Background Clinical trials have demonstrated the benefit of implantable cardioverter-defibrillators (ICDs) for the primary prevention of sudden cardiac death in selected high-risk individuals. ...Because of small numbers of women enrolled in these trials, outcomes for women after hospital discharge have not been well described. We compared procedure-related complications and outcomes after hospital discharge between men and women undergoing single- or dual-chamber ICD implantation for primary prevention. Methods In patients 65 years or older with Medicare fee-for-service coverage, we identified 38,912 initial implants (25% women) who received single- or dual-chamber ICDs for primary prevention between January 2006 and December 2009 in the NCDR and evaluated gender differences in outcomes. Results Women had greater comorbidity and more advanced heart failure (HF) at the time of ICD implantation than did men. Device-related complications, death at 6 months, all-cause readmissions, and HF readmissions at 6 months were significantly more common in women (7.2% vs 4.8%, 6.5% vs 5.6%, 37.2% vs 31.7%, and 14.0% vs 10.0% respectively; P < .001 for all). Women continued to have higher odds of procedural complications (odds ratio OR 1.39, 95% CI 1.26-1.53, P < .001), 6-month all-cause readmission (OR 1.22, 95% CI 1.16-1.28, P < .001), and 6-month HF readmission (OR 1.32, 95% CI 1.23-1.42, P < .001), with a trend toward higher 6-month mortality (OR 1.08, 95% CI 0.98-1.20, P = .123), compared with men, after adjusting for differences in baseline characteristics and device type (single vs dual chamber). Conclusions Among older patients receiving ICDs for primary prevention in clinical practice, women experience worse outcomes than do men. Reasons for gender differences in outcomes are poorly understood and require further investigation.
Background Little is known about the effect of nonadherence among patients with coronary artery disease (CAD) on a broad spectrum of outcomes including cardiovascular mortality, cardiovascular ...hospitalizations, and revascularization procedures. Methods This was a retrospective cohort study of 15 767 patients with CAD. Medication adherence was calculated as proportion of days covered for filled prescriptions of β-blockers, angiotensin-converting enzyme (ACE) inhibitors, and statin medications. Multivariable Cox regression assessed the association between medication nonadherence as a time-varying covariate and a broad range of outcomes, adjusting for demographics and clinical characteristics. Median follow-up was 4.1 years. Results Rates of medication nonadherence were 28.8% for β-blockers, 21.6% for ACE inhibitors, and 26.0% for statins. In unadjusted analysis, nonadherence to each class of medication was associated with higher all-cause and cardiovascular mortality. In multivariable analysis, nonadherence remained significantly associated with increased all-cause mortality risk for β-blockers (hazard ratio HR 1.50, 95% CI 1.33-1.71), ACE inhibitors (HR 1.74, 95% CI 1.52-1.98), and statins (HR 1.85, 95% CI 1.63-2.09). In addition, nonadherence remained significantly associated with higher risk of cardiovascular mortality for β-blockers (HR 1.53, 95% CI 1.16-2.01), ACE inhibitors (HR 1.66, 95% CI 1.26-2.20), and statins (HR 1.62, 95% CI 1.124-2.13). The findings of increased risk associated with nonadherence were consistent for cardiovascular hospitalization and revascularization procedures. Conclusions Nonadherence to cardioprotective medications is common in clinical practice and associated with a broad range of adverse outcomes. These findings suggest that medication nonadherence should be a target for quality improvement interventions to maximize the outcomes of patients with CAD.
Beyond Medication Prescription as Performance Measures Arnold, Suzanne V., MD, MHA; Spertus, John A., MD, MPH; Masoudi, Frederick A., MD, MSPH ...
