Approximately half of patients with atrial fibrillation and with risk factors for stroke are not treated with oral anticoagulation (OAC), whether it be with vitamin K antagonists (VKAs) or novel OACs ...(NOACs); and of those treated, many discontinue treatment. Leaders from academia, government, industry, and professional societies convened in Washington, DC, on December 3-4, 2012, to identify barriers to optimal OAC use and adherence and to generate potential solutions. Participants identified a broad range of barriers, including knowledge gaps about stroke risk and the relative risks and benefits of anticoagulant therapies; lack of awareness regarding the potential use of NOAC agents for VKA-unsuitable patients; lack of recognition of expanded eligibility for OAC; lack of availability of reversal agents and the difficulty of anticoagulant effect monitoring for the NOACs; concerns with the bleeding risk of anticoagulant therapy, especially with the NOACs and particularly in the setting of dual antiplatelet therapy; suboptimal time in therapeutic range for VKA; and costs and insurance coverage. Proposed solutions were to define reasons for oral anticoagulant underuse classified in ways that can guide intervention and improve use, to increase awareness of stroke risk as well as the benefits and risks of OAC use via educational initiatives and feedback mechanisms, to better define the role of VKA in the current therapeutic era including eligibility and ineligibility for different anticoagulant therapies, to identify NOAC reversal agents and monitoring strategies and make knowledge regarding their use publicly available, to minimize the duration of dual antiplatelet therapy and concomitant OAC where possible, to improve time in therapeutic range for VKA, to leverage observational data sets to refine understanding of OAC use and outcomes in general practice, and to better align health system incentives.
Background Time in therapeutic range (TTR) of international normalized ratio (INR) of 2.0 to 3.0 is important for the safety and effectiveness of warfarin anticoagulation. There are few data on TTR ...among patients with atrial fibrillation (AF) in community-based clinical practice. Methods Using the US Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF), we examined TTR (using a modified Rosendaal method) among 5,210 patients with AF on warfarin and treated at 155 sites. Patients were grouped into quartiles based on TTR data. Multivariable logistic regression modeling with generalized estimating equations was used to determine patient and provider factors associated with the lowest (worst) TTR. Results Overall, 59% of the measured INR values were between 2.0 and 3.0, with an overall mean and median TTR of 65% ± 20% and 68% (interquartile range IQR 53%-79%). The median times below and above the therapeutic range were 17% (IQR 8%-29%) and 10% (IQR 3%-19%), respectively. Patients with renal dysfunction, advanced heart failure, frailty, prior valve surgery, and higher risk for bleeding (ATRIA score) or stroke (CHA2 DS2 -VASc score) had significantly lower TTR ( P < .0001 for all). Patients treated at anticoagulation clinics had only slightly higher median TTR (69%) than those not (66%) ( P < .0001). Conclusions Among patients with AF in US clinical practices, TTR on warfarin is suboptimal, and those at highest predicted risks for stroke and bleeding were least likely to be in therapeutic range.
Nanette K. Wenger, MD ACCF/AHA Task Force Members Jeffrey L. Anderson, MD, FACC, FAHA, Chair; Alice K. Jacobs, MD, FACC, FAHA, Immediate Past Chair; Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect; ...Nancy M. Albert, PhD, CCNS, CCRN; Mark A. Creager, MD, FACC, FAHA; David DeMets, PhD; Steven M. Ettinger, MD, FACC; Robert A. Guyton, MD, FACC; Judith S. Hochman, MD, FACC, FAHA; Frederick G. Kushner, MD, FACC, FAHA; E. Magnus Ohman, MD, FACC; William Stevenson, MD, FACC, FAHA; Clyde W. Yancy, MD, FACC, FAHA Table of Contents Developed in Collaboration With the American College of Emergency Physicians, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine Preamble (UPDATED)...e182 Introduction (UPDATED)...e184 Organization of Committee and Evidence Review (UPDATED)...e184 Document Review and Approval (UPDATED)...e185 Purpose of