Journal: Circ Cardiovasc Qual Outcomes

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<div><h4>Patterns and Outcomes of Intensive Care on Acute Ischemic Stroke Patients in the US.</h4><i>Santos D, Maillie L, Dhamoon MS</i><br /><b>Background</b><br />Up to 20% of acute ischemic stroke (AIS) patients may benefit from intensive care unit (ICU)-level care; however, there are few studies evaluating ICU availability for AIS. We aim to summarize the proportion of elderly AIS patients in the United States who are admitted to an ICU and assess the national availability of ICU-level care in AIS.<br /><b>Methods</b><br />We performed a retrospective cohort study using de-identified Medicare inpatient datasets from January 1, 2016 through December 31, 2019 for US individuals aged ≥65 years. We used validated <i>International Classification of Diseases, Tenth Revision</i>, Clinical Modification codes to identify AIS admission and interventions. ICU-level care was identified by revenue center code. AIS patient characteristics and interventions were stratified by receipt of ICU-level care, comparing differences through calculated standardized mean difference score due to large sample sizes.<br /><b>Results</b><br />From 2016 through 2019, a total of 952 400 admissions by 850 055 individuals met criteria for hospital admission for AIS with 19.9% involving ICU-level care. Individuals were predominantly >75 years of age (58.5%) and identified as white (80.0%). Hospitals on average admitted 11.4% (SD 14.6) of AIS patients to the ICU, with the median hospital admitting 7.7% of AIS patients to the ICU. The ICU admissions were younger and more likely to receive reperfusion therapy but had more comorbid conditions and neurologic complications. Of the 5084 hospitals included, 1971 (38.8%) reported no ICU-level AIS care. Teaching hospitals (36.9% versus 1.6%, <i>P</i><0.0001) with larger AIS volume (<i>P</i><0.0001) or in larger metropolitan areas (<i>P</i><0.0001) were more likely to have an ICU available.<br /><b>Conclusions</b><br />We found evidence of national variation in the availability of ICU-level care for AIS admissions. Since ICUs may provide comprehensive care for the most severe AIS patients, continued effort is needed to examine ICU accessibility and utility among AIS.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 03 Feb 2023:e008961; epub ahead of print</small></div>
Santos D, Maillie L, Dhamoon MS
Circ Cardiovasc Qual Outcomes: 03 Feb 2023:e008961; epub ahead of print | PMID: 36734862
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<div><h4>Developing an Actionable Taxonomy of Persistent Hypertension Using Electronic Health Records.</h4><i>Lu Y, Xinxin Du C, Khidir H, Caraballo C, ... Curry LA, Krumholz HM</i><br /><b>Background</b><br />The digital transformation of medical data presents opportunities for novel approaches to manage patients with persistent hypertension. We sought to develop an actionable taxonomy of patients with persistent hypertension (defined as 5 or more consecutive measurements of blood pressure ≥160/100 mmHg over time) based on data from the electronic health records.<br /><b>Methods</b><br />This qualitative study was a content analysis of clinician notes in the electronic health records of patients in the Yale New Haven Health System. Eligible patients were 18 to 85 years and had blood pressure ≥160/100 mmHg at 5 or more consecutive outpatient visits between January 1, 2013 and October 31, 2018. A total of 1664 patients met criteria, of which 200 records were randomly selected for chart review. Through a systematic, inductive approach, we developed a rubric to abstract data from the electronic health records and then analyzed the abstracted data qualitatively using conventional content analysis until saturation was reached.<br /><b>Results</b><br />We reached saturation with 115 patients, who had a mean age of 68.1 (SD, 11.6) years; 54.8% were female; 52.2%, 30.4%, and 13.9% were White, Black, and Hispanic patients. We identified 3 content domains related to persistence of hypertension: (1) non-intensification of pharmacological treatment, defined as absence of antihypertensive treatment intensification in response to persistent severely elevated blood pressure; (2) non-implementation of prescribed treatment, defined as a documentation of provider recommending a specified treatment plan to address hypertension but treatment plan not being implemented; and (3) non-response to prescribed treatment, defined as clinician-acknowledged persistent hypertension despite documented effort to escalate existing pharmacologic agents and addition of additional pharmacologic agents with presumption of adherence.<br /><b>Conclusions</b><br />This study presents a novel actionable taxonomy for classifying patients with persistent hypertension by their contributing causes based on electronic health record data. These categories can be automated and linked to specific types of actions to address them.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 02 Feb 2023:e009453; epub ahead of print</small></div>
Lu Y, Xinxin Du C, Khidir H, Caraballo C, ... Curry LA, Krumholz HM
Circ Cardiovasc Qual Outcomes: 02 Feb 2023:e009453; epub ahead of print | PMID: 36727515
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<div><h4>Methods to Enhance Causal Inference for Assessing Impact of Clinical Informatics Platform Implementation.</h4><i>Gaies M, Olive MK, Owens GE, Charpie JR, ... Schwartz SM, Banerjee M</i><br /><b>Background</b><br />Hospitals are increasingly likely to implement clinical informatics tools to improve quality of care, necessitating rigorous approaches to evaluate effectiveness. We leveraged a multi-institutional data repository and applied causal inference methods to assess implementation of a commercial data visualization software in our pediatric cardiac intensive care unit.<br /><b>Methods</b><br />Natural experiment in the University of Michigan (UM) Cardiac Intensive Care Unit pre and postimplementation of data visualization software analyzed within the Pediatric Cardiac Critical Care Consortium clinical registry; we identified N=21 control hospitals that contributed contemporaneous registry data during the study period. We used the platform during multiple daily rounds to visualize clinical data trends. We evaluated outcomes-case-mix adjusted postoperative mortality, cardiac arrest and unplanned readmission rates, and postoperative length of stay-most likely impacted by this change. There were no quality improvement initiatives focused specifically on these outcomes nor any organizational changes at UM in either era. We performed a difference-in-differences analysis to compare changes in UM outcomes to those at control hospitals across the pre versus postimplementation eras.