Journal: Circ Cardiovasc Qual Outcomes

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Abstract

Incidence of Timely Outpatient Follow-Up Care After Emergency Department Encounters for Acute Heart Failure.

Kilaru AS, Illenberger N, Meisel ZF, Groeneveld PW, ... Mitra N, Merchant RM
Background
Patients who are discharged from the emergency department (ED) after an encounter for acute heart failure are at high risk for return hospitalization. These patients may benefit from timely outpatient follow-up care to reassess volume status, adjust medications, and reinforce self-care strategies. This study examines the incidence of outpatient follow-up care after ED encounters for acute heart failure and describes patient characteristics associated with obtaining timely follow-up care.
Methods
We conducted a retrospective cohort study using an administrative claims database for a large US commercial insurer, from January 1, 2012 to June 30, 2019. Participants included adult patients discharged from the ED with principal diagnosis of acute heart failure. The primary outcome was obtaining an in-person outpatient clinic visit for heart failure within 30 days. We also examined the competing risk of all-cause hospitalization within 30 days and without an intervening outpatient clinic visit. We estimated competing risk regression models to identify patient characteristics associated with obtaining outpatient follow-up and report cause-specific hazard ratios.
Results
The cohort included 52 732 patients, with mean age of 73.9 years (95% CI, 73.8-74.0) and 27 395 (52.0% [95% CI, 51.5-52.4]) female patients. Within 30 days of the ED encounter, 12 279 (23.2%) patients attended an outpatient clinic visit for heart failure, with 8382 (15.9%) patients hospitalized before they could obtain an outpatient clinic visit. In the adjusted analysis, patients that were younger, women, reporting non-Hispanic Black race, and had fewer previous clinic visits were less likely to obtain outpatient follow-up care.
Conclusions
Few patients obtain timely outpatient follow-up after ED visits for heart failure, although nearly 20% require hospitalization within 30 days. Improved transitions following discharge from the ED may represent an opportunity to improve outcomes for patients with acute heart failure.



Circ Cardiovasc Qual Outcomes: 08 Sep 2022:101161CIRCOUTCOMES122009001; epub ahead of print
Kilaru AS, Illenberger N, Meisel ZF, Groeneveld PW, ... Mitra N, Merchant RM
Circ Cardiovasc Qual Outcomes: 08 Sep 2022:101161CIRCOUTCOMES122009001; epub ahead of print | PMID: 36073354
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Abstract

Examining the Linear Association Between Blood Pressure Levels and Cardiovascular Diseases in the Absence of Major Risk Factors in China.

Zheng R, Xu Y, Li M, Lu J, ... Bi Y, 4C Study Group†
Background
Many studies demonstrate a J-shaped association between blood pressure and cardiovascular diseases (CVDs), but the findings are plagued by confounding from other traditional cardiovascular risk factors (CVRFs). Our aims were to examine the associations of systolic blood pressure (SBP) and diastolic blood pressure (DBP) levels with CVD in individuals without major CVRFs and whether there were thresholds for the association.
Methods
In the 4C study (China Cardiometabolic Disease and Cancer Cohort), 36 042 CVRF-free participants without CVD, diabetes, dyslipidemia, hypertension, or smoking were identified during 2011 to 2012. Among CVRF-free participants, 17 476 CVRF-preferable individuals with better glycemic (fasting glucose, <110 mg/dL; 2-hour post-load glucose, <140 mg/dL) and lipid profile (total cholesterol, <200 mg/dL; LDL [low-density lipoprotein] cholesterol, <130 mg/dL) were selected. The total person-years of follow-up for CVRF-free subjects and CVRF-preferable subjects were 130 147 and 63 573 person-years, respectively. Information on the development of major CVDs was collected during 2014 to 2016. Cox proportional hazard models were performed to estimate the risks for incident CVD by SBP and DBP groups, respectively.
Results
We found that both baseline SBP and DBP presented significantly linear associations with CVD risks in CVRF-free and CVRF-preferable participants. There is significant increase in the CVD risk among CVRF-free participants with baseline SBP level of 110 to 119 mm Hg (hazard ratio, 1.79 [95% CI, 1.19-2.71]), 120 to 129 mm Hg (hazard ratio, 2.03 [95% CI, 1.36-3.03]), and 130 to 139 mm Hg (hazard ratio, 2.15 [95% CI, 1.40-3.28]) compared with SBP <110 mm Hg. Significant increases were also observed for DBP level of 80 to 89 mm Hg (hazard ratio, 1.43 [95% CI, 1.03-1.97]) compared with DBP <70 mm Hg. Similar results were observed in CVRF-preferable participants.
Conclusions
SBP and DBP with levels currently considered normal were significantly and linearly associated with incident CVD without thresholds above 110/70 mm Hg among Chinese adults without major CVRFs.



