Showing papers in "Circulation-cardiovascular Quality and Outcomes in 2010"
TL;DR: In this paper, the authors evaluated the strength of associations between out-of-hospital cardiac arrest and key factors (event witnessed by a bystander or emergency medical services [EMS], provision of bystander cardiopulmonary resuscitation [CPR], initial cardiac rhythm, or the return of spontaneous circulation) and examined trends in OHCA survival over time.
Abstract: Background— Prior studies have identified key predictors of out-of-hospital cardiac arrest (OHCA), but differences exist in the magnitude of these findings In this meta-analysis, we evaluated the strength of associations between OHCA and key factors (event witnessed by a bystander or emergency medical services [EMS], provision of bystander cardiopulmonary resuscitation [CPR], initial cardiac rhythm, or the return of spontaneous circulation) We also examined trends in OHCA survival over time Methods and Results— An electronic search of PubMed, EMBASE, Web of Science, CINAHL, Cochrane DSR, DARE, ACP Journal Club, and CCTR was conducted (January 1, 1950 to August 21, 2008) for studies reporting OHCA of presumed cardiac etiology in adults Data were extracted from 79 studies involving 142 740 patients The pooled survival rate to hospital admission was 238% (95% CI, 211 to 266) and to hospital discharge was 76% (95% CI, 67 to 84) Stratified by baseline rates, survival to hospital discharge was more
1,584 citations
TL;DR: The GWTG-HF risk score provides clinicians with a validated tool for risk stratification that is applicable to a broad spectrum of patients with heart failure, including those with preserved left ventricular systolic function.
Abstract: Background— Effective risk stratification can inform clinical decision-making. Our objective was to derive and validate a risk score for in-hospital mortality in patients hospitalized with heart fa...
401 citations
TL;DR: Enrollment of women in randomized clinical trials has increased over time but remains low relative to their overall representation in disease populations, and efforts are needed to reach a level of representation that is adequate to ensure evidence-based sex-specific recommendations.
Abstract: Background— The 2007 American Heart Association guidelines for cardiovascular disease prevention in women drew heavily on results from randomized clinical trials; however, representation of women in trials of cardiovascular disease prevention has not been systematically assessed. Methods and Results— We abstracted 156 randomized clinical trials cited by the 2007 women’s prevention guidelines to determine female representation over time and by clinical indication, prevention type, location of trial conduct, and funding source. Both women and men were represented in 135 of 156 (86.5%) trials; 20 trials enrolled only men; 1 enrolled only women. Among all trials, the proportion of women increased significantly over time, from 9% in 1970 to 41% in 2006. Considering only trials that enrolled both women and men, female enrollment was 18% in 1970 and increased to 34% in 2006. Female representation was higher in international versus United States–only trials (32.7% versus 26.7%) and primary versus secondary preven...
387 citations
TL;DR: Higher patient satisfaction is associated with improved guideline adherence and lower inpatient mortality rates, suggesting that patients' satisfaction with their care provides important incremental information on the quality of acute myocardial infarction care.
Abstract: Background—Hospitals use patient satisfaction surveys to assess their quality of care. A key question is whether these data provide valid information about the medically related quality of hospital care. The objective of this study was to determine whether patient satisfaction is associated with adherence to practice guidelines and outcomes for acute myocardial infarction and to identify the key drivers of patient satisfaction. Methods and Results—We examined clinical data on 6467 patients with acute myocardial infarction treated at 25 US hospitals participating in the CRUSADE initiative from 2001 to 2006. Press Ganey patient satisfaction surveys for cardiac admissions were also available from 3562 patients treated at these same 25 centers over this period. Patient satisfaction was positively correlated with 13 of 14 acute myocardial infarction performance measures. After controlling for a hospital’s overall guideline adherence score, higher patient satisfaction scores were associated with lower risk-adjusted inpatient mortality (P0.025). One-quartile changes in both patient satisfaction and guideline adherence scores produced similar changes in predicted survival. For example, a 1-quartile change (75th to 100th) in either the patient satisfaction score or the guideline adherence score yielded the same change in predicted survival (odds ratio, 1.24; 95% CI, 1.02 to 1.49; and odds ratio, 1.24; 95% CI, 1.08 to 1.41, respectively). Satisfaction with nursing care was the most important determinant of overall patient satisfaction (P0.001). Conclusions—Higher patient satisfaction is associated with improved guideline adherence and lower inpatient mortality rates, suggesting that patients are good discriminators of the type of care they receive. Thus, patients’ satisfaction with their care provides important incremental information on the quality of acute myocardial infarction care. (Circ Cardiovasc Qual Outcomes. 2010;3:188-195.)
360 citations
TL;DR: Aging and population growth will increase cardiovascular disease by more than a half over the coming 20 years, and projected unfavorable trends in blood pressure, total cholesterol, diabetes, and body mass index may accelerate the epidemic.