<br /><b>Results</b><br />We compared 1436 pre versus 779 postimplementation admissions at UM to 19 854 (pre) versus 14 160 (post) at controls. Admission characteristics were similar between eras. Postimplementation at UM we observed relative reductions in cardiac arrests among medical admissions, unplanned readmissions, and postoperative length of stay by -14%, -41%, and -18%, respectively. The difference-in-differences estimate for each outcome was statistically significant (<i>P</i><0.05), suggesting the difference in outcomes at UM pre versus postimplementation is statistically significantly different from control hospitals during the same time.<br /><b>Conclusions</b><br />Clinical registries provide opportunities to thoroughly evaluate implementation of new informatics tools at single institutions. Borrowing strength from multi-institutional data and drawing ideas from causal inference, our analysis solidified greater belief in the effectiveness of this software across our institution.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 02 Feb 2023:e009277; epub ahead of print</small></div>
Gaies M, Olive MK, Owens GE, Charpie JR, ... Schwartz SM, Banerjee M
Circ Cardiovasc Qual Outcomes: 02 Feb 2023:e009277; epub ahead of print | PMID: 36727516
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<div><h4>Contemporary Management Before Chronic Total Occlusion Percutaneous Coronary Interventions: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program.</h4><i>Swat SA, Hebbe A, Plomondon ME, Park KE, ... Waldo SW, Valle JA</i><br /><b>Background</b><br />Guidelines recommend maximal antianginal medical therapy before attempted coronary artery chronic total occlusion (CTO) percutaneous coronary intervention (PCI). The degree to which this occurs in contemporary practice is unknown. We aimed to characterize the frequency and variability of preprocedural use of antianginal therapy and stress testing within 3 months before PCI of CTO (CTO PCI) across a nationally integrated health care system.<br /><b>Methods</b><br />We identified patients who underwent attempted CTO PCI from January 2012 to September 2018 within the Veterans Affairs Healthcare System. Patients were categorized by management before CTO PCI: presence of ≥2 antianginals, stress testing, and ≥2 antianginals and stress testing within 3 months of PCI attempt. Multivariable logistic regression and inverse propensity weighting were used for adjustment before trimming, with median odds ratios calculated for variability estimates.<br /><b>Results</b><br />Among 4250 patients undergoing attempted CTO PCI, 40% received ≥2 antianginal medications and 24% underwent preprocedural stress testing. The odds of antianginal therapy with more than one medication before CTO PCI did not change over the years of the study (odds ratio [OR], 1.0 [95% CI, 0.97-1.04]), whereas the odds of undergoing preprocedural stress testing decreased (OR, 0.97 [95% CI, 0.93-0.99]), and the odds of antianginal therapy with ≥2 antianginals and stress testing did not change (OR, 0.98 [95% CI, 0.93-1.04]). Median odds ratios (MOR) showed substantial variability in antianginal therapy across hospital sites (MOR, 1.3 [95% CI, 1.26-1.42]) and operators (MOR, 1.35 [95% CI, 1.26-1.63]). Similarly, preprocedural stress testing varied significantly by site (MOR, 1.68 [95% CI, 1.58-1.81]) and operator (MOR, 1.80 [95% CI, 1.56-2.38]).<br /><b>Conclusions</b><br />Just under half of patients received guideline-recommended management before CTO PCI, with significant site and operator variability. These findings suggest an opportunity to reduce variability in management before CTO PCI.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 01 Feb 2023:e008949; epub ahead of print</small></div>
Swat SA, Hebbe A, Plomondon ME, Park KE, ... Waldo SW, Valle JA
Circ Cardiovasc Qual Outcomes: 01 Feb 2023:e008949; epub ahead of print | PMID: 36722336
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<div><h4>Validity of International Classification of Diseases (ICD)-10 Diagnosis Codes for Identification of Acute Heart Failure Hospitalization and Heart Failure with Reduced Versus Preserved Ejection Fraction in a National Medicare Sample.</h4><i>Bates BA, Akhabue E, Nahass MM, Mukherjee A, ... Dave CV, Setoguchi S</i><br /><b>Background</b><br />Heart failure (HF) is a leading cause of hospitalization in older adults. Medicare data have been used to assess HF outcomes. However, the validity of ICD-10 diagnosis codes (used since 2015) to identify acute HF hospitalization or distinguish reduced (heart failure with reduced ejection fraction) versus preserved ejection fraction (HFpEF) is unknown in Medicare data.<br /><b>Methods</b><br />Using Medicare data (2015-2017), we randomly sampled 200 HF hospitalizations with ICD-10 diagnosis codes for HF in the first/second claim position in a 1:1:2 ratio for systolic HF (I50.2), diastolic HF (I50.3), and other HF (I50.X). The primary gold standards included recorded HF diagnosis by a treating physician for HF hospitalization, ejection fraction (EF)≤50 for heart failure with reduced ejection fraction, and EF>50 for HFpEF. If the quantitative EF was not present, then qualitative descriptions of EF were used for heart failure with reduced ejection fraction/HFpEF gold standards. Multiple secondary gold standards were also tested. Gold standard data were extracted from medical records using standardized forms and adjudicated by cardiology fellows/staff. We calculated positive predictive values with 95% CIs.<br /><b>Results</b><br />The 200-chart validation sample included 50 systolic, 50 diastolic, 47 combined dysfunction, and 53 unspecified HF patients. The positive predictive values of acute HF hospitalization was 98% [95% CI, 95-100] for first-position ICD-10 HF diagnosis and 66% [95% CI, 58-74] for first/second-position diagnosis. Quantitative EF was available for ≥80% of patients with systolic, diastolic, or combined dysfunction ICD-10 codes. The positive predictive value of systolic HF codes was 90% [95% CI, 82-98] for EFs≤50% and 72% [95% CI, 60-85] for EFs≤40%. The positive predictive value was 92% [95% CI, 85-100] for HFpEF for EFs>50%. The ICD-10 codes for combined or unspecified HF poorly predicted heart failure with reduced ejection fraction or HFpEF.<br /><b>Conclusions</b><br />ICD-10 principal diagnosis identified acute HF hospitalization with a high positive predictive value. Systolic and diastolic ICD-10 diagnoses reliably identified heart failure with reduced ejection fraction and HFpEF when EF 50% was used as the cutoff.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 23 Jan 2023:e009078; epub ahead of print</small></div>
