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BACKGROUND: The risk of ventricular arrhythmias (VAs) after cardiac resynchronization therapy (CRT) has been associated with ischemic disease/scar, sex, and possibly left ventricular mass (LVM). OBJECTIVE: The purpose of this study was to evaluate sex differences and baseline/postimplant change in LVM on VA risk after CRT implantation in patients with nonischemic cardiomyopathy and left bundle branch block. METHODS: In patients meeting the criteria, baseline and follow-up echocardiographic images were obtained for LVM assessment. VA events were reported from device diagnostics and therapies. VA risk was stratified by receiver operating characteristic (Youden index cutoff point) for baseline LVM and baseline/postimplant change in LVM, and baseline patient characteristics by using a multivariable Cox regression model. RESULTS: One hundred eighteen patients (71 female [60.2%]; mean age 60.5 ± 11.3 years; left ventricular ejection fraction 19.2% ± 7.0%; QRS duration 165.6 ± 20 ms; LVM 313.9 ± 108.8 g) were enrolled and followed up for a median of 90 months (interquartile range 44-158 months). Thirty-five patients (29.6%) received appropriate shocks or antitachycardia pacing at a median of 73.5 months (interquartile range 25-130 months) postimplantation. Males had a higher VA incidence (male 18 of 47 [38.3%] vs female 17 of 71 [23.9%]; P = .02). Baseline LVM > 308.9 g separated patients with higher VA risk (P = .001). Less than a 20% decrease in LVM increased VA risk (P < .001). Baseline LVM was the only baseline characteristic predicting VA events in the Cox regression model (hazard ratio 1.01; 95% confidence interval 1.001-1.009; log-rank, P = .003). Sex differences in VA risk were eliminated by the baseline LVM parameters. CONCLUSION: VA risk after CRT in nonischemic cardiomyopathy was associated with baseline LV > 308.9 g and a decrease in LVM ≤ 20%, without sex differences.
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BACKGROUND: Height, left ventricular (LV) size, and sex were proposed as additional criteria for patient selection for cardiac resynchronization therapy (CRT) but their connections with the QRS complex in left bundle branch block (LBBB) are little investigated. We evaluated these. METHODS: Among patients with "true" LBBB, QRS duration (QRSd) and amplitude, and LV hypertrophy indices, were correlated with patient's height and LV mass, and compared between sexes. RESULTS: In this study cohort (n = 220; 60 ± 12 years; left ventricular ejection fraction [LVEF] 21 ± 7%; mostly New York Heart Association II-III, QRSd 165 ± 19 ms; 57% female; 70% responders [LVEF increased ≥5%]), LV mass was increased in all patients. QRS amplitude did not correlate with LV mass or height in any individual lead or with Sokolow-Lyon or Cornell-Lyon indices. QRSd did not correlate with height. In contrast, QRSd correlated strongly with LV mass (r = .51). CRT response rate was greater in women versus men (84% vs. 58%, p < .001) despite shorter QRSd [7% shorter (p < .0001)]. QRSd normalized for height resulted in a 2.7% and for LV mass 24% greater index in women. CONCLUSION: True LBBB criteria do not exclude HF patients with increased LV mass. QRS amplitudes do not correlate with height or LV mass. Height does not affect QRSd. However, QRSd correlates with LV size. QRSd normalized for LV mass results in 24% greater value in women in the direction of sex-specific responses. LV mass may be a significant nonelectrical modifier of QRSd for CRT.