Abstract: Background— The relative effects of individual and combined risk factor trends on future cardiovascular disease in China have not been quantified in detail.
Methods and Results— Future risk factor trends in China were projected based on prior trends. Cardiovascular disease (coronary heart disease and stroke) in adults ages 35 to 84 years was projected from 2010 to 2030 using the Coronary Heart Disease Policy Model–China, a Markov computer simulation model. With risk factor levels held constant, projected annual cardiovascular events increased by >50% between 2010 and 2030 based on population aging and growth alone. Projected trends in blood pressure, total cholesterol, diabetes (increases), and active smoking (decline) would increase annual cardiovascular disease events by an additional 23%, an increase of approximately 21.3 million cardiovascular events and 7.7 million cardiovascular deaths over 2010 to 2030. Aggressively reducing active smoking in Chinese men to 20% prevalence in 2020 and 10% prevalence in 2030 or reducing mean systolic blood pressure by 3.8 mm Hg in men and women would counteract adverse trends in other risk factors by preventing cardiovascular events and 2.9 to 5.7 million total deaths over 2 decades.
Conclusions— Aging and population growth will increase cardiovascular disease by more than a half over the coming 20 years, and projected unfavorable trends in blood pressure, total cholesterol, diabetes, and body mass index may accelerate the epidemic. National policy aimed at controlling blood pressure, smoking, and other risk factors would counteract the expected future cardiovascular disease epidemic in China.
Received September 21, 2009; accepted March 15, 2010.
355 citations
TL;DR: Awareness of CVD as the leading cause of death among women has nearly doubled since 1997 but is stabilizing and continues to lag in racial/ethnic minorities.
Abstract: Background— Awareness of cardiovascular disease (CVD) risk has been linked to taking preventive action in women. The purpose of this study was to assess contemporary awareness of CVD risk and barriers to prevention in a nationally representative sample of women and to evaluate trends since 1997 from similar triennial surveys. Methods and Results— A standardized survey about awareness of CVD risk was completed in 2009 by 1142 women ≥25 years of age, contacted through random digit dialing oversampled for racial/ethnic minorities, and by 1158 women contacted online. There was a significant increase in the proportion of women aware that CVD is the leading cause of death since 1997 (P for trend=<0.0001). Awareness among telephone participants was greater in 2009 compared with 1997 (54% versus 30%, P<0.0001) but not different from 2006 (57%). In multivariate analysis, African American and Hispanic women were significantly less aware than white women, although the gap has narrowed since 1997. Only 53% of women s...
332 citations
TL;DR: With more than 1 million patients enrolled, GWTG-Stroke represents an integrated stroke and TIA registry that supports national surveillance, innovative research, and sustained quality improvement efforts facilitating evidence-based stroke/TIA care.
Abstract: Background— Stroke results in substantial death and disability. To address this burden, Get With The Guideline (GWTG)-Stroke was developed to facilitate the measurement, tracking, and improvement in quality of care and outcomes for acute stroke and transient ischemic attack (TIA) patients in the United States. Methods and Results— We analyzed the characteristics, performance measures, and in-hospital outcomes in the first 1 000 000 acute ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and TIA admissions from 1392 hospitals that participated in the GWTG-Stroke Program 2003 to 2009. Patients were 53.5% women, 73.3% white, and with mean age of 70.1±14.9 years. There were 601 599 (60.2%) ischemic strokes, 108 671 (10.9%) intracerebral hemorrhages, 34 945 (3.5%) subarachnoid hemorrhages, 26 977 (2.7%) strokes not classified, and 227 788 (22.8%) TIAs. Performance measures showed small to moderate differences by cerebrovascular event type. In-hospital mortality rate was highest among intracer...
300 citations
TL;DR: The authors provided a reliable estimate of the prognostic risk associated with Type D (distressed) personality, a general propensity to distress that is defined by high scores on the "negative affectivity" and "social inhibition" traits.
Abstract: Evidence Specific negative emotions have been related to adverse cardiac events, but a general propensity to psychological distress may also affect cardiovascular outcomes. In this summary article, we provide a reliable estimate of the prognostic risk associated with Type D (distressed) personality, a general propensity to distress that is defined by high scores on the “negative affectivity” and “social inhibition” traits. Quantitative analyses of prospective studies that included a total of 6121 patients with a cardiovascular condition indicated that Type D personality was associated with a more than 3-fold increased risk of adverse events (9 studies) and long-term psychological distress (11 studies). In addition, a narrative review of 29 studies showed that Type D personality and depression are distinct manifestations of psychological distress, with different and independent cardiovascular effects. There are also plausible biological and behavioral pathways that may explain this adverse effect of Type D personality. The findings reported in this summary article support the simultaneous use of specific and general measures of distress in cardiovascular research and practice.
