RESUMEN
BACKGROUND: Atrial fibrillation (AF) and heart failure with reduced ejection fraction frequently coexist. The AATAC (Ablation versus Amiodarone for Treatment of persistent Atrial fibrillation in patients with Congestive heart failure and an implantable device) trial suggests that catheter ablation may benefit these patients. However, applicability to contemporary ambulatory cardiology practice is unknown. METHODS AND RESULTS: Using the outpatient National Cardiovascular Data Registry® Practice Innovation and Clinical Excellence Registry, we identified participants meeting AATAC enrollment criteria between 2013 and 2014. Treatment with medications and procedures was assessed at registry inclusion. From 164 166 patients with AF and heart failure, 8483 (7%) patients potentially met AATAC inclusion criteria. Eligible subjects, compared to AATAC trial participants, were older (mean age, 71.2±11.4 years) and had greater comorbidity (coronary artery disease 79.2%, hypertension 82.4%, and diabetes mellitus 31.8%). AF was predominantly paroxysmal (65.5%), rather than persistent/permanent (16.7%) or new onset (17.8%), whereas all patients in the AATAC trial had persistent AF. Commonly used atrioventricular-nodal blocking agents were carvedilol (71.2%), digoxin (31.9%), and metoprolol (27.1%). Rhythm control with anti-arrhythmic drugs was reported in 29.0% of AATAC eligible patients (predominantly amiodarone [24.6%]) and 9.3% had undergone catheter ablation. Patients who underwent ablation were more likely to be younger and have less comorbidities than those who did not. CONCLUSIONS: Among the contemporary ambulatory AF/heart failure with reduced ejection fraction population, treatment is predominantly rate control with few catheter ablations. Application of AATAC findings has the potential to markedly increase the use of catheter ablation in this population, although significant differences in clinical profiles might influence ablation outcomes in practice.
Asunto(s)
Antiarrítmicos/uso terapéutico , Fibrilación Atrial/terapia , Ablación por Catéter/tendencias , Insuficiencia Cardíaca/fisiopatología , Pautas de la Práctica en Medicina/tendencias , Anciano , Anciano de 80 o más Años , Antiarrítmicos/efectos adversos , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/epidemiología , Fibrilación Atrial/fisiopatología , Ablación por Catéter/efectos adversos , Toma de Decisiones Clínicas , Femenino , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/epidemiología , Insuficiencia Cardíaca/terapia , Humanos , Masculino , Persona de Mediana Edad , Pacientes Ambulatorios , Selección de Paciente , Sistema de Registros , Factores de Riesgo , Volumen Sistólico , Resultado del Tratamiento , Estados Unidos/epidemiología , Función Ventricular IzquierdaRESUMEN
BACKGROUND: Little is known about facility-level variation in the use of revascularization procedures for the management of stable obstructive coronary artery disease. Furthermore, it is unknown if variation in the use of coronary revascularization is associated with use of other cardiovascular procedures. METHODS AND RESULTS: We evaluated all elective coronary angiograms performed in the Veterans Affairs system between September 1, 2007, and December 31, 2011, using the Clinical Assessment and Reporting Tool and identified patients with obstructive coronary artery disease. Patients were considered managed with revascularization if they received percutaneous coronary intervention (PCI) or coronary artery bypass grafting within 30 days of diagnosis. We calculated risk-adjusted facility-level rates of overall revascularization, PCI, and coronary artery bypass grafting. In addition, we determined the association between facility-level rates of revascularization and post-PCI stress testing. Among 15 650 patients at 51 Veterans Affairs sites who met inclusion criteria, the median rate of revascularization was 59.6% (interquartile range, 55.7%-66.7%). Across all facilities, risk-adjusted rates of overall revascularization varied from 41.5% to 88.1%, rate of PCI varied from 23.2% to 80.6%, and rate of coronary artery bypass graftingvariedfrom 7.5% to 36.5%. Of 6179 patients who underwent elective PCI, the median rate of stress testing in the 2 years after PCI was 33.7% (interquartile range, 30.7%-47.1%). There was no evidence of correlation between facility-level rate of revascularization and follow-up stress testing. CONCLUSIONS: Within the Veterans Affairs system, we observed large facility-level variation in rates of revascularization for obstructive coronary artery disease, with variation driven primarily by PCI. There was no association between facility-level use of revascularization and follow-up stress testing, suggesting use rates are specific to a particular procedure and not a marker of overall facility-level use.