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Terapia de Resincronización Cardíaca , Insuficiencia Cardíaca , Masculino , Humanos , Femenino , Bloqueo de Rama/diagnóstico , Bloqueo de Rama/terapia , Volumen Sistólico/fisiología , Función Ventricular Izquierda/fisiología , Resultado del Tratamiento , Electrocardiografía , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/terapia , Terapia de Resincronización Cardíaca/métodosRESUMEN
INTRODUCTION: A risk calculator paired with a personalized decision aid (RC&DA) may foster shared decision-making in primary care. We assessed the feasibility of using an RC&DA with patients in a primary care outpatient clinic and patients' experiences regarding communication and decision-making. METHODS: This pilot study was conducted with 15 patients of 3 primary care physicians at a clinic within a tertiary medical center. An atherosclerotic cardiovascular disease (ASCVD) risk calculator was used to generate a personalized RC&DA that displayed absolute 10-year risk information as an icon array graphic. Patient perceptions of utility of the RC&DA, preferences for decision-making, and uncertainty with risk reduction decisions were measured with a semi-structured interview. RESULTS: Patients reported that the RC&DA was easy to understand and knowledge gained was useful to modify their ASCVD risk. Patients used the RC&DA to make decisions and reported low uncertainty with those decisions. CONCLUSIONS: Our findings demonstrate the feasibility of, and positive patient experiences related to using, an RC&DA to facilitate shared decision-making between physicians and patients in an outpatient primary care setting.
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OBJECTIVES: Inappropriate antibiotic use for respiratory tract infection (RTI) is an ongoing problem linked to the emergence of drug resistance and other adverse effects. Less is known about the prescribing practices of individual physicians or the impact of physician prescribing habits on patient outcomes. We studied the prescribing practices of providers for acute RTIs in an integrated health system, identified patient factors associated with receipt of an antibiotic and assessed the relation between providers' adjusted prescribing rates and a number of patient outcomes. METHODS: This was a retrospective analysis of adults with an RTI visit to any primary care providers across the Cleveland Clinic Health System in 2011-2012. Patients with a history of chronic obstructive pulmonary disease or immunocompromised status were excluded. Logistic regression was used to examine patient factors associated with receipt of an antibiotic. RESULTS: Of 31,416 patients with an RTI, 54.8% received an antibiotic. Patient factors associated with antibiotic prescribing included white race (odds ratio [OR] 1.35, P < 0.001), presence of fever (OR 1.66, P < 0.001), and a diagnosis of bronchitis (OR 10.98, P < 0.001) or sinusitis (OR 33.85, P < 0.001). Among 290 providers with ≥10 RTI visits, adjusted antibiotic prescribing rates ranged from 0% to 100% (mean 49%). Antibiotics were prescribed more often for sinusitis (OR 33.85, P < 0.001), bronchitis (OR 10.98, P < 0.001), or pharyngitis (OR 1.76, P < 0.001) compared with upper respiratory tract infection. Patients who were prescribed antibiotics at the index visit were more likely to return for RTI within 1 year (adjusted OR 1.26, P < 0.001). Emergency department visits for respiratory complications were rare and not associated with antibiotic receipt. CONCLUSIONS: Antibiotic prescribing for RTI varies widely among physicians and cannot be explained by patient factors. Patients prescribed antibiotics for RTI were more likely to return for RTI.
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Antibacterianos/uso terapéutico , Prescripción Inadecuada/prevención & control , Médicos de Atención Primaria , Pautas de la Práctica en Medicina , Infecciones del Sistema Respiratorio/tratamiento farmacológico , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Ohio/epidemiología , Evaluación del Resultado de la Atención al Paciente , Médicos de Atención Primaria/normas , Médicos de Atención Primaria/estadística & datos numéricos , Pautas de la Práctica en Medicina/normas , Pautas de la Práctica en Medicina/estadística & datos numéricos , Mejoramiento de la Calidad , Infecciones del Sistema Respiratorio/clasificación , Infecciones del Sistema Respiratorio/epidemiología , Estudios RetrospectivosRESUMEN