Circ Cardiovasc Qual Outcomes: 06 Sep 2022:101161CIRCOUTCOMES121008774; epub ahead of print
Zheng R, Xu Y, Li M, Lu J, ... Bi Y, 4C Study Group†
Circ Cardiovasc Qual Outcomes: 06 Sep 2022:101161CIRCOUTCOMES121008774; epub ahead of print | PMID: 36065814
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Abstract

Association Between Care Fragmentation and Total Spending After Durable Left Ventricular Device Implant: A Mediation Analysis of Health Care-Associated Infections Within a National Medicare-Society of Thoracic Surgeons Intermacs Linked Dataset.

Kim KD, Funk RJ, Hou H, Airhart A, ... Likosky DS, Michigan Congestive Heart Failure Investigators
Background
Care fragmentation is associated with higher rates of infection after durable left ventricular assist device (LVAD) implant. Less is known about the relationship between care fragmentation and total spending, and whether this relationship is mediated by infections.
Methods
Total payments were captured from admission to 180 days post-discharge. Drawing on network theory, a measure of care fragmentation was developed based on the number of shared patients among providers (ie, anesthesiologists, cardiac surgeons, cardiologists, critical care specialists, nurse practitioners, physician assistants) caring for 4,987 Medicare beneficiaries undergoing LVAD implantation between July 2009 - April 2017. Care fragmentation was measured using average path length, which describes how efficiently information flows among network members; longer path length indicates greater fragmentation. Terciles based on the level of care fragmentation and multivariable regression were used to analyze the relationship between care fragmentation and LVAD payments and mediation analysis was used to evaluate the role of post-implant infections.
Results
The patient cohort was 81% male, 73% white, 11% Intermacs Profile 1 with mean (SD) age of 63.1 years (11.1). The mean (SD) level of care fragmentation in provider networks was 1.7 (0.2) and mean (SD) payment from admission to 180 days post-discharge was $246,905 ($109,872). Mean (SD) total payments at the lower, middle, and upper terciles of care fragmentation were $250,135 ($111,924), $243,288 ($109,376), and $247,290 ($108,241), respectively. In mediation analysis, the indirect effect of care fragmentation on total payments, through infections, was positive and statistically significant (β=16032.5, p=0.008).
Conclusions
Greater care fragmentation in the delivery of care surrounding durable LVAD implantation is associated with a higher incidence of infections, and consequently, higher payments for Medicare beneficiaries. Interventions to reduce care fragmentation may reduce the incidence of infections and in turn enhance the value of care for patients undergoing durable LVAD implantation.



Circ Cardiovasc Qual Outcomes: 06 Sep 2022:101161CIRCOUTCOMES121008592; epub ahead of print
Kim KD, Funk RJ, Hou H, Airhart A, ... Likosky DS, Michigan Congestive Heart Failure Investigators
Circ Cardiovasc Qual Outcomes: 06 Sep 2022:101161CIRCOUTCOMES121008592; epub ahead of print | PMID: 36065815
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Abstract

Urban Spatial Accessibility of Primary Care and Hypertension Control and Awareness on Chicago\'s South Side: A Study From the COMPASS Cohort.

Luo J, Kibriya MG, Zakin P, Craver A, ... Ahsan H, Aschebrook-Kilfoy B
Background
Understanding the relationship between hypertension and spatial accessibility of primary care can inform interventions to improve hypertension control and awareness, especially among disadvantaged populations. This study aims to investigate the association between spatial accessibility of primary care and hypertension control and awareness.
Methods
Participant data from the COMPASS (Chicago Multiethnic Prevention and Surveillance Study) between 2013 and 2019 were analyzed. All participants were geocoded. Locations of primary care providers in Chicago were obtained from MAPSCorps. A score was generated for spatial accessibility of primary care using an enhanced 2-step floating catchment area method. A higher score indicates greater accessibility. Measured hypertension was defined as systolic blood pressure ≥130 mm Hg or diastolic blood pressure ≥80 mm Hg. Logistic regression was used to estimate odds ratio and 95% CI for hypertension status in relation to accessibility score quartiles.
Results
Five thousand ninety-six participants (mean age, 53.4±10.8) were included. The study population was predominantly non-Hispanic black (84.0%), over 53% reported an annual household income <$15 000, and 37.3% were obese. Measured hypertension prevalence was 78.7% in this population, among which 37.7% were uncontrolled and 41.0% were unaware. A higher accessibility score was associated with lower measured hypertension prevalence. In fully adjusted models, compared with the first (lowest) quartile of accessibility score, the odds ratio strengthened from 0.82 (95% CI, 0.67-1.01) for the second quartile to 0.75 (95% CI, 0.62-0.91) for the third quartile, and further to 0.73 (95% CI, 0.60-0.89) for the fourth (highest) quartile. The increasing trend had a P<0.01. Similar associations were observed for both uncontrolled and unaware hypertensions. When stratified by neighborhood socioeconomic status, a higher accessibility score was associated with lower rates of unaware hypertension in both disadvantaged and nondisadvantaged neighborhoods.
Conclusions
Better spatial accessibility of primary care is associated with improved hypertension awareness and control.