Bates BA, Akhabue E, Nahass MM, Mukherjee A, ... Dave CV, Setoguchi S
Circ Cardiovasc Qual Outcomes: 23 Jan 2023:e009078; epub ahead of print | PMID: 36688301
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<div><h4>Palliative Care Across the Life Span for Children With Heart Disease: A Scientific Statement From the American Heart Association.</h4><i>Blume ED, Kirsch R, Cousino MK, Walter JK, ... Morell E, American Heart Association Pediatric Heart Failure and Transplantation Committee of the Council on Lifelong Congenital Heart Disease and Heart Health in the Young</i><br /><b>Aim</b><br />This summary from the American Heart Association provides guidance for the provision of primary and subspecialty palliative care in pediatric congenital and acquired heart disease.<br /><b>Methods</b><br />A comprehensive literature search was conducted from January 2010 to December 2021. Seminal articles published before January 2010 were also included in the review. Human subject studies and systematic reviews published in English in PubMed, ClinicalTrials.gov, and the Cochrane Collaboration were included.<br /><b>Structure</b><br />Although survival for pediatric congenital and acquired heart disease has tremendously improved in recent decades, morbidity and mortality risks remain for a subset of young people with heart disease, necessitating a role for palliative care. This scientific statement provides an evidence-based approach to the provision of primary and specialty palliative care for children with heart disease. Primary and specialty palliative care specific to pediatric heart disease is defined, and triggers for palliative care are outlined. Palliative care training in pediatric cardiology; diversity, equity, and inclusion considerations; and future research directions are discussed.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 12 Jan 2023:e000114; epub ahead of print</small></div>
Blume ED, Kirsch R, Cousino MK, Walter JK, ... Morell E, American Heart Association Pediatric Heart Failure and Transplantation Committee of the Council on Lifelong Congenital Heart Disease and Heart Health in the Young
Circ Cardiovasc Qual Outcomes: 12 Jan 2023:e000114; epub ahead of print | PMID: 36633003
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<div><h4>Nurturing Diverse Generations of the Medical Workforce for Success With Authenticity: An Association of Black Cardiologists\' Roundtable.</h4><i>Haynes NA, Johnson M, Lewsey SC, Alexander KM, ... Yancy CW, Albert MA</i><br /><AbstractText>The COVID-19 pandemic exposed the consequences of systemic racism in the United States with Black, Hispanic, and other racial and ethnic diverse populations dying at disproportionately higher rates than White Americans. Addressing the social and health disparities amplified by COVID-19 requires in part restructuring of the healthcare system, particularly the diversity of the healthcare workforce to better reflect that of the US population. In January 2021, the Association of Black Cardiologists hosted a virtual roundtable designed to discuss key issues pertaining to medical workforce diversity and to identify strategies aimed at improving racial and ethnic diversity in medical school, graduate medical education, faculty, and leadership positions. The Nurturing Diverse Generations of the Medical Workforce for Success with Authenticity roundtable brought together diverse stakeholders and champions of diversity and inclusion to discuss innovative ideas, solutions, and opportunities to address workforce diversification.</AbstractText><br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 05 Jan 2023:e009032; epub ahead of print</small></div>
Haynes NA, Johnson M, Lewsey SC, Alexander KM, ... Yancy CW, Albert MA
Circ Cardiovasc Qual Outcomes: 05 Jan 2023:e009032; epub ahead of print | PMID: 36603043
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<div><h4>Perioperative Considerations for Pediatric Patients With Congenital Heart Disease Presenting for Noncardiac Procedures: A Scientific Statement From the American Heart Association.</h4><i>Nasr VG, Markham LW, Clay M, DiNardo JA, ... Rotman C, American Heart Association Council on Lifelong Congenital Heart Disease and Heart Health in the Young and Council on Cardiovascular Radiology and Intervention</i><br /><AbstractText>Continuous advances in pediatric cardiology, surgery, and critical care have significantly improved survival rates for children and adults with congenital heart disease. Paradoxically, the resulting increase in longevity has expanded the prevalence of both repaired and unrepaired congenital heart disease and has escalated the need for diagnostic and interventional procedures. Because of this expansion in prevalence, anesthesiologists, pediatricians, and other health care professionals increasingly encounter patients with congenital heart disease or other pediatric cardiac diseases who are presenting for surgical treatment of unrelated, noncardiac disease. Patients with congenital heart disease are at high risk for mortality, complications, and reoperation after noncardiac procedures. Rigorous study of risk factors and outcomes has identified subsets of patients with minor, major, and severe congenital heart disease who may have higher-than-baseline risk when undergoing noncardiac procedures, and this has led to the development of risk prediction scores specific to this population. This scientific statement reviews contemporary data on risk from noncardiac procedures, focusing on pediatric patients with congenital heart disease and describing current knowledge on the subject. This scientific statement also addresses preoperative evaluation and testing, perioperative considerations, and postoperative care in this unique patient population and highlights relevant aspects of the pathophysiology of selected conditions that can influence perioperative care and patient management.</AbstractText><br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 15 Dec 2022:e000113; epub ahead of print</small></div>
Nasr VG, Markham LW, Clay M, DiNardo JA, ... Rotman C, American Heart Association Council on Lifelong Congenital Heart Disease and Heart Health in the Young and Council on Cardiovascular Radiology and Intervention
Circ Cardiovasc Qual Outcomes: 15 Dec 2022:e000113; epub ahead of print | PMID: 36519439