BACKGROUND: The impact of physician-patient relationship factors, such as physician empathy and burnout, on antibiotic prescribing has not been characterised. AIM: To assess associations between physician empathy and burnout and antibiotic prescribing for acute respiratory infections (ARIs) in primary care. DESIGN AND SETTING: Cross-sectional study of primary care practices in the Cleveland Clinic Health System in the US. METHOD: Patient and prescribing data were obtained from the medical record. All patients with primary diagnoses of ARIs from 1 January 2012 to 31 December 2013, except those with chronic obstructive pulmonary disease (COPD) or who were immunocompromised, were included. Physician empathy was measured using the Jefferson Scale of Empathy while physician burnout was measured using the Maslach Burnout Inventory. The relationship between empathy and burnout and antibiotic prescribing, adjusted for patient and provider characteristics, was analysed using multiple linear regression. RESULTS: In 5937 ARI visits to 102 primary care physicians, the median proportion resulting in antibiotic prescribing was 48.6% (interquartile range [IQR] 24.1% to 70.0%). Neither physician empathy (correlation coefficient [ß] 0.005, 95% confidence interval [CI] = -0.001 to 0.010, P = 0.07) nor any burnout measures were significantly associated with antibiotic prescribing: emotional exhaustion (ß 0.001, 95% CI = -0.005 to 0.006, P = 0.79), tendency to depersonalise patients (ß -0.009, 95% CI = -0.021 to 0.003, P = 0.13), and sense of personal accomplishment (ß -0.004, 95% CI = -0.014 to 0.006, P = 0.44). CONCLUSION: The authors found no significant association between empathy or burnout measures and antibiotic prescribing for ARIs in primary care. Other physician characteristics should be investigated to explain individual variation in antibiotic prescribing.
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Antibacterianos/uso terapéutico , Adhesión a Directriz/estadística & datos numéricos , Prescripción Inadecuada/estadística & datos numéricos , Médicos de Atención Primaria , Pautas de la Práctica en Medicina/estadística & datos numéricos , Atención Primaria de Salud , Infecciones del Sistema Respiratorio/tratamiento farmacológico , Adulto , Agotamiento Profesional/psicología , Estudios Transversales , Empatía , Femenino , Encuestas de Atención de la Salud , Humanos , Masculino , Persona de Mediana Edad , Relaciones Médico-Paciente , Médicos de Atención Primaria/psicología , Guías de Práctica Clínica como Asunto , Estados UnidosRESUMEN
OBJECTIVES: In this study, the authors sought to assess the impact of body and heart size on sex-specific cardiac resynchronization therapy (CRT) response rate, according to QRS duration (QRSd) as a continuum. BACKGROUND: Effects of CRT differ between sexes for any given QRSd. METHODS: New York Heart Association functional class III/IV patients with nonischemic cardiomyopathy and "true" left bundle branch block (LBBB) were evaluated. Left ventricular mass (LVM) and end-diastolic volume were measured echocardiographically. Positive response was defined by left ventricular ejection fraction (LVEF) improvement post-CRT. RESULTS: Among 130 patients (LVEF 19 ± 7.1%; QRSd 165 ± 20 ms; 55% female), CRT improved LVEF to 32 ± 14% (p < 0.001) during a median 2 years follow-up. Positive responses occurred in 103 of 130 (79%) (78% when QRSd <150 ms vs. 80% when QRSd ≥150 ms; p = 0.8). Body surface area (BSA), QRSd, and LVM were lower in women, but QRSd/LVM ratio greater (p < 0.0001). Sexes did not differ for pharmacotherapy and comorbidities, but female CRT response was greater: 90% (65 of 72) versus 66% (38 of 58) in males (p < 0.001). With QRSd as a continuum, the overall CRT-response relationship showed a progressive increase to plateau between 150 and 170 ms, then a decrease. Sex-specific differences were conspicuous: among females, a peak effect was observed between 135 and 150 ms, thereafter a decline, with the male response rate lower, but with a gradual increase as QRSd lengthened. Sex-specific differences were unaltered by BSA, but resolved with integration of LVM or end-diastolic volume. CONCLUSIONS: Sex differences in the QRSd-response relationship among CRT patients with LBBB were unexplained by application of strict LBBB criteria or by BSA, but resolved by QRSd normalization for heart size using LV mass or volume.