Journal of the American College of Cardiology,
11/2013, Letnik:
62, Številka:
19
Journal Article
Recenzirano
Odprti dostop
Objectives The aim of this study was to examine the prescribing patterns of medications quantified by the performance measures for acute myocardial infarction (AMI). Background Current performance ...measures for AMI are designed to improve quality by quantifying the use of evidence-based treatments. However, these measures only assess medication prescription. Whether patients receive optimal dosing of secondary prevention medications at the time of and after discharge after AMI is unknown. Methods We assessed treatment doses of beta-blockers, statins, and angiotensin-converting enzyme inhibitors (ACEI)/angiotensin II receptor blockers (ARBs) at discharge and 12 months after AMI among 6,748 patients from 31 hospitals enrolled in 2 U.S. registries (2003 to 2008). Prescribed doses were categorized as none, low (<50% target defined from seminal clinical trials), moderate (50% to 74% target), or goal (≥75% target). Patients with contraindications were excluded from analyses for that medication. Results Most eligible patients (>87%) were prescribed some dose of each medication at discharge, although only 1 in 3 patients were prescribed these medications at goal doses. Of patients not discharged on goal doses, up-titration during follow-up occurred infrequently (approximately 25% of patients for each medication). At 12 months, goal doses of beta-blockers, statins, and ACEI/ARBs were achieved in only 12%, 26%, and 32% of eligible patients, respectively. After multivariable adjustment, prescription of goal dose at discharge was strongly associated with being at goal dose at follow-up: beta-blockers, adjusted odds ratio (OR): 6.08 (95% confidence interval CI: 3.70 to 10.01); statins, adjusted OR: 8.22 (95% CI: 6.20 to 10.90); ACEI/ARBs, adjusted OR: 5.80 (95% CI: 2.56 to 13.16); p < 0.001 for each. Conclusions Although nearly all patients after an AMI are discharged on appropriate secondary prevention medications, dose increases occur infrequently, and most patients are prescribed doses below those with proven efficacy in clinical trials. Integration of dose intensity into performance measures might help improve the use of optimal medical therapy after AMI.
Abstract Background Limited literature exists on the association between medication adherence and outcomes among patients with heart failure. Methods and Results We conducted a retrospective ...longitudinal cohort study of 557 patients with heart failure with reduced ejection fraction (HFrEF) (defined by EF <50%) in a large health maintenance organization. We used multivariable Cox proportional hazards models to assess the relationship between adherence (with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, β-blockers, and aldosterone antagonists) and the primary outcome of all-cause mortality plus cardiovascular hospitalizations. Mean follow-up time was 1.1 years. Nonadherence (defined as <80% adherence) was associated with a statistically significant increase in the primary outcome in the cohort overall (hazard ratio 2.07, 95% confidence interval 1.62–2.64; P < .0001). This association remained significant when all 3 classes of heart failure medications and the components of the composite end point were considered separately and when the adherence threshold was varied to 70% or 90%. Conclusions Medication nonadherence was associated with an increased risk of all-cause mortality and cardiovascular hospitalizations in a community heart failure population. Further research is needed to define systems of care that optimize adherence among patients with heart failure.
Background Heart rate recovery (HRR) and chronotropic response to exercise (CR) each have prognostic value among patients undergoing exercise treadmill testing (ETT). However, little is known about ...their prognostic use in combination and in addition to the Duke Treadmill Score (DTS). Methods We studied 9,519 outpatients undergoing ETT between 2001 and 2004. Patients were categorized by HRR and CR. The primary outcome was all-cause mortality or nonfatal myocardial infarction (MI). Cox proportional hazards modeling was used to control for demographics, clinical history, and DTS. Results After multivariable adjustment for DTS and other demographic and clinical variables, patients with abnormal HRR and CR had higher rates of all-cause mortality or nonfatal MI, as compared to patients with normal HRR and CR (hazard ratio HR = 1.90, 95% CI 1.35-2.69). Addition of the HRR and CR to the DTS improved outcome prediction (c-statistic improved from 0.61 to 0.68). Low-risk DTS patients with abnormal HRR and CR had significantly higher rates of all-cause mortality or nonfatal MI (HR 2.59, 95% CI 1.55-4.32), compared to low-risk DTS patients with normal HRR and CR. Conclusions Abnormal HRR and CR identified ETT patients with higher rates of all-cause mortality or nonfatal MI and provided additional risk stratification among low-risk DTS patients. These results support the routine incorporation of HRR and CR in ETT reporting and suggest the need to evaluate whether further testing and/or more intensive treatment of these higher risk patients can improve outcomes.
