...the implementation and analysis of performance measures are discussed, including the use of composite measures and attribution as the foundation for a continually growing and improving healthcare ...system. New Insights Into the Selection of Possible Performance Measures Abbreviations Used Throughout the Report AMI, acute myocardial infarction CMS, Centers for Medicare and Medicaid Services D2B, American College of Cardiology Foundation Door-to-Balloon Alliance EMRs, electronic medical records ICER, incremental cost-effectiveness ratio INR, international normalized ratio IOM, Institute of Medicine MI, myocardial infarction NCQA, National Committee for Quality Assurance NQF, National Quality Forum PCI, percutaneous coronary intervention PCPI, American Medical Association-Physician Consortium for Performance Improvement Strength of Evidence Initial recommendations for construction of a performance measurement set (1) involved: 1) evaluating the strength of evidence supporting a potential performance measure, 2) defining the clinical significance of the outcome most likely to be achieved by adherence to a performance measure, and 3) assessing the magnitude of the association between adherence to the potential performance measure and a clinically important outcome. Because there can be strong financial incentives for a manufacturer to have its diagnostic or therapeutic products included in a performance measure, a clearly articulated approach to the selection of performance measures is needed.
Ventricular septal myectomy in patients with obstructive hypertrophic cardiomyopathy (HC) has been shown to reduce left ventricular (LV) outflow tract (LVOT) gradient and improve symptoms, although ...little data exist regarding changes in left atrial (LA) volume and LV diastolic function after myectomy. We investigated changes in LA size and LV diastolic function in patients with HC after septal myectomy from 2004 to 2011. We studied 25 patients (age 49.2 ± 13.1 years, 48% women) followed for a mean of 527 days after surgery who had serial echocardiography at baseline and at most recent follow-up, at least 6 months after myectomy. In addition to myectomy, 3 patients (12%) underwent Maze surgery and 13 (52%) underwent mitral valve surgery, of whom 5 had a mitral valve replacement or mitral annuloplasty. Patients with mitral valve replacement or mitral annuloplasty were excluded from LV diastolic function analysis. LA volume index decreased (from 47.2 ± 17.6 to 35.9 ± 17.0 ml/m2 , p = 0.001) and LV diastolic function improved with an increase in lateral e′ velocity (from 7.3 ± 2.9 to 9.8 ± 3.1 cm/sec, p = 0.01) and a decrease in E/e′ (from 14.8 ± 6.3 to 11.7 ± 5.5, p = 0.051). Ventricular septal thickness and LVOT gradient decreased, and symptoms of dyspnea and heart failure improved, with reduction in the New York Heart Association functional class III/IV symptoms from 21 (84%) to 1 (4%). In conclusion, relief of LVOT obstruction in HC by septal myectomy results in improved LV diastolic function and reduction in LA volume with improved symptoms.
Background Transcatheter aortic valve implantation may become a potential treatment for high-risk patients with aortic stenosis (AS). We analyzed our contemporary series of isolated aortic valve ...replacement (AVR) for AS to determine implications for patients referred for AVR. Methods From April 2004 through December 2008, 190 patients (mean age, 68 years; 68% men) underwent isolated AVR for AS. Mean ejection fraction was 0.58. Sixty-one percent underwent minimally invasive AVR and 18% were reoperations. Twenty-one percent were aged 80 years or older, and 34% were in New York Heart Association functional class III-IV. Estimated operative mortality was 3.6%. Results Thirty-day mortality was 0%. One in-hospital death (0.5%) occurred from complications of an esophageal perforation. Reoperation for bleeding occurred in 4.7%. Acute renal failure developed in 2.1%. Actuarial survival was 97% at 1 year and 94% at 3 years. Hospital length of stay was 7.0 days for patients aged 80 and older vs 5.0 days (p < 0.001), and they were less likely to be discharged to home (50% vs 83%, p < 0.001). Conclusions Contemporary results show that AVR for AS can be performed with low operative mortality and morbidity, although patients aged 80 years and older are at increased risk of prolonged recovery. Transcatheter aortic valve implantation may be an alternative for high-risk patients, but AVR is still appropriate for low-risk patients. The low risk of AVR supports the argument that asymptomatic patients who have a high likelihood of progression of AS may be considered for earlier surgical referral.
Intracranial hemorrhage in patients with mechanical heart valves carries a risk of thrombosis and of rehemorrhage. Because interruption of anticoagulation with a mechanical heart valve may lead to ...thrombotic events, cardiologist recommendations generally lean toward minimizing the time off anticoagulation, although valve guidelines do not specifically address the duration of anticoagulation interruption (1,2). ...when anticoagulation is resumed in these patients, there is a risk of recurrent hemorrhage, and longer periods of anticoagulation interruption should, in theory, reduce the risk of rehemorrhage. Because this scenario is rare, the extent of these 2 competing risks is poorly understood.