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<div><h4>Association Between Income and Risk of Out-of-Hospital Cardiac Arrest: A Retrospective Cohort Study.</h4><i>van Nieuwenhuizen BP, Tan HL, Blom MT, Kunst AE, van Valkengoed IGM</i><br /><b>Background</b><br />Previous studies have observed a higher out-of-hospital cardiac arrest (OHCA) risk among lower socioeconomic groups. However, due to the cross-sectional and ecological designs used in these studies, the magnitude of these inequalities is uncertain. This study is the first to assess the individual-level association between income and OHCA using a large-scale longitudinal study.<br /><b>Methods</b><br />This retrospective cohort study followed 1 688 285 adults aged 25 and above, living in the catchment area of an OHCA registry in a Dutch province. OHCA cases (n=5493) were linked to demographic and income registries. Cox proportional hazard models were conducted to determine hazard ratios of OHCA for household and personal income quintiles, stratified by sex and age.<br /><b>Results</b><br />The total incidence of OHCA per 100 000 person years was 30.9 in women and 87.1 in men. A higher OHCA risk was observed with lower household and personal income. Compared with the highest household income quintile, the adjusted hazard ratios from the second highest to the lowest household income quintiles ranged from 1.24 (CI=1.01-1.51) to 1.75 (CI=1.46-2.10) in women and from 0.95 (CI=0.68-1.34) to 2.30 (CI=1.74-3.05) in men. For personal income, this ranged from 0.95 (CI=0.68-1.34) to 2.30 (CI=1.74-3.05) in women and between 1.28 (CI=1.16-1.42) and 1.68 (CI=1.48-1.89) in men. Comparable household and personal income gradients were found across age groups except in the highest (>84 years) age group. For example, household income in women aged 65 to 74 ranged from 1.25 (CI=1.02-1.52) to 1.65 (CI=1.36-2.00). Sensitivity analyses assessing the prevalence of comorbidities at baseline and different lengths of follow-up yielded similar estimates.<br /><b>Conclusions</b><br />This study provides new evidence for a substantial increase in OHCA risk with lower income in different age and sex groups. Low-income groups are likely to be a suitable target for intervention strategies to reduce OHCA risk.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 12 Dec 2022:e009080; epub ahead of print</small></div>
van Nieuwenhuizen BP, Tan HL, Blom MT, Kunst AE, van Valkengoed IGM
Circ Cardiovasc Qual Outcomes: 12 Dec 2022:e009080; epub ahead of print | PMID: 36503278
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<div><h4>Efforts to Improve Survival Outcomes of Out-of-Hospital Cardiac Arrest in China: BASIC-OHCA.</h4><i>Xie X, Zheng J, Zheng W, Pan C, ... Xu F, BASIC-OHCA Coordinators and Investigators</i><br /><b>Background</b><br />Establishing registries to collect demographic characteristics, processes of care, and outcomes of patients with out-of-hospital cardiac arrest (OHCA) can better understand epidemiological trends, measure care quality, and identify opportunities for improvement. This study aimed to describe the design, implementation, and scientific significance of a nationwide registry-the BASIC-OHCA (Baseline Investigation of Out-of-Hospital Cardiac Arrest)-in China.<br /><b>Methods</b><br />BASIC-OHCA was designed as a prospective, multicenter, observational, population-based study. The BASIC-OHCA registry was developed based on Utstein templates. BASIC-OHCA includes all OHCA patients confirmed by emergency medical services (EMS) personnel regardless of age, sex, or cause. Patients declared dead at the scene by EMS personnel for any reasons are also included. To fully characterize an OHCA event, BASIC-OHCA collects data from 3 sources-EMS, the receiving hospital, and patient follow-up-and links them to form a single record. Once data entry is completed and quality is checked, individual identifiers are stripped from the record.<br /><b>Results</b><br />Currently, 32 EMS agencies in 7 geographic regions contribute data to BASIC-OHCA. They are distributed in the urban and rural areas, covering ≈9% of the population of mainland China. Data collection started on August 1, 2019. By July 31, 2020, a total of 92 913 EMS-assessed OHCA patients were enrolled. Among 28969 (31.18%) EMS-treated OHCAs\' the mean age was 65.79±17.36 years, and 68.35% were males. The majority of OHCAs (76.85%) occurred at home or residence. A shockable initial rhythm was reported in 5.43% of patients. Any return of spontaneous circulation, survival to hospital discharge, and favorable neurological outcome at hospital discharge were 5.98%, 1.15%, and 0.83%, respectively.<br /><b>Conclusions</b><br />BASIC-OHCA is the first nationwide registry on OHCA in China. It can be used as a public health surveillance system and as a platform to produce evidence-based practices to help identify opportunities for improvement.<br /><b>Registration</b><br />URL: https://www.<br /><b>Clinicaltrials</b><br />gov; Unique identifier: NCT03926325.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 12 Dec 2022:e008856; epub ahead of print</small></div>
Xie X, Zheng J, Zheng W, Pan C, ... Xu F, BASIC-OHCA Coordinators and Investigators
Circ Cardiovasc Qual Outcomes: 12 Dec 2022:e008856; epub ahead of print | PMID: 36503279
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<div><h4>Patient Preferences for Pharmaceutical and Device-based Treatments for Uncontrolled Hypertension: Discrete Choice Experiment.</h4><i>Kandzari DE, Weber MA, Poulos C, Coulter J, ... Jones D, Pathak A</i><br /><b>Background</b><br />Discrete choice experiment is a survey method used to understand how individuals make decisions and to quantify the relative importance of features. Using discrete choice experiment methods, we quantified patient benefit-risk preferences for hypertension treatments, including pharmaceutical and interventional treatments, like renal denervation.<br /><b>Methods</b><br />Respondents from the United States with physician-confirmed uncontrolled hypertension selected between treatments involving a procedure or pills, using a structured survey. Treatment features included interventional, noninterventional, or no hypertension treatment; number of daily blood pressure (BP) pills; expected reduction in office systolic BP; duration of effect; and risks of drug side effects, access site pain, or vascular injury. The results of a random-parameters logit model were used to estimate the importance of each treatment attribute.