Depression, anxiety, anger, and posttraumatic stress are specific markers of distress that have been related to cardiac disorder,1,–,5 whereas broader markers of psychological distress have received substantially less attention in cardiovascular research.6 However, the general distress shared across these specific markers may predict the development of coronary heart disease1 and may also partly account for the association of depression and anxiety with myocardial infarction,3 poor cardiac prognosis,4 and autonomic cardiac dysregulation.7 Hence, the conceptual idea of psychological distress as a cardiovascular risk marker may be broadened to include a general propensity to distress.
Many studies report on depression, anxiety, and cardiovascular outcomes.2,–,4 Although patients may go in and out of depressive and anxious episodes, there …
270 citations
TL;DR: Multiple imputation is focused on, in which missing cases are first filled in by several sets of plausible values to create multiple completed datasets, then standard complete-data procedures are applied to each completed dataset, and finally the multiple sets of results are combined to yield a single inference.
Abstract: Missing data are a pervasive problem in health investigations. We describe some background of missing data analysis and criticize ad hoc methods that are prone to serious problems. We then focus on multiple imputation, in which missing cases are first filled in by several sets of plausible values to create multiple completed datasets, then standard complete-data procedures are applied to each completed dataset, and finally the multiple sets of results are combined to yield a single inference. We introduce the basic concepts and general methodology and provide some guidance for application. For illustration, we use a study assessing the effect of cardiovascular diseases on hospice discussion for late stage lung cancer patients.
242 citations
TL;DR: Successful CTO recanalization is associated with significant early improvements in patient symptoms, function, and QoL but only among symptomatic patients.
Abstract: Background Data on the health status benefits of percutaneous coronary intervention for coronary chronic total occlusions (CTOs), a principal indication for the procedure, are lacking.
Methods and Results In the FlowCardia Approach to CTO Recanalization (FACTOR) trial, patients (n=125) completed the Seattle Angina Questionnaire (SAQ) at baseline and 1 month after percutaneous coronary intervenion. One-month health status outcomes were compared by multivariable analysis, adjusting for group differences between those whose CTO was successfully and unsuccessfully recanalized. These changes were also analyzed according to baseline symptoms. Procedural success was 55% (n=64) and independently associated with angina relief (difference between those with successful and unsuccessful percutaneous coronary intervention [Δ] in SAQ angina frequency=9.5 points; 95% confidence interval, 1.6 to 17.5; P =0.019), improved physical function (Δ in SAQ physical limitation=13.1 points; 95% confidence interval, 5.1 to 21.1; P =0.001), and enhanced quality of life (Δ in SAQ quality of life [QoL]=20.3 points; 95% confidence interval, 11.9 to 28.6; P <0.001). The benefit of successful percutaneous coronary intervention was greatest in symptomatic patients as compared with asymptomatic patients although statistically significantly so only for QoL (ΔSAQ angina frequency domain=10.3 versus 4.3 points, P =0.51, Δphysical limitation =15.9 versus 6.3 points, P =0.25; ΔQoL=27.3 versus 8.5 points, P =0.047).
Conclusions Successful CTO recanalization is associated with significant early improvements in patient symptoms, function, and QoL but only among symptomatic patients. Percutaneous treatment of a CTO offers the potential to provide significant health status benefits in symptomatic patients.
216 citations
TL;DR: Recurring hospitalizations and repeat revascularization procedures suggest that neither patients, physicians, nor healthcare systems should assume that a first admission for a lower-extremity PAD procedure serves as a permanent resolution of this costly and debilitating condition.
Abstract: Background—Peripheral artery disease (PAD) is common and imposes a high risk of major systemic and limb ischemic events. The REduction of Atherothrombosis for Continued Health (REACH) Registry is an international prospective registry of patients at risk of atherothrombosis caused by established arterial disease or the presence of ≥3 atherothrombotic risk factors. Methods and Results—We compared the 2-year rates of vascular-related hospitalizations and associated costs in US patients with established PAD across patient subgroups. Symptomatic PAD at enrollment was identified on the basis of current intermittent claudication with an ankle-brachial index (ABI) <0.90 or a history of lower-limb revascularization or amputation. Asymptomatic PAD was diagnosed on the basis of an enrollment ABI <0.90 in the absence of symptoms. Overall, 25 763 of the total 68 236–patient REACH cohort were enrolled from US sites; 2396 (9.3%) had symptomatic and 213 (0.8%) had asymptomatic PAD at baseline. One- and cumulative 2-year ...
TL;DR: The elderly and women were more likely to exhibit longer delays in seeking medical care after the development of symptoms suggestive of AMI compared with other groups, and further research is needed to more fully understand the reasons for delay in these vulnerable groups.