These Guidelines...e185 Overview of the Acute Coronary Syndromes...e186 Definition of Terms...e186 Pathogenesis of UA/NSTEMI...e186 Presentations of UA and NSTEMI...e189 Management Before UA/NSTEMI and Onset of UA/NSTEMI...e189 Identification of Patients at Risk of UA/NSTEMI...e189 Interventions to Reduce Risk of UA/NSTEMI...e190 Onset of UA/NSTEMI...e191 Recognition of Symptoms by Patient...e191 Silent and Unrecognized Events...e191 Initial Evaluation and Management...e191 Clinical Assessment...e191 Emergency Department or Outpatient Facility Presentation...e195 Questions to Be Addressed at the Initial Evaluation...e196 Early Risk Stratification...e196 Estimation of the Level of Risk...e198 Rationale for Risk Stratification...e198 History...e198 Anginal Symptoms and Anginal Equivalents...e198 Demographics and History in Diagnosis and Risk Stratification...e199 Estimation of Early Risk at Presentation...e200 Electrocardiogram...e202 Physical Examination...e203 Noncardiac Causes of Symptoms and Secondary Causes of Myocardial Ischemia...e204 Cardiac Biomarkers of Necrosis and the Redefinition of AMI...e204 Creatine Kinase-MB...e205 Cardiac Troponins...e205 Clinical Use...e205 Clinical Use of Marker Change Scores...e207 Bedside Testing for Cardiac Markers...e208 Myoglobin and CK-MB Subforms Compared With Troponins...e208 Summary Comparison of Biomarkers of Necrosis: Singly and in Combination...e208 Other Markers and Multimarker Approaches...e208 Ischemia...e208 Coagulation ...e209 Platelets...e209 Inflammation...e209 B-Type Natriuretic Peptides...e210 Immediate Management...e210 Chest Pain Units...e211 Discharge From ED or Chest Pain Unit...e212 Early Hospital Care...e213 Anti-Ischemic and Analgesic Therapy...e214 General Care...e215 Use of Anti-Ischemic Therapies...e215 Nitrates...e215 Morphine Sulfate...e217 Beta-Adrenergic Blockers...e217 Calcium Channel Blockers...e219 Inhibitors of the Renin-Angiotensin-Aldosterone System...e220 Other Anti-Ischemic Therapies...e221 Intra-Aortic Balloon Pump Counterpulsation...e221 Analgesic Therapy...e221 Recommendations for Antiplatelet/Anticoagulant Therapy in Patients for Whom Diagnosis of UA/NSTEMI Is Likely or Definite (UPDATED)...e221 Antiplatelet Therapy: Recommendations (UPDATED)...e221 Anticoagulant Therapy: Recommendations...e223 Additional Management Considerations for Antiplatelet and Anticoagulant Therapy: Recommendations (UPDATED)...e223 Antiplatelet/Anticoagulant Therapy in Patients for Whom Diagnosis of UA/NSTEMI Is Likely or Definite (NEW SECTION)...e224 Newer P2Y12 Receptor Inhibitors...e224 Choice of P2Y12 Receptor Inhibitors for PCI in UA/NSTEMI...e227 Timing of Discontinuation of P2Y12 Receptor Inhibitor Therapy for Surgical Procedures...e227 Interindividual Variability in Responsiveness to Clopidogrel...e228 Optimal Loading and Maintenance Dosages of Clopidogrel...e228 Proton Pump Inhibitors and Dual Antiplatelet Therapy for ACS...e229 Glycoprotein IIb/IIIa Receptor Antagonists (Updated to Incorporate Newer Trials and Evidence)...e230 Older Antiplatelet Agents and Trials (Aspirin, Ticlopidine, Clopidogrel)...e231 Aspirin...e231 Adenosine Diphosphate Receptor Antagonists and Other Antiplatelet Agents...e233 Anticoagulant Agents and Trials...e236 Unfractionated Heparin...e237 Low-Molecular-Weight Heparin...e238 LMWH Versus UFH...e238 Extended Therapy with LMWHs...e241 Direct Thrombin Inhibitors...e241 Factor Xa Inhibitors...e244 Long-Term Anticoagulation...e245 Platelet GP IIb/IIIa Receptor Antagonists...e246 Fibrinolysis...e251 Initial Conservative Versus Initial Invasive Strategies (UPDATED)...e251 General Principles...e252 Rationale for the Initial Conservative Strategy...e252 Rationale for the Invasive Strategy...e253 Timing of Invasive Therapy (NEW SECTION)...e253 Immediate Angiography...e254 Deferred Angiography...e254 Comparison of Early Invasive and Initial Conservative Strategies...e254 Subgroups...e257 Care Objectives...e258 Risk Stratification Before Discharge...e260 Care Objectives...e260 Noninvasive Test Selection...e262 Selection for Coronary Angiography...e263 Patient Counseling...e263 Coronary Revascularization...e263 Recommendations for Revascularization With PCI and CABG in Patients With UA/NSTEMI (UPDATED)...e263 Late Hospital Care, Hospital Discharge, and