<br /><b>Results</b><br />Among 400 patients completing the survey between 2020 and 2021, demographics included: 52% women, mean age 59.2±13.0 years, systolic BP 155.1±12.3 mm Hg, and 1.8±0.9 prescribed antihypertensive medications. Reduction in office systolic BP was the most important treatment attribute. The remaining attributes, in decreasing order, were duration of effect, whether treatment was interventional, number of daily pills, risk of vascular injury, and risk of drug side effects. Risk of access site pain did not influence choice. In general, respondents preferred noninterventional over interventional treatments, yet only a 2.3 mm Hg reduction in office systolic BP was required to offset this preference. Small reductions in office systolic BP would offset risks of vascular injury or drug side effects. At least a 20% risk of vascular injury or drug side effects would be tolerated in exchange for improved BP.<br /><b>Conclusions</b><br />Reduction in systolic BP was identified as the most important driver of patient treatment preference, while treatment-related risks had less influence. The results indicate that respondents would accept interventional treatments in exchange for modest reductions in systolic BP compared with those observed in renal denervation trials.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 09 Dec 2022:e008997; epub ahead of print</small></div>
Kandzari DE, Weber MA, Poulos C, Coulter J, ... Jones D, Pathak A
Circ Cardiovasc Qual Outcomes: 09 Dec 2022:e008997; epub ahead of print | PMID: 36484251
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<div><h4>Association of Parental Cardiovascular Health With Disability-Adjusted Life Years in the Offspring: Results From the Framingham Heart Study.</h4><i>Muchira JM, Gona PN, Mogos MF, Stuart-Shor EM, ... Piano MR, Hayman LL</i><br /><b>Background</b><br />Disability-adjusted life years (DALYs) are used to evaluate the relative burden of diseases in populations to help set prevention or treatment priorities. The impact of parental cardiovascular health (CVH) on healthy life years lost from cardiovascular disease (CVD) in adult offspring is unknown. We compared parent-offspring CVD DALYs trends over the life course and examined the association of parental CVH with offspring CVD DALYs.<br /><b>Methods</b><br />Using data from the Framingham Heart Study, 4814 offspring-mother-father trios were matched for age at selected baseline exams. CVH score was computed from the number of CVH metrics attained at recommended levels: poor (0-2), intermediate (3-4), and ideal (5-7). CVD DALYs were defined as the sum of years of life lost and years lived with CVD. Age-sex-standardized life expectancy and disability weights were derived from the actuarial life tables and Global Burden of Disease study, respectively. Multivariable-adjusted linear regression was used to investigate the association of parental CVH with offspring CVD DALYs.<br /><b>Results</b><br />Over an equal 47-year follow-up, parents lost nearly twice the number of CVD DALYs compared to their offspring (23 234 versus 12 217). However, age-adjusted CVD DALYs were higher at younger ages and similar along the life course for parents and offspring. One-unit increase in parental CVH was associated with 5 healthy life months saved in offspring. Offspring of mothers with ideal versus poor CVH had 3 healthy life years saved (β=-3.0 DALYs [95% CI, -5.6 to -0.3]). No statistically significant association was found between paternal CVH categories and offspring CVD DALYs.<br /><b>Conclusions</b><br />Higher maternal and paternal CVH were associated with increased healthy life years in offspring; however, the association was strongest between mothers and offspring. Investment in CVH promotion along the life course has the potential to reduce the burden of CVD in the current and future generation of adults.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 09 Dec 2022:e008809; epub ahead of print</small></div>
Muchira JM, Gona PN, Mogos MF, Stuart-Shor EM, ... Piano MR, Hayman LL
Circ Cardiovasc Qual Outcomes: 09 Dec 2022:e008809; epub ahead of print | PMID: 36484252
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<div><h4>Nationwide Implementation of a Population Management Dashboard for Monitoring Direct Oral Anticoagulants: Insights From the Veterans Affairs Health System.</h4><i>Dorsch MP, Chen CS, Allen AL, Sales AE, ... Sussman JB, Barnes GD</i><br /><b>Background</b><br />Direct oral anticoagulants are first-line therapy for common thrombotic conditions, including atrial fibrillation and venous thromboembolism. Despite their strong efficacy and safety profile, evidence-based prescribing can be challenging given differences in dosing based on indication, renal function, and drug-drug interactions. The Veterans Health Affairs developed and implemented a population management dashboard to support pharmacist review of anticoagulant prescribing. The dashboard includes information about direct oral anticoagulants and dose prescribed, renal function, age, and weight, potential interacting medications, and the need for direct oral anticoagulant medication refills. It is a stand-alone system.<br /><b>Methods</b><br />Using login data from the dashboard, nationwide implementation was evaluated using elements from the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework.<br /><b>Results</b><br />Between August 2016 and June 2020, 150/164 sites within the Veterans Health Affairs system used the dashboard, averaging 1875 patients per site. The dashboard was made available to sites on a staggered basis. Moderate or high adoption, defined as at least one login on at least 2 separate days per month, began slowly with 3/5 sites in the pilot phase but rapidly grew to 142/150 (94.7%) sites by June 2020. The average number of unique users per site increased from 2.4 to 7.5 over the study period. Moderate to high adoption of the dashboard\'s use was maintained for > 6 months in 126/150 (84.0%) sites by the end of the study period.<br /><b>Conclusions</b><br />There was rapid and sustained implementation and adoption of a population health dashboard for evidence-based anticoagulant prescribing across the national United States Veterans Health Administration health system. The impact of this tool on clinical outcomes and strategies to replicate this care model in other health systems will be important for broad dissemination and uptake.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 09 Dec 2022:e009256; epub ahead of print</small></div>
Dorsch MP, Chen CS, Allen AL, Sales AE, ... Sussman JB, Barnes GD
Circ Cardiovasc Qual Outcomes: 09 Dec 2022:e009256; epub ahead of print | PMID: 36484253