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Bloqueo de Rama/terapia , Terapia de Resincronización Cardíaca , Ventrículos Cardíacos/patología , Bloqueo de Rama/patología , Bloqueo de Rama/fisiopatología , Desfibriladores Implantables , Ecocardiografía , Electrocardiografía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Tamaño de los Órganos , Factores Sexuales , Volumen Sistólico , Resultado del TratamientoAsunto(s)
Enfermedades Cardiovasculares/epidemiología , Selección de Paciente , Apnea Obstructiva del Sueño/diagnóstico , Apnea Obstructiva del Sueño/epidemiología , Comorbilidad , Presión de las Vías Aéreas Positiva Contínua , Diabetes Mellitus/epidemiología , Humanos , Polisomnografía , Factores de Riesgo , Apnea Obstructiva del Sueño/terapiaRESUMEN
BACKGROUND: Defensive medicine represents one cause of economic losses in healthcare. Studies that measured its cost have produced conflicting results. OBJECTIVE: To directly measure the proportion of primary care costs attributable to defensive medicine. RESEARCH DESIGN AND METHODS: Six-week prospective study of primary care physicians from four outpatient practices. On 3 distinct days, participants were asked to rate each order placed the day before on the extent to which it represented defensive medicine, using a 5-point scale from 0 (not at all defensive) to 4 (entirely defensive). MAIN OUTCOME MEASURES: This study calculated the order defensiveness score for each order (the defensiveness/4) and the physician defensive score (the mean of all orders defensiveness scores). Each order was assigned a weighted cost by multiplying the total cost of that order (based on Medicare reimbursement rates) by the order defensiveness score. The proportion of total cost attributable to defensive medicine was calculated by dividing the weighted cost of defensive orders by the total cost of all orders. RESULTS: Of 50 eligible physicians, 23 agreed to participate; 21 returned the surveys and rated 1234 individual orders on 347 patients. Physicians wrote an average of 3.6 ± 1.0 orders/visit with an associated total cost of $72.60 ± 18.5 per order. Across physicians, the median physician defensive score was 0.018 (IQR = [0.008, 0.049]) and the proportion of costs attributable to defensive medicine was 3.1% (IQR = [0.5%, 7.2%]). Physicians with defensive scores above vs below the median had a similar number of orders and total costs per visit. Physicians were more likely to place defensive orders if trained in community hospitals vs academic centers (OR = 4.29; 95% CI = 1.55-11.86; p = 0.01). CONCLUSIONS: This study describes a new method to directly quantify the cost of defensive medicine. Defensive medicine appears to have minimal impact on primary care costs.
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Medicina Defensiva/economía , Gastos en Salud/estadística & datos numéricos , Atención Primaria de Salud/economía , Atención Primaria de Salud/estadística & datos numéricos , Femenino , Humanos , Seguro de Salud/estadística & datos numéricos , Masculino , Estudios Prospectivos , Factores Sexuales , Estados UnidosRESUMEN
BACKGROUND: QRS morphology and QRS duration (QRSd) determine cardiac resynchronization therapy (CRT) candidate selection but criteria require refinement. OBJECTIVE: To assess CRT effect according to QRSd, treated by dichotomization vs a continuous function, and modulation by gender. METHODS: Patients selected were those with New York Heart Association class III/IV heart failure and with left bundle branch block and nonischemic cardiomyopathy (to test "pure" CRT effect) with pre- and postimplant echocardiographic evaluations. Positive response was defined as increased left ventricular ejection fraction (LVEF) post-CRT. RESULTS: In 212 patients (LVEF 19% ± 7.1%; QRSd 160 ± 23 ms; 105 (49.5%) women), CRT increased LVEF to 30% ± 15% (P < .001) during a median follow-up of 2 years. Positive response occurred in 150 of 212 (71%) patients. Genders did not differ for QRSd, pharmacotherapy, and comorbidities, but response to CRT among women was greater: incidence 84% (88 of 105) in women vs 58% (62 of 107) in men (P < .001); increase in LVEF 15% ± 14% vs 7.2% ± 13%, respectively (P < .001). Overall, the response rate was 58% when QRSd <150 ms and 76% when QRSd ≥150 ms (P = .009). This probability differed between genders: 86% in women vs 36% in men (P < .001) when QRSd <150 ms and 83% vs 69%, respectively, when QRSd ≥150 ms (P = .05). Thus, female response rates remained high whether QRSd was <150 ms or ≥150 ms (86% vs 83%; P = .77) but differed in men (36% vs 69%; P < .001). With QRSd as a continuum, the CRT-response relationship was nonlinear and significantly different between genders. Female superiority at shorter QRSd inverted with prolongation >180 ms. CONCLUSION: The QRSd-CRT response relationship in patients with heart failure and with left bundle branch block and nonischemic cardiomyopathy is better described by a sex-specific continuous function and not by dichotomization by 150 ms, which excludes a large proportion of women with potentially favorable outcome.