Asunto(s)
Puente de Arteria Coronaria/tendencias , Estenosis Coronaria/terapia , Prestación Integrada de Atención de Salud/tendencias , Disparidades en Atención de Salud/tendencias , Intervención Coronaria Percutánea/tendencias , Pautas de la Práctica en Medicina/tendencias , Evaluación de Procesos, Atención de Salud/tendencias , United States Department of Veterans Affairs , Anciano , Angiografía Coronaria/tendencias , Puente de Arteria Coronaria/estadística & datos numéricos , Estenosis Coronaria/diagnóstico por imagen , Ecocardiografía de Estrés/tendencias , Femenino , Humanos , Masculino , Persona de Mediana Edad , Intervención Coronaria Percutánea/estadística & datos numéricos , Valor Predictivo de las Pruebas , Evaluación de Programas y Proyectos de Salud , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos , Vasodilatadores/administración & dosificaciónRESUMEN
BACKGROUND: Despite higher thromboembolism risk, women with atrial fibrillation have lower oral anticoagulation (OAC) use compared to men. The influence of the CHA2DS2-VASc score or the introduction of non-vitamin K OACs on this relationship is not known. METHODS AND RESULTS: Using the PINNACLE National Cardiovascular Data Registry from 2008 to 2014, we compared the association of sex with OAC use (warfarin or non-vitamin K OACs) overall and by CHA2DS2-VASc score and examined temporal trends in OAC use by sex. Multivariable regression models assessed the association between sex and OAC use in those with CHA2DS2-VASc scores ≥2. Temporal analyses assessed changes in OAC use by sex over time. Of the 691 906 atrial fibrillation patients, 48.5% were women. Women were significantly less likely than men to use any OAC overall (56.7% versus 61.3%; P<0.001) and at all levels of CHA2DS2-VASc score (adjusted risk ratio 9% to 33% lower, all P<0.001). Compared to other thromboembolic risk factors, female sex was associated with lower use of OAC (risk ratio 0.90, 95%CI 0.90-0.91). Over time, non-vitamin K OAC use increased at a slightly higher rate in women (56.2% increase per year, 95%CI 54.6% to 57.9%) compared to men (53.6% increase per year, 95%CI 52.0% to 55.2%), yet women remained less likely to receive any OAC at all time points (P<0.001). CONCLUSIONS: Among patients with atrial fibrillation, women were significantly less likely to receive OAC at all levels of the CHA2DS2-VASc score. Despite increasing non-vitamin K OAC use, women had persistently lower rates of OAC use compared to men over time.
Asunto(s)
Anticoagulantes/administración & dosificación , Fibrilación Atrial/tratamiento farmacológico , Disparidades en Atención de Salud/tendencias , Pautas de la Práctica en Medicina/tendencias , Accidente Cerebrovascular/prevención & control , Tromboembolia/prevención & control , Warfarina/administración & dosificación , Administración Oral , Anciano , Anciano de 80 o más Años , Fibrilación Atrial/complicaciones , Fibrilación Atrial/diagnóstico , Distribución de Chi-Cuadrado , Técnicas de Apoyo para la Decisión , Factor F , Femenino , Hemorragia/inducido químicamente , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Sistema de Registros , Factores de Riesgo , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/etiología , Tromboembolia/diagnóstico , Tromboembolia/etiología , Estados UnidosRESUMEN
BACKGROUND: Thirty-day readmission after percutaneous coronary intervention (PCI) is common, costly, and linked to poor patient outcomes. Accordingly, facility-level 30-day readmission rates have been considered as a potential quality measure. However, it is unknown whether facility-level 30-day readmission rates are associated with facility-level mortality. We sought to determine the effect of 30-day readmissions after PCI on mortality at both the patient and facility level in the Veterans Administration hospital system. METHODS AND RESULTS: We included all patients who underwent PCI in the Veterans Administration hospital system nationally from October 2007 through August 2012, comparing all-cause mortality rates between patients with and without 30-day readmissions following PCI. Patients were then aggregated at the hospital level to evaluate the correlation between hospital-level readmission rates with hospital-level 1-year mortality rates. Among 41 069 patients undergoing PCI at 62 sites, 12.2% were readmitted within 30 days of discharge. Patients with 30-day readmission had higher risk-adjusted mortality (hazard ratio 1.53, 95% CI 1.44-1.63, P<0.0001). Facilities varied widely in 30-day readmission rates (systemwide range of 6.6-19.4%, median 11.8%, interquartile range 10.0-13.2%); however, adjusted facility-level readmission rates were not correlated with adjusted 1-year mortality rates. CONCLUSIONS: Thirty-day readmissions after PCI are common and are a significant risk factor for mortality for individual patients even after robust statistical adjustment for clinical confounding. However, lack of correlation between readmission and mortality at the facility level suggests that quality improvement based on facility-level readmission rates will not modify mortality in this high-risk group.