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<div><h4>Patient-Reported Versus Physician-Assessed Health Status in Heart Failure With Reduced and Preserved Ejection Fraction From ASIAN-HF Registry.</h4><i>Teramoto K, Tay WT, Tromp J, Katherine Teng TH, ... Mark Richards A, Lam CSP</i><br /><b>Background</b><br />We aimed to assess if discordance between patient-reported Kansas City Cardiomyopathy Questionnaire (KCCQ)-overall summary (os) score and physician-assessed New York Heart Association (NYHA) class is common among patients with heart failure (HF) with reduced or preserved ejection fraction, and determine its association with outcomes.<br /><b>Methods</b><br />A total of 4818 patients with HF were classified according to KCCQ-os score (range 0-100, dichotomized by median value 71.9 into high [good] versus low [bad]) and NYHA class (I/II [good] or III/IV [bad]) as concordant good (low NYHA class, high KCCQ-os score), concordant bad (high NYHA class, low KCCQ-os score), discordant worse NYHA class (high NYHA class, high KCCQ-os score), and discordant worse KCCQ-os score (low NYHA class, low-KCCQ-os score). The composite of HF hospitalization or death at 1 year was compared across groups.<br /><b>Results</b><br />There were 2070 (43.0%) concordant good, 1099 (22.8%) concordant bad, 331 (6.9%) discordant worse NYHA class, and 1318 (27.4%) discordant worse KCCQ-os score patients. Compared with concordant good, adverse outcomes were the highest in concordant bad (HR, 2.7 [95% CI, 2.2-3.5]) followed by discordant worse KCCQ-os score (HR, 1.8 [95% CI, 1.4-2.2]) and discordant worse NYHA class (HR, 1.5 [95% CI, 1.0-2.3]); with no modification by HF phenotype (preserved versus reduced ejection fraction, <i>P</i><sub>interaction</sub>=0.52). At 6 months, 1403 (48%) experienced clinically significant improvement in KCCQ-os score (≥5 points increase over 6 months). Patients with improved KCCQ-os at 6 months (HR, 0.65 [95% CI, 0.47-0.92]) had better outcomes and the association was not modified by HF phenotype (<i>P</i><sub>interaction</sub>=0.40).<br /><b>Conclusions</b><br />One-third of patients with HF had discordance between patient-reported and clinician-assessed health status, largely attributable to worse patient-reported outcomes. Such discordance, particularly in those with discordantly worse KCCQ, should alert physicians to an increased risk of HF hospitalization and death, and prompt further assessment for potential drivers of worse patient-reported outcomes relative to physicians\' assessment.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 09 Dec 2022:e009134; epub ahead of print</small></div>
Teramoto K, Tay WT, Tromp J, Katherine Teng TH, ... Mark Richards A, Lam CSP
Circ Cardiovasc Qual Outcomes: 09 Dec 2022:e009134; epub ahead of print | PMID: 36484254
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<div><h4>Implementation of an Electronic Health Records-Based Safe Contrast Limit for Preventing Contrast-Associated Acute Kidney Injury After Percutaneous Coronary Intervention.</h4><i>Yuan N, Zhang J, Khaki R, Leong D, ... Cheng S, Ebinger JE</i><br /><b>Background</b><br />Contrast-associated acute kidney injury (CA-AKI) after percutaneous coronary intervention is associated with increased mortality. We assessed the effectiveness of an electronic health records safe contrast limit tool in predicting CA-AKI risk and reducing contrast use and CA-AKI.<br /><b>Methods</b><br />We created an alert displaying the safe contrast limit to cardiac catheterization laboratory staff prior to percutaneous coronary intervention. The alert used risk factors automatically extracted from the electronic health records. We included procedures from June 1, 2020 to October 1, 2021; the intervention went live February 10, 2021. Using difference-in-differences analysis, we evaluated changes in contrast volume and CA-AKI rates after contrast limit tool implementation compared to control hospitals. Cardiologists were surveyed prior to and 9 months after alert implementation on beliefs, practice patterns, and safe contrast estimates for example patients.<br /><b>Results</b><br />At the one intervention site, there were 508 percutaneous coronary interventions before and 531 after tool deployment. At 15 control sites, there were 3550 and 3979 percutaneous coronary interventions, respectively. The contrast limit predicted CA-AKI with an accuracy of 64.1%, negative predictive value of 93.3%, and positive predictive value of 18.7%. After implementation, in high/modifiable risk patients (defined as having a calculated contrast limit <500ml) there was a small but significant -4.60 mL/month (95% CI, -8.24 to -1.00) change in average contrast use but no change in CA-AKI rates (odds ratio, 0.96 [95% CI, 0.84-1.10]). Low-risk patients had no change in contrast use (-0.50 mL/month [95% CI, -7.49 to 6.49]) or CA-AKI (odds ratio, 1.24 [95% CI, 0.79-1.93]). In assessing CA-AKI risk, clinicians heavily weighted age and diabetes but often did not consider anemia, cardiogenic shock, and heart failure.<br /><b>Conclusions</b><br />Clinicians often used a simplified assessment of CA-AKI risk that did not include important risk factors, leading to risk estimations inconsistent with established models. Despite clinician skepticism, an electronic health records-based contrast limit tool more accurately predicted CA-AKI risk and was associated with a small decrease in contrast use during percutaneous coronary intervention but no change in CA-AKI rates.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 07 Dec 2022:e009235; epub ahead of print</small></div>
Yuan N, Zhang J, Khaki R, Leong D, ... Cheng S, Ebinger JE
Circ Cardiovasc Qual Outcomes: 07 Dec 2022:e009235; epub ahead of print | PMID: 36475471
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<div><h4>Population-Based Epidemiology of Heart Failure in a Low-Income Country: The Haiti Cardiovascular Disease Cohort.</h4><i>Kingery JR, Roberts NL, Lookens Pierre J, Sufra R, ... Pape JW, McNairy M</i><br /><b>Background</b><br />Cardiovascular disease disproportionately affects persons living in low- and middle-income countries and heart failure (HF) is thought to be a leading cause. Population-based studies characterizing the epidemiology of HF in these settings are lacking. We describe the age-standardized prevalence, survival, subtypes, risk factors, and 1-year mortality of HF in the population-based Haiti Cardiovascular Disease Cohort.<br /><b>Methods</b><br />Participants were recruited using multistage cluster-area random sampling in Port-au-Prince, Haiti. A total of 2981 completed standardized history and exam, laboratory measures, and cardiac imaging. Clinical HF was defined by Framingham criteria. Kaplan-Meier and Cox proportional hazard regression assessed mortality among participants with and without HF; logistic regression identified associated factors.