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Bloqueo de Rama/terapia , Terapia de Resincronización Cardíaca/métodos , Cardiomiopatías/terapia , Electrocardiografía , Insuficiencia Cardíaca/terapia , Anciano , Bloqueo de Rama/complicaciones , Bloqueo de Rama/fisiopatología , Cardiomiopatías/complicaciones , Cardiomiopatías/fisiopatología , Ecocardiografía , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/complicaciones , Humanos , Masculino , Persona de Mediana Edad , Probabilidad , Estudios Retrospectivos , Factores Sexuales , Resultado del Tratamiento , Función Ventricular IzquierdaRESUMEN
BACKGROUND: Earlier studies in patients with reduced left ventricular ejection fraction (LVEF) ≤35% and prolonged QRS showed better survival outcomes with cardiac resynchronization therapy (CRT). Some patients respond dramatically to CRT by improving their LVEF to the normal range and are considered "super-responders." Our aim was to determine whether super-responders survival increases to levels comparable to the general population. We compared the survival of super-responders to the general population matched for age and sex. METHODS: Of 909 patients with CRT device implantation between September 1998 and July 2008, 814 patients had pre- and post-CRT echocardiogram. A total of 95 patients with LVEF ≥ 50% following CRT were classified as super-responders. For 92 super-responders, who had U.S. Social Security numbers, an age- and sex-matched example was selected from the Social Security Life Tables. An expected survival plot of the matched population was then compared to the actual survival of super-responders. RESULTS: Super-responders had comparable survival to the age-sex matched general population (P = 0.53), and Kaplan-Meier survival analysis in 92 patients showed that super-responders with CRT pacemakers had similar survival to those with CRT implantable cardioverter defibrillators (P = 0.77). Super-responders were more likely to be females (54% vs 25%, P < 0.001) and less likely to have significant coronary artery disease (62% vs 42%, P < 0.001). CONCLUSIONS: Normalization of LVEF by CRT improves survival to levels comparable to the general population. This observation favors the concept that some CRT candidates have a cardiomyopathy likely generated by the conduction abnormality that is reversible through biventricular pacing.
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Terapia de Resincronización Cardíaca/mortalidad , Terapia de Resincronización Cardíaca/estadística & datos numéricos , Insuficiencia Cardíaca/epidemiología , Insuficiencia Cardíaca/prevención & control , Volumen Sistólico , Disfunción Ventricular Izquierda/mortalidad , Disfunción Ventricular Izquierda/prevención & control , Distribución por Edad , Anciano , Comorbilidad , Femenino , Humanos , Masculino , Ohio/epidemiología , Prevalencia , Estudios Retrospectivos , Factores de Riesgo , Distribución por Sexo , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND: The risk of death and complications of infective endocarditis (IE) treated medically has to be balanced against those from surgery in constructing a therapeutic approach. Recent literature has drawn conflicting conclusions on the benefit of surgery for IE. We reviewed patients treated surgically for IE at the Cleveland Clinic from 2003 to 2007 to examine their outcomes. METHODS: A retrospective review of consecutive patients who underwent surgery for native and prosthetic valve endocarditis between January 1, 2003, and December 31, 2007, was conducted. Surgical outcomes were reviewed to include survival and postoperative complications. Survival was evaluated at end of hospital stay, 30 days, 1 year, and at last follow-up. RESULTS: Four hundred twenty-eight patients underwent surgery for IE during the study period: 248 (58%) had native valve endocarditis and 180 (42%) had prosthetic valve endocarditis. Overall 90% of patients survived to hospital discharge. When compared with patients with native valve infection, patients with prosthetic infection had significantly higher 30-day mortality (13% versus 5.6%; p<0.01), but long-term survival was not significantly different (35% versus 29%; p=0.19). Patients with IE caused by Staphylococcus aureus had significantly higher hospital mortality (15% versus 8.4%; p<0.05), 6-month mortality (23% versus 15%; p=0.05), and 1-year mortality (28% versus 18%; p=0.02) compared with non-S aureus IE. CONCLUSIONS: Surgical treatment of IE was associated with 90% hospital survival. Outcomes within the 30 days were better for native valve than for prosthetic valve endocarditis. Long-term outcomes were similar. Finally, S aureus was associated with significantly higher mortality compared with other pathogens.