Asunto(s)
Infarto del Miocardio/cirugía , Intervención Coronaria Percutánea/estadística & datos numéricos , Anciano , Femenino , Humanos , Estimación de Kaplan-Meier , Tiempo de Internación , Masculino , Persona de Mediana Edad , Infarto del Miocardio/mortalidad , Readmisión del Paciente/estadística & datos numéricos , Intervención Coronaria Percutánea/mortalidad , Estudios Retrospectivos , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Stigma against the obese is well described in health care and may contribute to disparities in medical decision-making. It is unknown whether similar disparity exists for obese patients in cardiovascular care. We evaluated the association between body mass index (BMI) and prescription of guideline-recommended medications in patients undergoing elective percutaneous coronary intervention. METHODS AND RESULTS: Using data from the Veterans Affairs Clinical Assessment, Reporting, and Tracking System Program, we identified patients undergoing elective percutaneous coronary intervention from 2007 to 2012, stratifying them by category of BMI. We described rates of prescription for class I guideline recommended medications for each BMI category (normal, overweight, and obese). Multivariable logistic regression assessed the association between BMI category and medication prescription. Seventeen thousand thirty-seven patients were identified, with 35.3% having overweight BMI, and 50.8% obese BMI. Obese patients were more likely than normal BMI patients to be prescribed ß-blockers (OR 1.34), statins (OR 1.39), or ACE/ARB (odds ratio [OR] 1.52; all significant) when indicated. Overweight patients were more likely than normal BMI patients to be prescribed statins (OR 1.29) and angiotensin-converting enzymes/angiotensin II receptor blockers (OR 1.41) when indicated. There was no association between BMI category and prescription of anticoagulants. CONCLUSIONS: Over 85% of patients undergoing elective percutaneous coronary intervention in the Veterans Affairs are overweight or obese. Rates of guideline-indicated medication prescription were <70% among all patients, and across BMI categories, with an association between increased BMI and greater use of guideline-recommended medications. Our findings offer a possible contribution to the obesity paradox seen in many cardiovascular conditions.
Asunto(s)
Antagonistas Adrenérgicos beta/uso terapéutico , Antagonistas de Receptores de Angiotensina/uso terapéutico , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Anticoagulantes/uso terapéutico , Enfermedad de la Arteria Coronaria/terapia , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Obesidad/epidemiología , Anciano , Índice de Masa Corporal , Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/terapia , Toma de Decisiones Clínicas , Comorbilidad , Enfermedad de la Arteria Coronaria/epidemiología , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Sobrepeso/epidemiología , Intervención Coronaria Percutánea , Guías de Práctica Clínica como Asunto , Estudios Retrospectivos , Estados Unidos/epidemiología , United States Department of Veterans AffairsRESUMEN
OBJECTIVE: To determine the incremental risk of coronary stents on adverse events in surgical patients and whether it varies over time from stent placement. BACKGROUND: Postoperative adverse cardiac events decrease as the time from stent placement increases, but the risk attributable to the stent versus the underlying cardiac disease is uncertain, as prior studies lack a control surgical population. METHODS: Data for patients with coronary stents implanted in a VA hospital from 2000 to 2010 were matched with VA Surgical Quality Improvement Program data to identify noncardiac surgery within 24 months of stent placement. Each patient with stent was matched with 2 surgical patients without stent on surgical characteristics and cardiac risk factors. Outcomes of myocardial infarction (MI), revascularization, and death within 30 days after surgery were modeled using logistic regression. Adjusted risk differences between stented and nonstented populations were compared across time after stent placement. RESULTS: Adverse cardiac events followed surgery in 531 (5.7%) of the 9391 patients with stent and 680 (3.6%) of the 18,782 patients without stent (P < 0.001). In adjusted models, 30-day postoperative MI (odds ratio = 1.90; 95% confidence interval, 1.57-2.30) and revascularization (odds ratio = 2.03; 95% confidence interval, 1.65-2.50) but not mortality (odds ratio = 0.84; 95% confidence interval, 0.69-1.02) were higher in the stented cohort. Assessing trends over the 2 years after stent placement, the incremental risk for MI decreased from 5% immediately after stent placement to 2% at 1 year and then was no longer significantly elevated. The incremental risk did not vary by stent type. CONCLUSIONS: Surgery after coronary stent placement is associated with an approximate 2% absolute risk for postoperative MI but no difference in mortality compared with nonstented matched controls.