<br /><b>Results</b><br />Among all participants, the median age was 40 years (interquartile range, 27-55), and 58.2% were female. Median follow-up was 15.4 months (interquartile range, 9-22). The age-standardized HF prevalence was 3.2% (93/2981 [95% CI, 2.6-3.9]). The average age of participants with HF was 57 years (interquartile range, 45-65), and 67.7% were female. The first significant increase in HF prevalence occurred between 30 to 39 and 40 to 49 years (1.1% versus 3.7%, <i>P</i>=0.003). HF with preserved ejection fraction was the most common HF subtype (71.0%). Age (adjusted odds ratio, 1.36 [1.12-1.66] per 10-year increase), hypertension (2.14 [1.26-3.66]), obesity (3.35 [95% CI, 1.99-5.62]), poverty (2.10 [1.18-3.72]), and renal dysfunction (5.42 [2.94-9.98]) were associated with HF. One-year HF mortality was 6.6% versus 0.8% (hazard ratio, 7.7 [95% CI, 2.9-20.6]; <i>P</i><0.0001).<br /><b>Conclusions</b><br />The age-standardized prevalence of HF in this low-income setting was alarmingly high at 3.2%-5-fold higher than modeling estimates for low- and middle-income countries. Adults with HF were two decades younger and 7.7× more likely to die at 1 year compared with those in the community without HF. Further research characterizing the population burden of HF in low- and middle-income countries can guide resource allocation and development of pragmatic HF prevention and treatment interventions, ultimately reducing global cardiovascular disease health disparities.<br /><b>Registration</b><br />URL: https://www.<br /><b>Clinicaltrials</b><br />gov; Unique identifier: NCT03892265.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 06 Dec 2022:e009093; epub ahead of print</small></div>
Kingery JR, Roberts NL, Lookens Pierre J, Sufra R, ... Pape JW, McNairy M
Circ Cardiovasc Qual Outcomes: 06 Dec 2022:e009093; epub ahead of print | PMID: 36472189
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<div><h4>Association of Clinical Setting With Sociodemographics and Outcomes Following Endovascular Femoropopliteal Artery Revascularization in the United States.</h4><i>Raja A, Wadhera RK, Choi E, Chen S, ... Yeh RW, Secemsky EA</i><br /><b>Background</b><br />After the Centers for Medicare and Medicaid Services modified reimbursement rates for outpatient peripheral vascular intervention in 2008 with the intent of improving access to care, providers began to increasingly perform peripheral vascular interventions in privately owned office-based clinics. Little is known about the characteristics of patients treated in this setting and their long-term outcomes as compared with those treated in hospital-based centers.<br /><b>Methods</b><br />In this retrospective cohort study, Medicare beneficiaries ≥66 years undergoing outpatient femoropopliteal peripheral vascular interventions in office-based clinics and hospital-based centers from 2015 to 2017 were identified. Sociodemographics, comorbidities, and institutional characteristics were compared across sites. Multivariable Cox proportional hazards models were used to estimate the adjusted associations between practice site location and outcomes. The primary outcome was the composite of major amputation or death analyzed through the end of follow-up.<br /><b>Results</b><br />Among 134 869 patients, 29.9% were treated in office-based clinics and 70.1% in hospital-based centers. Patients treated in office-based clinics were more often Black (16.9% versus 11.9%), dually enrolled in Medicaid (26.3% versus 19.6%), and residents of lower-resourced regions (32.6% versus 25.6%). Over a median follow-up time of 800 days (interquartile range, 531-1119 days), patients treated in office-based clinics had reduced risks of major amputation or death compared with outpatients treated in hospital-based centers (hazard ratio, 0.92 [95% CI, 0.89-0.95]). They also had lower adjusted all-cause mortality (hazard ratio, 0.93 [95% CI, 0.90-0.96]), major lower extremity amputation (hazard ratio, 0.84 [95% CI, 0.79-0.89]), and all-cause hospitalization (hazard ratio, 0.86 [95% CI, 0.84-0.88]). These findings persisted after stratification by critical limb ischemia, race, dual enrollment, and regional socioeconomic status, as well as among operators treating patients in both clinical settings.<br /><b>Conclusions</b><br />In this large nationwide analysis of Medicare beneficiaries, office-based clinics treated a more socioeconomically disadvantaged population compared with hospital-based centers. Long-term outcomes were comparable between locations. As such, these clinics appear to be selecting lower-risk patients for outpatient peripheral vascular interventions, although there remains the possibility of unmeasured confounding.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 06 Dec 2022:e009199; epub ahead of print</small></div>
Raja A, Wadhera RK, Choi E, Chen S, ... Yeh RW, Secemsky EA
Circ Cardiovasc Qual Outcomes: 06 Dec 2022:e009199; epub ahead of print | PMID: 36472193
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<div><h4>Sex Disparities in Failure to Rescue After Cardiac Surgery in California and New York.</h4><i>Alabbadi S, Rowe G, Gill G, Vouyouka A, Chikwe J, Egorova N</i><br /><b>Background</b><br />Women have a higher risk of mortality than men after cardiac surgery independent of other risk factors. The reason for this may not be limited to patient-specific variables. Failure to rescue (FTR) patients from death after a postoperative complication is a nationally endorsed quality care metric. We aimed to identify whether sex disparities exist in the quality of care after cardiac surgery using FTR rates.<br /><b>Methods</b><br />A retrospective analysis of 30 973 men (70.4%) and 13 033 women (29.6%) aged over 18 years undergoing coronary artery bypass graft or valve surgery in New York (2016-2019) and California (2016-2018) who experienced at least one serious postoperative complication. The primary outcome was the FTR. Multivariable logistic regression was used to identify predictors of death after complication. Propensity matching was used to adjust for baseline differences between sexes and yielded 12 657 pairs.<br /><b>Results</b><br />Female patients that experienced complications were older (mean age 67.8 versus 66.7, <i>P</i><0.001), more frail (median frailty score 0.1 versus 0.07, <i>P</i><0.001), and had more comorbidities (median Charlson score 2.5 versus 2.3, <i>P</i><0.001) than male patients. The overall FTR rate was 5.7% (2524), men were less likely to die after a complication than women (4.8% versus 8%, <i>P</i><0.001). Independent predictors of FTR included female sex (relative risk [RR]: 1.46 [CI, 1.30-1.62]), area-level poverty rate >20% (RR, 1.21 [CI, 1.01-1.59]), higher frailty (RR, 2.83 [CI, 1.35-5.93]), undergoing concomitant coronary artery bypass graft and valve surgeries (RR, 1.69 [CI, 1.49-1.9]), and higher number of postoperative complications (RR, 16.28 [CI, 14-18.89]). In the propensity-matched cohorts, the FTR rate remained significantly lower among men than women (6.0% versus 8.0%, <i>P</i><0.001).<br /><b>Conclusions</b><br />Women are less likely to be rescued from death following postoperative complications, independent of socioeconomic and clinical characteristics. Further research is warranted to investigate the clinical practices contributing to this disparity in quality of care following cardiac surgery.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 02 Dec 2022:e009050; epub ahead of print</small></div>