Abstract: Background— Coronary heart disease is the leading cause of morbidity and mortality in American men and women. Although there have been dramatic changes in the management of patients hospitalized with acute myocardial infarction (AMI) over the past several decades, a considerable proportion of patients with AMI continue to delay seeking medical care in a timely manner. This review provides an overview of the published literature that has examined age and sex differences in extent of prehospital delay in patients hospitalized with AMI. Methods and Results— A systematic review of the literature from 1960 to 2008, including publications that provided data on duration of prehospital delay in patients hospitalized with AMI, was conducted. A total of 44 articles (42 studies) were included in the present analysis. The majority of studies showed that in patients hospitalized with AMI, women and older persons were more likely to arrive at the hospital later than men and younger persons. Several factors associated w...
TL;DR: HF exerts a major health burden in respect to age-adjusted rates of first hospitalization, poor overall survival, and premature life-years lost, like most common forms of cancer combined.
Abstract: BACKGROUND: The contemporary impact of heart failure (HF) versus the most common forms of cancer as reflected by related first-ever hospitalizations and subsequent case-fatality rates is unknown. METHODS AND RESULTS: Using a national registry in Sweden, we compared the rate of first-ever hospitalization and associated short- and long-term survival for HF, acute myocardial infarction (AMI), and the most common forms of cancer on an age and sex-specific basis during 1988 to 2004 in 949 733 Swedish patients (1 162 309 hospital admissions in total). Annual incidence of first-ever hospitalization for HF, AMI, and cancer in Sweden were 484, 424, and 373 (lung, colorectal, prostate, and bladder cancer combined) per 100 000 men and 470, 280, and 350 (lung, colorectal, bladder, breast, and ovarian cancer combined) per 100 000 women age >20 years. The ratio of individual cases of HF to cancer was 1.37:1 (465 998 versus 340 738). Despite improvements in 30-day and 5-year survival (adjusted 7% and 6% increase per calendar year for men and women, respectively), HF was associated with unadjusted case-fatality rate of 59% within 5 years and 196 400 deaths versus 58% and 131 000 deaths in patients with cancer. During 10-year follow-up, HF was associated with 66 318 versus 55 364 premature life-years lost than all common forms of cancer in men. In women, the equivalent figures were 59 535 versus 64 533 premature life-years lost. CONCLUSIONS: These data confirm that, like most common forms of cancer combined, HF exerts a major health burden in respect to age-adjusted rates of first hospitalization, poor overall survival, and premature life-years lost.
TL;DR: More than 1 in 4 patients newly starting warfarin for atrial fibrillation discontinued therapy in the first year despite a low overall hemorrhage rate, indicating which patients are most appropriately initiated and maintained on therapy.
Abstract: Background—Although warfarin is widely recommended to prevent atrial fibrillation-related thromboembolism, many eligible patients do not take warfarin. The objective of this study was to describe factors associated with warfarin discontinuation in patients newly starting warfarin for atrial fibrillation. Methods and Results—We identified 4188 subjects newly starting warfarin in the Anticoagulation and Risk Factors in Atrial Fibrillation Study and tracked longitudinal warfarin use through pharmacy and laboratory databases. Data on patient characteristics, international normalized ratio (INR) tests, and incident hospitalizations for hemorrhage were obtained from clinical and laboratory databases. Multivariable Cox regression analysis was used to identify independent predictors of prolonged warfarin discontinuation, defined as ≥180 consecutive days off warfarin. Within 1 year after warfarin initiation, 26.3% of subjects discontinued therapy despite few hospitalizations for hemorrhage (2.3% of patients). The ...
TL;DR: The results provide support for use of a stepwise stratification system aimed at improving risk communication, and they provide a baseline for public health efforts aimed at increasing the proportion of Americans with low short-term and low lifetime risk for cardiovascular disease.
Abstract: Background— National guidelines for primary prevention suggest consideration of lifetime risk for cardiovascular disease in addition to 10-year risk, but it is currently unknown how many US adults would be identified as having low short-term but high lifetime predicted risk if stepwise stratification were used. Methods and Results— We included 6329 cardiovascular disease–free and nonpregnant individuals ages 20 to 79 years, representing approximately 156 million US adults, from the National Health and Nutrition Examination Survey 2003 to 2004 and 2005 to 2006. We assigned 10-year and lifetime predicted risks to stratify participants into 3 groups: low 10-year (<10%)/low lifetime (<39%) predicted risk, low 10-year (<10%)/high lifetime (≥39%) predicted risk, and high 10-year (≥10%) predicted risk or diagnosed diabetes. The majority of US adults (56%, or 87 million individuals) are at low short-term but high lifetime predicted risk for cardiovascular disease. Twenty-six percent (41 million adults) are at low...