Asunto(s)
Enfermedades Cardiovasculares/epidemiología , Complicaciones Posoperatorias/epidemiología , Stents/efectos adversos , Procedimientos Quirúrgicos Operativos , Anciano , Enfermedades Cardiovasculares/mortalidad , Femenino , Hospitales de Veteranos , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND: Dabigatran is a novel oral anti-coagulant (NOAC) that reduces risk of stroke in patients with non-valvular atrial fibrillation (NVAF). It does not require routine monitoring with laboratory testing which may have an adverse impact on adherence. We aimed to describe adherence to dabigatran in the first year after initiation and assess the association between non-adherence to dabigatran and clinical outcomes in a large integrated healthcare system. METHODS: We studied a national cohort of 5,376 patients with NVAF, initiated on dabigatran between October-2010 and September-2012 at all Veterans Affairs hospitals. Adherence to dabigatran was calculated as proportion of days covered (PDC) and association between PDC and outcomes was assessed using standard regression techniques. RESULTS: Mean age of the study cohort was 71.3 ± 9.7 years; 98.3% were men and mean CHADS2 score was 2.4 ± 1.2 (mean CHA2DS2VASc score 3.2 ± 1.4). Median PDC was 94% (IQR 76%-100%; mean PDC 84% ± 22%) over a median follow-up of 244 days (IQR 140-351). A total of 1,494 (27.8%) patients had a PDC <80% and were classified as non-adherent. After multivariable adjustment, lower adherence was associated with increased risk for combined all-cause mortality and stroke (HR 1.13, 95% CI 1.07-1.19 per 10% decrease in PDC). Adherence to dabigatran was not associated with non-fatal bleeding or myocardial infarction. CONCLUSIONS: In the year after initiation, adherence to dabigatran for a majority of patients is very good. However, 28% of patients in our cohort had poor adherence. Furthermore, lower adherence to dabigatran was associated with increased adverse outcomes. Concerted efforts are needed to optimize adherence to NOACs.
Asunto(s)
Antitrombinas/uso terapéutico , Bencimidazoles/uso terapéutico , Cumplimiento de la Medicación/estadística & datos numéricos , Infarto del Miocardio/prevención & control , Accidente Cerebrovascular/prevención & control , beta-Alanina/análogos & derivados , Anciano , Anciano de 80 o más Años , Fibrilación Atrial/complicaciones , Estudios de Cohortes , Dabigatrán , Femenino , Hemorragia/inducido químicamente , Humanos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Análisis Multivariante , Estudios Retrospectivos , Factores de Riesgo , Accidente Cerebrovascular/etiología , Resultado del Tratamiento , Estados Unidos , United States Department of Veterans Affairs , beta-Alanina/uso terapéuticoRESUMEN
BACKGROUND: The objective of this study is to examine practice-level variation in rates of guideline-recommended treatment for outpatients with heart failure and reduced ejection fraction, and to examine the association between treatment variation and practice site, independent of patient factors. METHODS AND RESULTS: Cardiology practices participating in the National Cardiovascular Disease Registry Practice Innovation and Clinical Excellence registry from July 2008 to December 2010 were evaluated. Practice rates of treatment with angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and ß-blockers and an optimal combined treatment measure were determined for patients with heart failure and reduced ejection fraction and no documented contraindications. Multivariable hierarchical regression models were adjusted for demographics, insurance status, and comorbidities. A median rate ratio was calculated for each therapy, which describes the likelihood that the treatment of a patient with given comorbidities would differ at 2 randomly selected practices. We identified 12 556 patients from 45 practices. The unadjusted practice-level prescription rates ranged from 44% to 100% for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (median, 85%; interquartile range, 75%-89%), from 49% to 100% for ß-blockers (median, 92%; interquartile range, 83%-95%), and from 37% to 100% for optimal combined treatment (median, 79%; interquartile range, 66%-85%). The adjusted median rate ratio was 1.11 (95% confidence interval, 1.08-1.18) for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers therapy, 1.08 (95% confidence interval, 1.05-1.15) for ß-blockers therapy, and 1.17 (1.13-1.26) for optimal combined treatment. CONCLUSIONS: Variation in the use of guideline-recommended medications for patients with heart failure and reduced ejection fraction exists in the outpatient setting. Addressing practice-level differences may be an important component of improving quality of care for patients with heart failure and reduced ejection fraction.