Post-Hospital Discharge Care...e263 Medical Regimen and Use of Medications...e263 Long-Term Medical Therapy and Secondary Prevention...e265 Convalescent and Long-Term Antiplatelet Therapy (UPDATED)...e266 Beta Blockers...e266 Inhibition of the Renin-Angiotensin-Aldosterone System...e267 Nitroglycerin...e267 Calcium Channel Blockers...e267 Warfarin Therapy (UPDATED)...e267 Lipid Management...e268 Blood Pressure Control...e270 Diabetes Mellitus...e270 Smoking Cessation...e270 Weight Management...e271 Physical Activity...e271 Patient Education...e272 Influenza...e272 Depression...e272 Nonsteroidal Anti-Inflammatory Drugs...e272 Hormone Therapy...e272 Antioxidant Vitamins and Folic Acid...e273 Postdischarge Follow-Up...e273 Cardiac Rehabilitation...e274 Return to Work and Disability...e275 Other Activities...e276 Patient Records and Other Information Systems...e277 Special Groups...e277 Women...e277 Profile of UA/NSTEMI in Women...e278 Management...e278 Pharmacological Therapy...e278 Coronary Artery Revascularization...e278 Initial Invasive Versus Initial Conservative Strategy...e279 Stress Testing...e281 Conclusions...e281 Diabetes Mellitus (UPDATED)...e281 Profile and Initial Management of Diabetic and Hyperglycemic Patients With UA/NSTEMI...e281 Intensive Glucose Control (NEW SECTION)...e282 Coronary Revascularization...e283 Conclusions...e284 Post-CABG Patients...e284 Pathological Findings...e285 Clinical Findings and Approach...e285 Conclusions...e285 Older Adults...e285 Pharmacological Management...e286 Functional Studies...e286 Percutaneous Coronary Intervention in Older Patients...e287 Contemporary Revascularization Strategies in Older Patients...e287 Conclusions...e287 Chronic Kidney Disease (UPDATED) ...e288 Angiography in Patients With CKD (NEW SECTION)...e288 Cocaine and Methamphetamine Users...e290 Coronary Artery Spasm With Cocaine Use...e290 Treatment...e291 Methamphetamine Use and UA/NSTEMI...e292 Variant (Prinzmetal's) Angina...e292 Clinical Picture...e292 Pathogenesis...e292 Diagnosis...e293 Treatment...e293 Prognosis...e293 Cardiovascular "Syndrome X"...e294 Definition and Clinical Picture...e294 Treatment...e295 Takotsubo Cardiomyopathy...e295 Conclusions and Future Directions...e295 Recommendations for Quality of Care and Outcomes for UA/NSTEMI (NEW SECTION)...e297 Quality Care and Outcomes (NEW SECTION)...e297 References...e297 Appendix 1.
Background There is a paucity of information on clinical characteristics, care patterns, and clinical outcomes for hospitalized intracerebral hemorrhage (ICH) patients with chronic kidney disease ...(CKD). We assessed characteristics, care processes, and in-hospital outcome among ICH patients with CKD in the Get With the Guidelines–Stroke (GWTG-Stroke) program. Methods We analyzed 113,059 ICH patients hospitalized at 1472 US centers participating in the GWTG-Stroke program between January 2009 and December 2012. In-hospital mortality and use of 2 predefined ICH performance measures were examined based on glomerular filtration rate. Renal dysfunction was categorized as a dichotomous (+CKD = estimated glomerular filtration rate <60) or rank ordered variable as CKD (<60), and by clinical stage: (normal ≥90, mild ≥60-<90, moderate ≥30-<60, severe ≥15-<30, and/or kidney failure <15 or dialysis). Results There were 33,219 (29%) ICH patients with CKD. Patients with CKD were more likely to be older, female, and with comorbid conditions such as diabetes. Compared with patients with normal kidney function, those with CKD were slightly less likely to receive deep venous thrombosis (DVT) prophylaxis but similarly received discharge smoking cessation intervention. Inpatient mortality was also higher for those with CKD (adjusted odds ratio OR, 1.47; 95% confidence interval CI, 1.42-1.52), mild dysfunction (adjusted OR, 1.12; 95% CI, 1.08-1.16), moderate dysfunction (adjusted OR, 1.46; 95% CI, 1.39-1.53), severe dysfunction (adjusted OR, 1.96; 95% CI, 1.81-2.12), and kidney failure (adjusted OR, 2.22; 95% CI, 2.04-2.43) relative to those with normal renal function. Conclusions Chronic kidney disease is present in nearly a third of patients hospitalized with ICH and is associated with slightly worse care and substantially higher mortality than those with normal renal function.