TL;DR: High RSRs persist for AMI and HF and clinically meaningful variation exists for RSMRs and RSRRs for both conditions and the results suggest continued opportunities for improvement in patient outcomes for HF and AMI.
Abstract: Background—Patient outcomes provide a critical perspective on quality of care. The Centers for Medicare and Medicaid Services (CMS) is publicly reporting hospital 30-day risk-standardized mortality rates (RSMRs) and risk-standardized readmission rates (RSRRs) for patients hospitalized with acute myocardial infarction (AMI) and heart failure (HF). We provide a national perspective on hospital performance for the 2010 release of these measures. Methods and Results—The hospital RSMRs and RSRRs are calculated from Medicare claims data for fee-for-service Medicare beneficiaries, 65 years or older, hospitalized with AMI or HF between July 1, 2006, and June 30, 2009. The rates are calculated using hierarchical logistic modeling to account for patient clustering, and are risk-adjusted for age, sex, and patient comorbidities. The median RSMR for AMI was 16.0% and for HF was 10.8%. Both measures had a wide range of hospital performance with an absolute 5.2% difference between hospitals in the 5th versus 95th percen...
TL;DR: Individual NSAIDs have different degrees of cardiovascular safety, which must be considered when choosing appropriate treatment, and the results suggest that naproxen has a safer cardiovascular risk-profile.
Abstract: Background—Studies have raised concern on the cardiovascular safety of nonsteroidal antiinflammatory drugs (NSAIDs). We studied safety of NSAID therapy in a nationwide cohort of healthy individuals. Methods and Results—With the use of individual-level linkage of nationwide administrative registers, we identified a cohort of individuals without hospitalizations 5 years before first prescription claim of NSAIDs and without claimed drug prescriptions for selected concomitant medication 2 years previously. The risk of cardiovascular death, a composite of coronary death or nonfatal myocardial infarction, and fatal or nonfatal stroke associated with the use of NSAIDs was estimated by case-crossover and Cox proportional hazard analyses. The entire Danish population age 10 years or more consisted of 4 614 807 individuals on January 1, 1997, of which 2 663 706 (57.8%) claimed at least 1 prescription for NSAIDs during 1997 to 2005. Of these; 1 028 437 individuals were included in the study after applying selection ...
TL;DR: For second-line therapy of paroxysmal AF, ablation is superior to AAD treatment at improving symptoms and QOL, and recurrent arrhythmias most strongly correlated with QOL changes over time.
Abstract: Background—In patients with paroxysmal atrial fibrillation (AF), catheter ablation maintains sinus rhythm more effectively than antiarrhythmic drugs (AADs), but its effect on symptoms and quality of life (QOL) has not been fully characterized. Methods and Results—We evaluated symptoms and QOL in a multicenter, randomized trial comparing catheter ablation with AADs as second-line treatment for patients with paroxysmal AF. The Short Form (SF)-36 health survey and the AF Symptom Checklist were administered at baseline and 3, 6, and 9 months after a blanking or dose-titration period. The primary between-group comparisons were conducted at 3 months because of permitted crossover from AAD to ablation beyond this time. Additional analyses based on subsequent follow-up were performed, including the construction of mixed linear regression models to assess the impact of multiple factors on follow-up QOL scores.At baseline in both the ablation (n=103) and the AAD (n=56) groups, 7 of 8 SF-36 scales were well below po...
TL;DR: Frequent exposure to tobacco smoke is independently associated with arterial changes of preclinical atherosclerosis and increased ApoB levels among healthy adolescents.
Abstract: Background— Exposure to tobacco smoke is associated with markers of preclinical atherosclerosis in adults, but its effect on arterial structure in adolescents is unknown. Methods and Results— Healthy 13-year-old adolescents from the atherosclerosis prevention trial STRIP were studied. Maximum carotid and aortic intima-media thickness and brachial artery flow-mediated dilation were measured in 494 adolescents using high-resolution ultrasound. Serum lipid, lipoprotein, and apolipoprotein (Apo) A-I and B concentrations were determined using standard methods. Exposure to tobacco smoke was measured annually between ages 8 and 13 years using serum cotinine concentrations, analyzed with gas chromatography. To define longitudinal exposure, cotinine values of children having serum cotinine measured 2 to 6 times during follow-up were averaged and divided into tertiles (exposure groups): low (n=160), intermediate (n=171), and high (n=163). Adolescents with higher longitudinal exposure to tobacco smoke had increased ...
TL;DR: Cognitive dysfunction is common in elderly patients with atrial fibrillation and is related to less effective anticoagulation and more vascular events, suggesting that if improved anticogeulation was provided, vascular events and bleeding would be reduced.