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Endocarditis/cirugía , Prótesis Valvulares Cardíacas , Infecciones Relacionadas con Prótesis/cirugía , Adulto , Anciano , Antiinfecciosos/uso terapéutico , Insuficiencia de la Válvula Aórtica/epidemiología , Insuficiencia de la Válvula Aórtica/etiología , Insuficiencia de la Válvula Aórtica/cirugía , Bacteriemia/epidemiología , Bioprótesis/efectos adversos , Terapia Combinada , Comorbilidad , Desbridamiento , Endocarditis/tratamiento farmacológico , Endocarditis/epidemiología , Endocarditis/etiología , Femenino , Estudios de Seguimiento , Prótesis Valvulares Cardíacas/efectos adversos , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/epidemiología , Insuficiencia de la Válvula Mitral/etiología , Insuficiencia de la Válvula Mitral/cirugía , Infecciones Relacionadas con Prótesis/tratamiento farmacológico , Infecciones Relacionadas con Prótesis/epidemiología , Infecciones Relacionadas con Prótesis/etiología , Reoperación , Estudios Retrospectivos , Abuso de Sustancias por Vía Intravenosa/complicaciones , Resultado del Tratamiento , Insuficiencia de la Válvula Tricúspide/epidemiología , Insuficiencia de la Válvula Tricúspide/etiología , Insuficiencia de la Válvula Tricúspide/cirugíaRESUMEN
BACKGROUND: In patients with chronic systolic heart failure who undergo cardiac resynchronization therapy (CRT), improvements in left ventricular ejection fraction (LVEF) and reductions in left ventricular volume are generally modest. A minority of patients experience a dramatic response to CRT (super-responders), but the attributes associated with these patients have not been fully characterized. OBJECTIVE: The purpose of this study was to identify baseline clinical attributes of super-responders and to assess the survival benefit associated with this response. METHODS: We reviewed clinical, echocardiographic, and ECG data from a cohort of 233 patients undergoing new implantation of a CRT device between December 2001 and November 2006. All patients had a baseline LVEF < or =40% and New York Heart Association class II to IV symptoms on standard medical therapy. Patients whose absolute LVEF improved by > or =20% were termed super-responders. A multivariate model was constructed to determine factors predictive of super-response, and an assessment of mortality was made. RESULTS: In this cohort of 233 patients, 32 (13.7%) met criteria for super-response. In univariate analysis, super-responders were more likely to be female and have a native left bundle branch block, lower preimplant brain natriuretic peptide and red cell distribution width levels, and smaller baseline left ventricular volumes with trends toward having more nonischemic cardiomyopathy and midventricular lead positions. In multivariate analysis, only left bundle branch block remained significantly associated with super-response. Super-responders had a considerably lower incidence of mortality compared to non-super-responders (9.4% vs 43.2%, P = .006) at mean follow-up of 5.5 +/- 1.2 years. CONCLUSION: Baseline left bundle branch block is strongly associated with super-response to CRT. Super-responders derive better long-term outcomes with CRT than do non-super-responders.