Circ Cardiovasc Qual Outcomes: 06 Sep 2022:101161CIRCOUTCOMES121008845; epub ahead of print
Luo J, Kibriya MG, Zakin P, Craver A, ... Ahsan H, Aschebrook-Kilfoy B
Circ Cardiovasc Qual Outcomes: 06 Sep 2022:101161CIRCOUTCOMES121008845; epub ahead of print | PMID: 36065817
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Abstract

Association of Rapid Response Teams With Hospital Mortality in Medicare Patients.

Girotra S, Jones PG, Peberdy MA, Vaughan-Sarrazin MS, Chan PS, American Heart Association GWTG-Resuscitation Investigators
Background
Although rapid response teams have been widely promoted as a strategy to reduce unexpected hospital deaths, most studies of rapid response teams have not adjusted for secular trends in mortality before their implementation. We examined whether implementation of a rapid response team was associated with a reduction in hospital mortality after accounting for preimplementation mortality trends.
Methods
Among 56 hospitals in Get With The Guidelines-Resuscitation linked to Medicare, we calculated the annual rates of case mix-adjusted mortality for each hospital during 2000 to 2014. We constructed a hierarchical log-binomial regression model of mortality over time (calendar-year), incorporating terms to capture the effect of rapid response teams, to determine whether implementation of rapid response teams was associated with reduction in hospital mortality that was larger than expected based on preimplementation trends, while adjusting for hospital case mix index.
Results
The median annual number of Medicare admissions was 5214 (range, 408-18 398). The median duration of preimplementation and postimplementation period was 7.6 years (≈2.5 million admissions) and 7.2 years (≈2.6 million admissions), respectively. Hospital mortality was decreasing by 2.7% annually during the preimplementation period. Implementation of rapid response teams was not associated with a change in mortality during the initial year (relative risk for model intercept, 0.98 [95% CI, 0.94-1.02]; P=0.30) or in the mortality trend (relative risk for model slope, 1.01 per year [95% CI, 0.99-1.02]; P=0.30). Among individual hospitals, implementation of a rapid response team was associated with a lower-than-expected mortality at only 4 (7.1%) and higher-than-expected mortality at 2 (3.7%) hospitals.
Conclusions
Among a large and diverse sample of US hospitals, we did not find implementation of rapid response teams to be associated with reduction in hospital mortality. Studies are needed to understand best practices for rapid response team implementation, to ensure that hospital investment in these teams improves patient outcomes.



Circ Cardiovasc Qual Outcomes: 06 Sep 2022:101161CIRCOUTCOMES122008901; epub ahead of print
Girotra S, Jones PG, Peberdy MA, Vaughan-Sarrazin MS, Chan PS, American Heart Association GWTG-Resuscitation Investigators
Circ Cardiovasc Qual Outcomes: 06 Sep 2022:101161CIRCOUTCOMES122008901; epub ahead of print | PMID: 36065818
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Abstract

Association Between Medicare Program Type and Health Care Access, Acute Care Utilization, and Affordability Among Adults With Cardiovascular Disease.