Abstract: Background— Patients with atrial fibrillation usually are elderly and may have cognitive dysfunction These patients may receive less effective oral anticoagulation, resulting in more vascular events and bleeding Methods and Results— In an analysis of cognitive function associated with the time in therapeutic range (TTR) in the Atrial Fibrillation Clopidogrel Trial With Irbesartan for Prevention of Vascular Events, 2510 patients (mean age, 71±95 years) from 27 countries completed the Mini-Mental State Examination (MMSE) Of these patients, 171 (68%) had an MMSE score <24, suggesting dementia, and 194 (77%) had intermediate scores of 24 to 25 Low MMSE scores were correlated with a low TTR Even mild cognitive impairment was associated with a TTR below the median (<65%) Patients with an MMSE score <26 had more vascular events (67% versus 36% per 100 patient-years; P=0002) and more bleeding (96% versus 7% per 100 patient-years; P=004) After controlling for TTR, the MMSE no longer conferred increa
TL;DR: Postdischarge mortality of patients with acute myocardial infarction is increasing, primarily because of higher noncardiovascular mortality in the older age groups, especially from respiratory and renal diseases, septicemia, and cancer.
Abstract: Background—We assessed trends in the prognosis of patients with acute myocardial infarction hospitalized in New Jersey hospitals. In recent decades, in-hospital mortality has declined markedly but the decline in longer-term mortality is less pronounced, implying that mortality after discharge has worsened. Methods and Results—Using the Myocardial Infarction Data Acquisition System (MIDAS), we examined the outcomes of 285 397 patients hospitalized for a first acute myocardial infarction between 1986 and 2007. Mortality at discharge decreased by 9.4% from 16.9% to 7.5% (annual change, −0.44; 95% confidence interval, −0.49 to −0.40), but the decrease at 1 year was less pronounced (6.4%) because of an increase in mortality from discharge to 1 year after discharge (from 12.1% to 13.9%; annual change, +0.15; 95% confidence interval, +0.10 to +0.20). Mortality from 30 days after discharge to 1 year, a measure not affected by length of stay, increased by 1.2% (annual change, +0.10; 95% confidence interval, +0.06 ...
TL;DR: The DASH diet should substantially reduce the risk of CHD, and with the exception of an interaction between dietary pattern and race suggesting a greater risk reduction in blacks than whites, results were similar across subgroups.
Abstract: Background—The Dietary Approaches to Stop Hypertension (DASH) diet is recommended in the 2005 US Dietary Guidelines. To understand the potential benefits of DASH on coronary heart disease (CHD), we applied the Framingham risk equations to calculate 10-year risk of developing CHD using data from the DASH trial. Methods and Results—In the DASH trial, 459 individuals with prehypertension or stage-1 hypertension not taking antihypertensive medication were randomly assigned to 1 of 3 diets: control, fruits and vegetables (F/V), or DASH (rich in fruits, vegetables, low-fat dairy, and reduced in fats and cholesterol). Weight was held constant. Estimated 10-year CHD risk was the primary outcome of this secondary analysis. Among 436 participants with complete data, mean (SD) age was 44.7 (10.7) years, 51% were male, and 60% were African-American. Median 10-year CHD risk was 0.98% at baseline and decreased in all groups. Compared with control, the relative risk ratio comparing 8-week with baseline 10-year CHD risk ...
TL;DR: Low HbA1c was associated with increased all-cause mortality among US adults without diabetes and remained statistically significant after further multivariable adjustment for lifestyle, cardiovascular factors, metabolic factors, red blood cell indices, iron storage indices, and liver function indices.
Abstract: Background—Among individuals without diabetes, elevated hemoglobin A1c (HbA1c) has been associated with increased morbidity and mortality, but the literature is sparse regarding the prognostic impo...
TL;DR: VIRGO is a large, observational study of the presentation, treatment, and outcomes of young women and men with AMI to determine sex differences in the distribution and prognostic importance of biological, demographic, clinical, and psychosocial risk factors.
Abstract: Background—Among individuals with ischemic heart disease, young women with an acute myocardial infarction (AMI) represent an extreme phenotype associated with an excess mortality risk. Although women younger than 55 years of age account for less than 5% of hospitalized AMI events, almost 16 000 deaths are reported annually in this group, making heart disease a leading killer of young women. Despite a higher risk of mortality compared with similarly aged men, young women have been the subject of few studies. Methods and Results—Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) is a large, observational study of the presentation, treatment, and outcomes of young women and men with AMI. VIRGO will enroll 2000 women, 18 to 55 years of age, with AMI and a comparison cohort of 1000 men with AMI from more than 100 participating hospitals. The aims of the study are to determine sex differences in the distribution and prognostic importance of biological, demographic, clinical, and psy...
TL;DR: Results suggest that equalizing patients' health beliefs, medication adherence, and experiences with care could ameliorate disparities in BP control and additional attention must focus on the factors associated with race to identify, and ultimately intervene on, the causes of racial disparities inBP outcomes.