Background There are no sex-specific survival comparisons between patients with heart failure (HF) with reduced and those with preserved ejection fraction. Large registries noting women have better ...survival than men combined HF patients with reduced and preserved EF. Other registries that compared patients with reduced and preserved EF did not analyze their data by sex. We sought to evaluate sex/EF differences in mortality and risk factors for survival in hospitalized patients with HF. Methods We included hospitals fully participating in Get With The Guidelines-Heart Failure that admitted HF patients with reduced (EF <40%) or preserved (EF ≥50%) EF. The primary end point was in-hospital mortality. Multivariate generalized estimating equation logistic models were used to compute odds ratios accounting for hospital clustering. Results The study cohort consisted of 51,428 patients with EF <40% (36% women, 64% men) and 37,699 patients with EF ≥50% (65% women, 35% men). Women compared with men with reduced and preserved EF were older and more likely to have hypertension, depression, or valvular heart disease and less likely to have coronary artery disease or peripheral vascular disease. There were no sex differences in in-hospital mortality (EF <40%, 2.69% women vs 2.89% men, P = .20; EF ≥50%, 2.61% women vs 2.62% men, P = .96), and risk factors such as age, systolic blood pressure, heart rate, and history of renal failure/dialysis were highly predictive of death for each sex/EF subgroup. Conclusions In a large, multicenter registry, we found that despite differences in baseline characteristics, women and men with reduced and preserved EF have similar in-hospital mortality and risk factors predicting death.
Background Prior studies have suggested an association between higher heart rate and higher mortality, particularly in chronic heart failure (HF). Whether this relationship holds true in patients ...hospitalized with HF and differs between patients in sinus rhythm (SR) and atrial fibrillation (AF) has not been well studied. Methods We examined 145,221 admissions for HF from 295 hospitals enrolled in Get With The Guidelines-Heart Failure from January 2005 through September 2011. The associations of admission heart rate with in-hospital outcomes were evaluated overall and by heart rhythm. Results Patients presenting at higher heart rate tended to be younger and have less comorbidities. In-hospital mortality had a J-shaped relationship with heart rate, with the lowest mortality rate associated with heart rates between 70 and 75. However, the relationship differed between patients presenting in SR and AF: at heart rates above 100, the mortality curve for AF plateaued, whereas that for SR continued to rise. Higher heart rate was independently associated with higher mortality (SR adjusted OR 1.21, 95% CI 1.15-1.28 per 10 beat per minute increase in heart rate between 70-105; AF adjusted OR 1.20, 95% CI 1.14-1.27). Findings were similar when stratifying patients by ischemic etiology, diabetes, ejection fraction, blood pressure, and β-blocker use. Conclusions Higher admission heart rate is independently associated with worse outcomes in patients admitted for HF, including those in SR and AF. Whether early heart rate reduction improves outcomes in patients hospitalized with HF is worthy of investigation.
Backgound Few studies have examined associations among insurance status, treatment, and outcomes in patients hospitalized for intracerebral hemorrhage (ICH). Methods Through retrospective analyses of ...the Get With The Guidelines (GWTG)-Stroke database, a national prospective stroke registry, from April 2003 to April 2011, we identified 95,986 nontransferred subjects hospitalized with ICH. Insurance status was categorized as Private/Other, Medicaid, Medicare, or None/Not Documented (ND). Associations between insurance status and in-hospital outcomes and quality of care measures were analyzed using patient- and hospital-specific variables as covariates. Results There were significant differences in age and frequency of comorbid conditions by insurance group. Compliance with evidence-based quality of care indicators varied across all insurance status groups ( P < .0001) but was generally high. In adjusted analysis with the Private insurance group as reference, the None/ND group most consistently demonstrated higher odds ratios (ORs) for quality of care measures (Dysphagia Screen: OR 1.10, 95% confidence interval CI 1.02-1.17, P = .0096; Stroke Education: OR 1.16, 95% CI 1.05-1.29, P = .0042; and Rehabilitation: OR 1.25, 95% CI 1.08-1.44, P = .0027). In-hospital mortality rates were higher for None/ND, Medicaid, and Medicare patients; after risk adjustment, the None/ND group had the highest mortality risk (OR 1.29, 95% CI 1.21-1.38, P < .0001). Medicare and Medicaid patients had lower adjusted odds for both independent ambulation at discharge and discharge to home when compared with the Private/Other group. Conclusions GWTG-Stroke ICH patients demonstrated differences in mortality, functional status, discharge destination, and quality of care measures associated with insurance status.