Oseran AS, Sun T, Aggarwal R, Kyalwazi A, Yeh RW, Wadhera RK
Background
Medicare Advantage plans now provide health insurance coverage to >24 million older adults in the United States, and enrollment is increasing among individuals with cardiovascular disease (CVD). Whether Medicare Advantage enrollment is associated with similar health care access, acute care utilization, and financial strain for adults with CVD compared with traditional Medicare is unknown.
Methods
We performed a cross-sectional study of Medicare beneficiaries 65 years or older with CVD using the 2019 National Health Interview Survey. We fit multivariable logistic regression models to examine the association of Medicare program type (Medicare Advantage versus traditional Medicare) with measures of health care access, acute care utilization, and affordability.
Results
The weighted population included 11 013 437 Medicare beneficiaries, of whom 3 922 104 (35.6%) were enrolled in Medicare Advantage, and 7 091 334 (64.4%) were enrolled in traditional Medicare. Medicare Advantage and traditional Medicare enrollees were similar with respect to age, sex, racial/ethnic distribution, and household income; however, Medicare Advantage beneficiaries were more likely to live in an urban setting (82.7% versus 76.0%; P=0.01) and to be college educated (24.2% versus 19.0%; P=0.01). Medicare Advantage beneficiaries were more likely to have a usual source of care (93.5% versus 88.9%; OR, 1.99 [95% CI, 1.33-2.98)]; however, there were no other differences in health care access or utilization. Medicare Advantage beneficiaries were more likely to have problems paying medical bills (16.5% versus 11.6%; OR, 1.68 [1.17-2.40]) and to worry about paying medical bills (40.1% versus 33.8%; OR, 1.37 [1.07-1.76]) compared with those enrolled in traditional Medicare.
Conclusions
Adults with CVD in Medicare Advantage were more likely to experience financial strain related to their medical bills compared with those in traditional Medicare. As enrollment in Medicare Advantage grows, policy efforts should focus on ensuring care is affordable for patients with CVD.



Circ Cardiovasc Qual Outcomes: 02 Sep 2022:101161CIRCOUTCOMES121008762; epub ahead of print
Oseran AS, Sun T, Aggarwal R, Kyalwazi A, Yeh RW, Wadhera RK
Circ Cardiovasc Qual Outcomes: 02 Sep 2022:101161CIRCOUTCOMES121008762; epub ahead of print | PMID: 36052688
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Abstract

Characterizing the Accuracy of ICD-10 Administrative Claims for Aortic Valve Disease.

Strom JB, Xu J, Sun T, Song Y, ... Wadhera RK, Yeh RW
Background: Administrative claims for aortic stenosis (AS) regurgitation (AR) may be useful but their accuracy and ability to identify individuals at risk for valve-related outcomes has not been well characterized.
Methods:
Using echocardiographic (TTE) reports linked to US Medicare claims, 2017-2018, the performance of candidate International Classification of Diseases, 10th Revision (ICD-10) claims to ascertain AS/AR was evaluated. The optimal performing algorithm was tested against outcomes at 1-year after TTE in a separate 100% sample of US Medicare claims, 2017-2019.
Results:
Of those included in the derivation (N = 5497, mean age 74.4 ± 11.0 years, 49.7% female), any AS or AR was present in 24% and 38.8%, respectively. The sensitivity and specificity of ICD-10 code I35.0 for identification of any AS was 53.1% and 94.8%, respectively. Amongst those with an I35.0 code, 40.3% had severe AS. Claims were unable to distinguish disease severity (i.e. severe vs. non-severe) or subtype (e.g. bicuspid or rheumatic AS), and were insensitive and nonspecific for AR of any severity. Among all beneficiaries who received a TTE (N = 4,033,844), adjusting for age, sex, and 27 comorbidities, those with an I35.0 code had a higher adjusted risk of all-cause mortality (adjusted hazard ratio [HR] 1.33, 95% CI 1.31-1.34), heart failure hospitalization (adjusted HR 1.37, 95% CI 1.34-1.41), and aortic valve replacement (adjusted HR 34.96, 95% CI 33.74-36.22). Conclusions: Among US Medicare beneficiaries receiving a TTE, ICD-10 claims, though identifying a population at significant greater risk of valve-related outcomes, failed to identify nearly half of individuals with AS and were unable to distinguish disease severity or subtype. These results argue against the widespread use of ICD-10 claims to screen for patients with AS and suggest the need for improved coding algorithms and alternative systems to extract TTE data for quality improvement and hospital benchmarking.




Circ Cardiovasc Qual Outcomes: 27 Aug 2022; epub ahead of print
Strom JB, Xu J, Sun T, Song Y, ... Wadhera RK, Yeh RW
Circ Cardiovasc Qual Outcomes: 27 Aug 2022; epub ahead of print | PMID: 36029191
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Abstract

Maintaining a National Acute Kidney Injury Risk Prediction Model to Support Local Quality Benchmarking.