Alabbadi S, Rowe G, Gill G, Vouyouka A, Chikwe J, Egorova N
Circ Cardiovasc Qual Outcomes: 02 Dec 2022:e009050; epub ahead of print | PMID: 36458533
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<div><h4>Comparative Effectiveness and Safety of Direct Oral Anticoagulants Versus Warfarin Among Adults With Cancer and Atrial Fibrillation.</h4><i>Mehta HB, An H, Ardeshirrouhanifard S, Raji MA, Alexander GC, Segal JB</i><br /><b>Background</b><br />While clinical guidelines recommend direct-acting oral anticoagulants (DOAC) over warfarin to treat isolated nonvalvular atrial fibrillation, guidelines are silent regarding nonvalvular atrial fibrillation treatment among individuals with cancer, reflecting the paucity of evidence in this setting. We quantified relative risk of ischemic stroke or systemic embolism and major bleeding (primary outcomes), and all-cause and cardiovascular death (secondary outcomes) among older individuals with cancer and nonvalvular atrial fibrillation comparing DOACs and warfarin.<br /><b>Methods</b><br />This retrospective cohort study used Surveillance, Epidemiology, and End Results cancer registry and linked US Medicare data from 2010 through 2016, and included individuals diagnosed with cancer and nonvalvular atrial fibrillation who newly initiated DOAC or warfarin. We used inverse probability of treatment weighting to control confounding. We used competing risk regression for primary outcomes and cardiovascular death, and Cox proportional hazard regression for all-cause death.<br /><b>Results</b><br />Among 7675 individuals included in the cohort, 4244 (55.3%) received DOACs and 3431 (44.7%) warfarin. In the inverse probability of treatment weighting analysis, there was no statistically significant difference among DOAC and warfarin users in the risk of ischemic stroke or systemic embolism (1.24 versus 1.19 events per 100 person-years, adjusted hazard ratio 1.41 [95% CI, 0.92-2.14]), major bleeding (3.08 versus 4.49 events per 100 person-years, adjusted hazard ratio 0.90 [95% CI, 0.70-1.17]), and cardiovascular death (1.88 versus 3.14 per 100 person-years, adjusted hazard ratio 0.82 [95% CI, 0.59-0.1.13]). DOAC users had significantly lower risk of all-cause death (7.09 versus 13.3 per 100 person-years, adjusted hazard ratio 0.81 [95% CI, 0.69-0.94]) compared to warfarin users.<br /><b>Conclusions</b><br />Older adults with cancer and atrial fibrillation exposed to DOACs had similar risks of stroke and systemic embolism and major bleeding as those exposed to warfarin. Relative to warfarin, DOAC use was associated with a similar risk of cardiovascular death and a lower risk of all-cause death.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 01 Dec 2022:e008951; epub ahead of print</small></div>
Mehta HB, An H, Ardeshirrouhanifard S, Raji MA, Alexander GC, Segal JB
Circ Cardiovasc Qual Outcomes: 01 Dec 2022:e008951; epub ahead of print | PMID: 36453260
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<div><h4>Examination of Sexual Identity Differences in the Prevalence of Hypertension and Antihypertensive Medication Use Among US Adults: Findings From the Behavioral Risk Factor Surveillance System.</h4><i>Sharma Y, Bhargava A, Doan D, Caceres BA</i><br /><b>Background</b><br />Recent evidence suggests that sexual minority (eg, gay/lesbian, bisexual) adults might be at increased risk of hypertension compared with heterosexual adults. However, disparities by sexual identity in antihypertensive medication use among adults with hypertension have not been comprehensively examined.<br /><b>Methods</b><br />We analyzed data from the Behavioral Risk Factor Surveillance System (2015-2019), to examine sexual identity differences in the prevalence of hypertension and antihypertensive medication use among adults. We ran sex-stratified logistic regression models to estimate the odds ratios of diagnosis of hypertension and antihypertensive medication use among sexual minority (ie, gay/lesbian, bisexual, and other) and heterosexual adults (reference group).<br /><b>Results</b><br />The sample included 420 340 participants with a mean age of 49.7 (±17.0) years, of which 66.7% were Non-Hispanic White. Compared with heterosexual participants of the same sex, bisexual women (adjusted odds ratio, 1.19 [95% CI, 1.03-1.37]) and gay men (adjusted odds ratio, 1.18 [95% CI, 1.03-1.35]) were more likely to report having been diagnosed with hypertension. Among women with diagnosed hypertension, bisexual women had lower odds of current antihypertensive medication use (adjusted odds ratio, 0.71 [95% CI, 0.56-0.90]). Among men with diagnosed hypertension, gay men were more likely than heterosexual men to report current antihypertensive medication use (adjusted odds ratio, 1.39 [95% CI, 1.10-1.78]). Compared with heterosexual participants of the same sex, there were no differences in hypertension or antihypertensive medication use among lesbian women, bisexual men, and participants who reported their sexual identity as other.<br /><b>Conclusions</b><br />Clinical and public health interventions are needed to reduce the risk of hypertension among bisexual women and gay men. Bisexual women were at higher risk of untreated hypertension, which may be attributed to lower health care utilization due to fear of discrimination from health care providers and socioeconomic disadvantage. Future research is needed to better understand factors that may contribute to untreated hypertension among bisexual women with hypertension.<br /><br /><br /><br /><small>Circ Cardiovasc Qual Outcomes: 01 Dec 2022; 15:e008999</small></div>

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