Abstract Cardiovascular disease (CVD) is a leading cause of death and disability in the United States. National quality programs such as the National Cardiovascular Data Registry (NCDR®) permit ...assessments of the quality of care and outcomes for broad populations of patients with CVD. This report provides data from 2014 from four NCDR® hospital quality programs: 1) CathPCI® for coronary angiography and percutaneous coronary intervention (667,424 procedures performed in 1,612 hospitals) ICD™ for implantable cardioverter defibrillators (158,649 procedures performed in 1,715 hospitals); 3) ACTION®-GWTG™ for acute coronary syndromes (182,903 patients admitted to 907 hospitals); and 4) IMPACT® for cardiac catheterization and intervention for pediatric and adult congenital heart disease (20,169 procedures in 76 hospitals). The report provides perspectives on the demographic and clinical characteristics of enrolled patients; characteristics of participating centers; selected measures of processes and outcomes of care.
Background Fewer women than men undergo implantable cardioverter defibrillator (ICD) implantation for the primary prevention of sudden cardiac death. The criteria used to select patients for ICD ...implantation may be more permissive among men than for women. We hypothesized that women who undergo primary prevention ICD implantation more often meet strict trial enrollment criteria for this therapy. Methods We studied 59,812 patients in the National Cardiovascular Data Registry ICD registry undergoing initial primary prevention ICD placement between January 2005 and April 2007. Patients were classified as meeting or not meeting enrollment criteria of either the MADIT-II or SCD-HeFT trials. Multivariable analyses assessed the association between gender and concordance with trial criteria adjusting for demographic, clinical, and system characteristics. Results Among the cohort, 27% (n = 16,072) were women. Overall, 85.2% of women and 84.5% of men met enrollment criteria of either trial ( P = .05). In multivariable analyses, women were equally likely to meet trial criteria (OR 1.04, 95% CI 0.99-1.10) than men. Significantly more women than men met the trial enrollment criteria among patients older than age 65 (86.6% of women vs 85.3% of men, OR 1.11, 95% CI 1.03-1.19), but this difference was not found among younger patients (82.5% of women vs 83.0% of men, OR 0.97, 95% CI 0.89-1.07). Conclusions In a national cohort undergoing primary prevention ICD implantation, older women were only slightly more likely then men to meet the enrollment criteria for MADIT II or SCD-HeFT. Relative overutilization in men is not an important explanation for gender differences in ICD implantation.
Objectives This study sought to examine the contemporary incidence, predictors and outcomes of acute kidney injury in patients undergoing percutaneous coronary interventions. Background Acute kidney ...injury (AKI) is a serious and potentially preventable complication of percutaneous coronary interventions (PCIs) that is associated with adverse outcomes. The contemporary incidence, predictors, and outcomes of AKI are not well defined, and clarifying these can help identify high-risk patients for proactive prevention. Methods A total of 985,737 consecutive patients underwent PCIs at 1,253 sites participating in the National Cardiovascular Data Registry Cath-PCI registry from June 2009 through June 2011. AKI was defined on the basis of changes in serum creatinine level in the hospital according to the Acute Kidney Injury Network (AKIN) criteria. Using multivariable regression analyses with generalized estimating equations, we identified patient characteristics associated with AKI. Results Overall, 69,658 (7.1%) patients experienced AKI, with 3,005 (0.3%) requiring new dialysis. On multivariable analyses, the factors most strongly associated with development of AKI included ST-segment elevation myocardial infarction (STEMI) presentation (odds ratio OR: 2.60; 95% confidence interval CI: 2.53 to 2.67), severe chronic kidney disease (OR: 3.59; 95% CI: 3.47 to 3.71), and cardiogenic shock (OR: 2.92; 95% CI: 2.80 to 3.04). The in-hospital mortality rate was 9.7% for patients with AKI and 34% for those requiring dialysis compared with 0.5% for patients without AKI (p < 0.001). After multivariable adjustment, AKI (OR: 7.8; 95% CI: 7.4 to 8.1, p < 0.001) and dialysis (OR: 21.7; 95% CI: 19.6 to 24.1; p < 0.001) remained independent predictors of in-hospital mortality. Conclusions Approximately 7% of patients undergoing a PCI experience AKI, which is strongly associated with in-hospital mortality. Defining strategies to minimize the risk of AKI in patients undergoing PCI are needed to improve the safety and outcomes of the procedure.
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