Public reporting has been proposed as a strategy to improve health care quality. Percutaneous coronary interventions (PCIs) performed in the United States from July 1, 2009, to June 30, 2011, ...included in the CathPCI Registry were identified (n = 1,340,213). Patient characteristics and predicted and observed in-hospital mortality were compared between patients treated with PCI in states with mandated public reporting (Massachusetts, New York, Pennsylvania) and states without mandated public reporting. Most PCIs occurred in states without mandatory public reporting (88%, n = 1,184,544). Relative to patients treated in nonpublic reporting states, those who underwent PCI in public reporting states had similar predicted in-hospital mortality (1.39% vs 1.37%, p = 0.17) but lower observed in-hospital mortality (1.19% vs 1.41%, adjusted odds ratio ORadj 0.80; 95% confidence interval CI 0.74, 0.88; p <0.001). In patients for whom outcomes were available at 180 days, the differences in mortality persisted (4.6% vs 5.4%, ORadj 0.85, 95% CI 0.79 to 0.92, p <0.001), whereas there was no difference in myocardial infarction (ORadj 0.97, 95% CI 0.89 to 1.07) or revascularization (ORadj 1.05, 95% CI 0.92 to 1.20). Hospital readmissions were increased at 180 days in patients who underwent PCI in public reporting states (ORadj 1.08, 95% CI 1.03 to 1.12, p = 0.001). In conclusion, patients who underwent PCI in states with mandated public reporting of outcomes had similar predicted risks but significantly lower observed risks of death during hospitalization and in the 6 months after PCI. These findings support considering public reporting as a potential strategy for improving outcomes of patients who underwent PCI although further studies are warranted to delineate the reasons for these differences.
Background Guidelines recommend noninvasive tests (NITs) to risk stratify and identify patients with higher likelihood of coronary artery disease (CAD) prior to elective coronary angiography. ...However, a high percentage of patients are found to have nonobstructive CAD. We aimed to understand the relationship between patient characteristics, NIT findings, and the likelihood of nonobstructive CAD. Methods Patients undergoing elective catheterization without history of CAD were identified from 1,128 hospitals in National Cardiovascular Data Registry's CathPCI Registry between July 2009 and December 2011. Noninvasive tests included stress electrocardiogram, stress echocardiogram, stress radionuclide, stress cardiac magnetic resonance, and computed tomographic angiography. Patient demographics, risk factors, symptoms, and NIT results were correlated with the presence of nonobstructive CAD , defined as all native coronary stenoses <50%. Results Of 661,063 patients undergoing elective angiography, 386,003 (58.4%) had nonobstructive CAD. Preprocedure NIT was performed in 64% of patients; 51.9% were reported to be abnormal, but only 9% had high-risk findings. Independent factors associated with nonobstructive CAD were younger age, female sex, atypical chest pain, and a low-risk NIT. Patients with high-risk findings on NIT were more likely to have obstructive CAD (adjusted odds ratio 3.03 2.86-3.22). Noninvasive test findings had minimal incremental value beyond clinical factors for predicting obstructive disease ( C index = 0.75 for clinical factors vs 0.74 for NIT findings). Conclusion In current practice, about two-thirds of patients undergo NIT prior to elective cardiac catheterization, yet most patients have nonobstructive CAD. The weak correlation between most NIT results and the likelihood of obstructive CAD provides further impetus for improving preangiography assessment of likelihood of disease.
Given the attendant risks of mortality and morbidity, acute MI remains a principal focus of cardiovascular therapeutics. ...30-day mortality and rehospitalization rates for acute MI are publicly ...reported in an effort to promote optimal acute MI care, and aspects of MI care delivery are the focus of local, regional, and national quality initiatives (1-3). Updates or revisions to the American College of Cardiology (ACC)/American Heart Association (AHA) practice guidelines for PCI, ST-segment elevation myocardial infarction (STEMI), and unstable angina (UA)/non-ST-segment elevation myocardial infarction (NSTEMI) have been published within the last 3 years, building upon prior versions published earlier in the decade (5-7).
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