Objectives The aim of this study was to assess the influence of enrolling site location and enrollment performance on the generalizability of STICH (Surgical Treatment for Ischemic Heart Failure) ...trial results. Background The international STICH trial seeks to define the role of cardiac surgery for patients with ischemic cardiomyopathy. Methods Baseline characteristics of 2,136 randomized STICH patients were entered into a multivariate equation created using the Duke Databank for Cardiovascular Diseases to predict their 5-year risk for death without cardiac surgery. Patients ordered by increasing predicted risk were assigned to 1 of 32 risk at randomization (RAR) groups created to share one-thirty-second of total predicted deaths. Numbers of patients sharing the same RAR group were compared between higher and lower enrolling site groupings and for countries tending to enroll high- or low-risk patients. Results Country of enrollment was a stronger determinant of risk diversity than site enrollment performance among patients enrolled at 127 sites in 26 countries. Mean RAR differences among countries ranged from 9.4 (Singapore) to 18.6 (Germany). However, 1,614 of 2,136 patients (76%) from countries enrolling lower-risk patients shared the same RAR group with patients from countries enrolling higher-risk patients. Baseline characteristics responsible for risk differences of patients enrolled in the 2 country groupings were sufficiently similar to exert little influence on clinical decision making. Conclusions STICH randomized patients are characterized by a continuous spectrum of risk, without discordant dominance from any site or country. Clinical site diversity promises to enhance the generalization of STICH trial results to a broad population of patients with ischemic cardiomyopathy. (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease; NCT00023595 )
Objectives The purpose of this study was to characterize the relationship between heart rate and post-discharge outcomes in patients with hospitalization for heart failure (HHF) with reduced ejection ...fraction (EF) in sinus rhythm. Background A reduction in heart rate improves clinical outcomes in patients with chronic heart failure and in sinus rhythm, but the association between heart rate and post-discharge outcomes in patients with HHF is presently unclear. Methods This post-hoc analysis of the EVEREST (Efficacy of Vasopressin Antagonism in Heart Failure: Outcome Study With Tolvaptan) trial examined 1,947 patients with HHF and EF ≤40% not in atrial fibrillation/flutter or pacemaker dependent. Results The median follow-up period was 9.9 months. At baseline, patients with a higher heart rate tended to be younger with lower EF and were more likely to have worse New York Heart Association functional class and higher natriuretic peptide levels. After adjustment for clinical risk factors, baseline heart rate was not predictive of all-cause mortality (p ≥ 0.066). However, at ≥70 beats/min, every 5-beat increase in 1-week post-discharge heart rate was independently associated with increased all-cause mortality (hazard ratio: 1.13 95% confidence interval: 1.05 to 1.22; p = 0.002). Similarly, every 5-beat increase ≥70 beats/min in 4-week post-discharge heart rate was predictive of all-cause mortality (hazard ratio: 1.12 95% confidence interval: 1.05 to 1.19; p = 0.001). Conclusions In this large cohort of patients with HHF with reduced EF and in sinus rhythm, baseline heart rate did not correlate with all-cause mortality. In contrast, at ≥70 beats/min, higher heart rate in the early post-discharge period was independently predictive of death during subsequent follow-up. Further study of post-discharge heart rate as a potential therapeutic target in this high-risk population is encouraged.
Acute Heart Failure Syndromes and Coronary Perfusion Beohar, Nirat, MD, FACC; Erdogan, Ata K., MD; Lee, Daniel C., MD ...
Journal of the American College of Cardiology,
07/2008, Letnik:
52, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Acute Heart Failure Syndromes and Coronary Perfusion Nirat Beohar, Ata K. Erdogan, Daniel C. Lee, Hani N. Sabbah, Morton J. Kern, John Teerlink, Robert O. Bonow, Mihai Gheorghiade Acute heart failure ...syndromes (AHFS) represent a significant public health burden, with a high post-discharge mortality and rehospitalization rate. A significant number of patients with heart failure have underlying coronary artery disease and may be at greater risk from hemodynamic alterations that can diminish coronary perfusion. In AHFS, the relationship among vasoactive medications, coronary perfusion, and potential myocardial injury needs further investigation. Newer techniques now available to evaluate coronary perfusion should provide guidance for the evaluation of existing and future vasoactive therapies for AHFS.
...recommendations for athletic participation in people with these conditions are based on cohort analyses of nonathletic subjects and consensus opinion. Reviewer Employment Research Grant Other ...Research Support Speakers Bureau/Honoraria Expert Witness Ownership Interest Consultant/Advisory Board Other Michael S. Emery Greenville Health System None None None None None None None Geetha Raghuveer Children's Mercy Hospital None None None None None None None Table 2 Left Ventricular Dimensions in Elite Athletes BSA indicates body surface area; LVEDD, left ventricular end-diastolic dimension; and LVESD, left ventricular end-systolic dimension.
Performance Matters in Heart Failure Bonow, Robert O., MD, MS; Gheorghiade, Mihai, MD
Journal of the American College of Cardiology,
01/2014, Letnik:
63, Številka:
2
Journal Article
Recenzirano
Odprti dostop
Whether the diagnosis of heart failure was primary or secondary, the lack of either assessment of LV function or appropriate use of ACE inhibitors/ARBs was associated with significantly higher ...post-discharge mortality rates at 1 year. ...there is evidence of an important gap in care affecting a large number of heart failure patients who are currently under the radar screen of public scrutiny, and hence there is an opportunity for substantial quality improvement.
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