Abstract: Background— Racial disparities in blood pressure (BP) control are well documented but poorly understood; prior studies have only included a limited range of potential explanatory factors. We examined a comprehensive set of putative factors related to blood pressure control, including patient clinical and sociodemographic characteristics, beliefs about BP and BP medications, medication adherence, and experiences of discrimination, to determine if the impact of race on BP control remains after accounting for such factors.
Methods and Results— We recruited 806 white and black patients with hypertension from an urban safety-net hospital. From a questionnaire administered to patients after their clinic visits, electronic medical record and BP data, we assessed an array of patient factors. We then examined the association of patient factors with BP control by modeling it as a function of the covariates using random-effects logistic regression. Blacks indicated worse medication adherence, more discrimination, and more concerns about high BP and BP medications, compared with whites. After accounting for all factors, race was no longer a significant predictor of BP control.
Conclusions— Results suggest that equalizing patients’ health beliefs, medication adherence, and experiences with care could ameliorate disparities in BP control. Additional attention must focus on the factors associated with race to identify, and ultimately intervene on, the causes of racial disparities in BP outcomes.
Received March 6, 2009; accepted December 3, 2009.
TL;DR: HAA develops in nearly half of acute myocardial infarction hospitalizations among patients treated medically or with percutaneous coronary intervention, commonly in the absence of documented bleeding, and is associated with worse mortality and health status.
Abstract: Background Anemia is common among patients hospitalized with acute myocardial infarction and is associated with poor outcomes. Less is known about the incidence, correlates, and prognostic implications of acute, hospital-acquired anemia (HAA).
Methods and Results We identified 2909 patients with acute myocardial infarction who had normal hemoglobin (Hgb) on admission in the multicenter TRIUMPH registry and defined HAA by criteria proposed by Beutler and Waalen. We used hierarchical Poisson regression to identify independent correlates of HAA and multivariable proportional hazards regression to identify the association of HAA with mortality and health status. At discharge, 1321 (45.4%) patients had HAA, of whom 348 (26.3%) developed moderate-severe HAA (Hgb <11 g/dL). The incidence of HAA varied significantly across hospitals (range, 33% to 69%; median rate ratio for HAA, 1.13; 95% confidence interval, 1.07 to 1.23, adjusting for patient characteristics). Although documented bleeding was more frequent with more severe HAA, fewer than half of the patients with moderate-severe HAA had any documented bleeding. Independent correlates of HAA included age, female sex, white race, chronic kidney disease, ST-segment elevation myocardial infarction, acute renal failure, use of glycoprotein IIb/IIIa inhibitors, in-hospital complications (cardiogenic shock, bleeding and bleeding severity), and length of stay. After adjustment for GRACE score and bleeding, patients with moderate-severe HAA had higher mortality rates (hazard ratio, 1.82; 95% confidence interval, 1.11 to 2.98 versus no HAA) and poorer health status at 1 year.
Conclusions HAA develops in nearly half of acute myocardial infarction hospitalizations among patients treated medically or with percutaneous coronary intervention, commonly in the absence of documented bleeding, and is associated with worse mortality and health status. Better understanding of how HAA can be prevented and whether its prevention can improve patient outcomes is needed.
TL;DR: Variability in cardiologists' propensity to test and treat partly underlies regional variation in utilization of general health and cardiology services.
Abstract: Background— Regional variation in healthcare utilization, including cardiac testing and procedures, is well documented. Some factors underlying such variation are understood, including resource supply. However, less is known about how physician behaviors and attitudes may influence variation in utilization across regions. Methods and Results— We performed a survey of a national sample of cardiologists using patients vignettes to ascertain physicians’ self-reported propensity to test and treat patients with cardiovascular problems, computing a Cardiac Intensity Score for each physician based on his/her responses intended to measure the physician’s propensity to recommend high-tech and/or invasive tests and treatments. In addition, we asked under what circumstances they would order a cardiac catheterization “for other than purely clinical reasons.” For some survey items, there was substantial variation in physician responses. We found that the Cardiac Intensity Score was associated with 2 measures of popula...
TL;DR: Lower SS is associated with worse health status and more depressive symptoms over the first year of acute myocardial infarction recovery, particularly for women.
