual data training initiative and remote source data verification audit on a retrospective multicentre dataset. CCRC investigators across nine institutions were trained to extract and enter data into a robust dataset on patients with tetralogy of Fallot who required neonatal intervention. Centres provided de-identified source files for a randomised 10% patient sample audit. Key auditing variables, discrepancy types, and severity levels were analysed across two study groups, primary repair and staged repair. RESULTS Of the total 572 study patients, data from 58 patients (31 staged repairs and 27 primary repairs) were source data verified. Amongst the 1790 variables audited, 45 discrepancies were discovered, resulting in an overall accuracy rate of 97.5%. High accuracy rates were consistent across all CCRC institutions ranging from 94.6% to 99.4% and were reported for both minor (1.5%) and major discrepancies type classifications (1.1%). CONCLUSION Findings indicate that implementing a virtual multicentre training initiative and remote source data verification audit can identify data quality concerns and produce a reliable, high-quality dataset. Remote auditing capacity is especially important during the current COVID-19 pandemic.
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Hsu JC, Reynolds MR, Song Y, Doros G, Lubitz SA, Gehi AK, Turakhia MP, Maddox TM. Outpatient Prescription Practices in Patients with Atrial Fibrillation (From the NCDR PINNACLE Registry). Am J Cardiol 2021; 155:32-39. [PMID: 34284863 DOI: 10.1016/j.amjcard.2021.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 06/02/2021] [Accepted: 06/14/2021] [Indexed: 12/01/2022]
Abstract
This study sought to evaluate inappropriate prescribing practices in an atrial fibrillation (AF) population, as outlined by the 2016 ACC/AHA Clinical Performance and Quality Measures for Adults with Atrial Fibrillation or Atrial Flutter document. The 2016 AF quality measures document specified medications to avoid in certain AF populations, including aspirin and anticoagulant combination therapy in patients without cardiovascular disease, and non-dihydropyridine calcium channel blockers in patients with reduced ejection fraction. Using data from the NCDR PINNACLE registry, a national outpatient cardiology practice registry, we assessed rates of inappropriate prescription of two types of medications among AF outpatients from 5/1/2008-5/1/2016. Overall rates of inappropriate prescription and variation by practice were calculated. Patient and practice factors associated with inappropriate prescription were assessed in adjusted analyses. A total of 107,759 of 658,250 (16.4%) patients without cardiovascular disease were inappropriately prescribed an antiplatelet and anticoagulant together, and 5,731 of 150,079 (3.8%) patients with reduced ejection fraction were inappropriately prescribed a non-dihydropyridine calcium channel blocker. Overall, 14.8% of AF patients were prescribed medications that were not recommended. Both patient and practice factors were associated with inappropriate prescribing, and the adjusted practice-level median odds ratio for inappropriate prescription was 1.70 (95% CI: 1.61-1.82), indicating a 70% likelihood that 2 random practices would treat identical AF patients differently. In a large registry of AF patients treated in cardiology practices, overall rates of inappropriate prescription practices, as defined by the 2016 AF quality measures, were relatively low, but significant practice variation was present.
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Affiliation(s)
- Jonathan C Hsu
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Diego, San Diego, California.
| | | | - Yang Song
- Baim Institute for Clinical Research, Boston, Massachusetts
| | - Gheorghe Doros
- Baim Institute for Clinical Research, Boston, Massachusetts
| | - Steven A Lubitz
- Cardiac Arrhythmia Service and Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Anil K Gehi
- University of North Carolina, Chapel Hill, North Carolina
| | - Mintu P Turakhia
- VA Palo Alto Health Care Syste, Palo Alto, CA; Center for Digital Health; Stanford University School of Medicine, Stanford, California
| | - Thomas M Maddox
- Healthcare Innovation Lab, BJC HealthCare/Washington University School of Medicine; Division of Cardiology, Washington University School of Medicine, St. Louis, Missouri
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50
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Daimee UA, Aslam F, Parzynski CS, Desai NR, Curtis JP. Longitudinal Outcomes Associated With Non-Evidence-Based Implantable Cardioverter-Defibrillators Among Medicare Beneficiaries (From the National Cardiovascular Data Registry). Am J Cardiol 2021; 155:64-71. [PMID: 34315569 DOI: 10.1016/j.amjcard.2021.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/04/2021] [Accepted: 06/14/2021] [Indexed: 11/19/2022]
Abstract
Primary prevention implantable cardioverter-defibrillators (ICDs) in patients with recent myocardial infarction or coronary revascularization and those with newly diagnosed or severe heart failure (HF) are considered non-evidence-based, as defined by pivotal randomized clinical trials. Although non-evidence-based ICDs have been associated previously with greater risk of in-hospital adverse events, longitudinal outcomes are not known. We used Medicare-linked data from the National Cardiovascular Data Registry's ICD Registry to identify patients discharged alive following first-time primary prevention ICD implantations performed between 2010 and 2013. We compared longitudinal outcomes, including all-cause mortality and all-cause hospital readmission among patients receiving non-evidence-based versus evidence-based ICDs, up to 4.75 years after implantation, using multivariable time-to-event analyses. Of 71,666 ICD implantations, 9,609 (13.4%) were classified as non-evidence-based. Compared to patients receiving evidence-based ICDs, non-evidence-based ICD recipients had greater mortality risk at 90 days (HR = 1.44, CI: 1.37 - 1.52, p <0.0001) and at 1 year (HR = 1.19, CI: 1.15 - 1.24, p <0.0001), but similar mortality risk at 3 years (HR = 1.03, CI: 0.98 - 1.08, p = 0.2630). Risk of all-cause hospitalization was higher in patients with non-evidence-based ICDs at 90 days (HR = 1.17, CI: 1.14 - 1.20, p <0.0001), but the difference diminished at 1 year (HR = 1.04, CI 1.00 - 1.07, p = 0.0272) and at 3 years (HR = 0.94, CI: 0.90 - 0.99, p = 0.0105). In conclusion, among patients undergoing primary prevention ICD implantations between 2010 and 2013, those with non-evidence-based ICDs were at increased risk of mortality and readmission during longitudinal follow-up. Differences in the risk of mortality and hospitalization were highest in the first year following device implantation.
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Affiliation(s)
- Usama A Daimee
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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