Abstract: Background Prior studies have associated low social support (SS) with increased rehospitalization and mortality after acute myocardial infarction. However, relatively little is known about whether similar patterns exist for other outcomes, such as health status and depressive symptoms, and whether these patterns vary by sex. Methods and Results Using data from 2411 English- or Spanish-speaking patients with acute myocardial infarction enrolled in a 19-center prospective study, we examined the association of SS (low, moderate, high) with health status (angina, disease-specific quality of life, general physical and mental functioning) and depressive symptoms over the first year of recovery. Overall and sex-stratified associations were evaluated using mixed-effects Poisson and linear regression, adjusting for site, baseline health status, baseline depressive symptoms, and demographic and clinical factors. Patients with the lowest SS (relative to those with the highest) had increased risk of angina (relative risk, 1.27; 95% confidence interval [CI], 1.10, 1.48); lower disease-specific quality of life (mean difference [β]=−3.33; 95% CI, −5.25, −1.41), lower mental functioning (β=−1.72; 95% CI, −2.65, −0.79), and more depressive symptoms (β=0.94; 95% CI, 0.51, 1.38). A nonsignificant trend toward lower physical functioning (β=−0.87; 95% CI, −1.95, 0.20) was observed. In sex-stratified analyses, the relationship between SS and outcomes was stronger for women than for men, with a significant SS-by-sex interaction for disease-specific quality of life, physical functioning, and depressive symptoms (all P Conclusions Lower SS is associated with worse health status and more depressive symptoms over the first year of acute myocardial infarction recovery, particularly for women.
TL;DR: A careful look at recently published literature reveals only modest advancements toward clarifying sex-based differences in the pathophysiology of ischemic heart disease and sex- based differences in outcome.
Abstract: After at least 2 decades of growing awareness on coronary heart disease in women, we are left with many questions, few answers, and plenty of opinions. Review articles, books, sessions at scientific meetings, and commentaries regarding various aspects of heart disease in women have proliferated. These reports have highlighted important sex differences in the pathophysiology, presentation, and treatment of ischemic heart disease and have denounced pervasive sex-related disparities in referral and treatment for heart disease as a major reason for outcome differences between the sexes. Such activities have been useful in driving attention to heart disease in women, an area largely ignored by the scientific community and the public just 15 to 20 years ago. However, we must recognize that to date, limited data substantiate many of these statements; such recognition is important to guide future research efforts. A careful look at recently published literature reveals only modest advancements toward clarifying sex-based differences in the pathophysiology of ischemic heart disease and sex-based differences in outcome. At the same time, key questions concerning strategies for prevention and treatment of heart disease in women remain unanswered, and cardiovascular clinical trials continue to include fewer women than men.1
A fundamental question is whether the mechanisms underlying ischemic heart disease in women differ from those in men. This is an important question because if pathophysiology differs in women, such differences can inform strategies for prevention, detection, and treatment that would be most effective for women. That pathophysiology may differ in women compared with men is suggested by several factors. First, despite having more symptoms and physical limitations,2,3 women have less obstructive coronary heart disease than men along the entire spectrum of acute coronary syndromes4 and when referred for revascularization.5,6 Second, the syndrome of chest pain without obstructive coronary artery disease …
TL;DR: Patients with nonobstructive CAD were significantly less likely to receive secondary prevention medication prescription at hospital discharge, as compared with patients with obstructive CAD, and this findings highlight an opportunity to improve the quality of care for CAD patients with non obstructive disease.
Abstract: Background— Secondary prevention therapies are indicated for patients with coronary artery disease (CAD). However, patients with nonobstructive CAD may be less likely to receive these therapies compared with patients with obstructive CAD. Therefore, we compared rates of secondary prevention medication prescription between patients with nonobstructive and obstructive CAD.
Methods and Results— We conducted a retrospective cohort study of 1 489 745 CAD patients undergoing cardiac catheterization in 786 US centers between 2004 and 2007. We measured rates of aspirin, statin, β-blocker, and angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB) prescription at hospital discharge among eligible patients; 237 167 (15.9%) patients had nonobstructive CAD and 1 252 578 (84.1%) had obstructive CAD. Compared with obstructive CAD patients, nonobstructive CAD patients had significantly lower rates of rates of aspirin (72.7% versus 90.9%), statin (60.0% versus 80.3%), β-blocker (57.9% versus 79.4%), and ACEI/ARB (45.9% versus 58.6%; all probability values <0.0001) prescription at hospital discharge. After multivariable adjustment, nonobstructive CAD patients remained significantly less likely to receive prescriptions for aspirin (odds ratio, 0.37; 95% confidence interval, 0.35 to 0.39), statins (odds ratio, 0.45; 95% confidence interval, 0.43 to 0.48), β-blockers (odds ratio, 0.46; 95% CI, 0.44 to 0.47), or ACEI/ARBs (odds ratio, 0.83; 95% confidence interval, 0.8 to 0.86) compared with obstructive CAD patients. Secondary analyses of selected subgroups supported the primary findings.
Conclusions— Patients with nonobstructive CAD were significantly less likely to receive secondary prevention medication prescription at hospital discharge, as compared with patients with obstructive CAD. These findings highlight an opportunity to improve the quality of care for CAD patients with nonobstructive disease.