Davis SE, Brown JR, Dorn C, Westerman D, Solomon RJ, Matheny ME
Background
The utility of quality dashboards to inform decision-making and improve clinical outcomes is tightly linked to the accuracy of the information they provide and, in turn, accuracy of underlying prediction models. Despite recognition of the need to update prediction models to maintain accuracy over time, there is limited guidance on updating strategies. We compare predefined and surveillance-based updating strategies applied to a model supporting quality evaluations among US veterans.
Methods
We evaluated the performance of a US Department of Veterans Affairs-specific model for postcardiac catheterization acute kidney injury using routinely collected observational data over the 6 years following model development (n=90 295 procedures in 2013-2019). Predicted probabilities were generated from the original model, an annually retrained model, and a surveillance-based approach that monitored performance to inform the timing and method of updates. We evaluated how updating the national model impacted regional quality profiles. We compared observed-to-expected outcome ratios, where values above and below 1 indicated more and fewer adverse outcomes than expected, respectively.
Results
The original model overpredicted risk at the national level (observed-to-expected outcome ratio, 0.75 [0.74-0.77]). Annual retraining updated the model 5×; surveillance-based updating retrained once and recalibrated twice. While both strategies improved performance, the surveillance-based approach provided superior calibration (observed-to-expected outcome ratio, 1.01 [0.99-1.03] versus 0.94 [0.92-0.96]). Overprediction by the original model led to optimistic quality assessments, incorrectly indicating most of the US Department of Veterans Affairs\' 18 regions observed fewer acute kidney injury events than predicted. Both updating strategies revealed 16 regions performed as expected and 2 regions increasingly underperformed, having more acute kidney injury events than predicted.
Conclusions
Miscalibrated clinical prediction models provide inaccurate pictures of performance across clinical units, and degrading calibration further complicates our understanding of quality. Updating strategies tailored to health system needs and capacity should be incorporated into model implementation plans to promote the utility and longevity of quality reporting tools.



Circ Cardiovasc Qual Outcomes: 12 Aug 2022:101161CIRCOUTCOMES121008635; epub ahead of print
Davis SE, Brown JR, Dorn C, Westerman D, Solomon RJ, Matheny ME
Circ Cardiovasc Qual Outcomes: 12 Aug 2022:101161CIRCOUTCOMES121008635; epub ahead of print | PMID: 35959674
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Abstract

Artificial Intelligence-Enabled Model for Early Detection of Left Ventricular Hypertrophy and Mortality Prediction in Young to Middle-Aged Adults.

Liu CM, Hsieh ME, Hu YF, Wei TY, ... Chen SA, Tseng VS
Background
Concealed left ventricular hypertrophy (LVH) is a prevalent condition that is correlated with a substantial risk of cardiovascular events and mortality, especially in young to middle-aged adults. Early identification of LVH is warranted. In this work, we aimed to develop an artificial intelligence (AI)-enabled model for early detection and risk stratification of LVH using 12-lead ECGs.
Methods
By deep learning techniques on the ECG recordings from 28 745 patients (20-60 years old), the AI model was developed to detect verified LVH from transthoracic echocardiography and evaluated on an independent cohort. Two hundred twenty-five patients from Japan were externally validated. Cardiologists\' diagnosis of LVH was based on conventional ECG criteria. The area under the curve (AUC), sensitivity, and specificity were applied to evaluate the model performance. A Cox regression model estimated the independent effects of AI-predicted LVH on cardiovascular or all-cause death.
Results
The AUC of the AI model in diagnosing LVH was 0.89 (sensitivity: 90.3%, specificity: 69.3%), which was significantly better than that of the cardiologists\' diagnosis (AUC, 0.64). In the second independent cohort, the diagnostic performance of the AI model was consistent (AUC, 0.86; sensitivity: 85.4%, specificity: 67.0%). After a follow-up of 6 years, AI-predicted LVH was independently associated with higher cardiovascular or all-cause mortality (hazard ratio, 1.91 [1.04-3.49] and 1.54 [1.20-1.97], respectively). The predictive power of the AI model for mortality was consistently valid among patients of different ages, sexes, and comorbidities, including hypertension, diabetes, stroke, heart failure, and myocardial infarction. Last, we also validated the model in the international independent cohort from Japan (AUC, 0.83).
Conclusions
The AI model improved the detection of LVH and mortality prediction in the young to middle-aged population and represented an attractive tool for risk stratification. Early identification by the AI model gives every chance for timely treatment to reverse adverse outcomes.



Circ Cardiovasc Qual Outcomes: 12 Aug 2022:101161CIRCOUTCOMES121008360; epub ahead of print
Liu CM, Hsieh ME, Hu YF, Wei TY, ... Chen SA, Tseng VS
Circ Cardiovasc Qual Outcomes: 12 Aug 2022:101161CIRCOUTCOMES121008360; epub ahead of print | PMID: 35959675
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Abstract

Indications for Left Atrial Appendage Occlusion in the United States and Associated In-Hospital Outcomes: Results From the NCDR LAAO Registry.

Daimee UA, Wang Y, Masoudi FA, Varosy PD, ... Curtis JP, Freeman JV
Background
The Food and Drug Administration approved left atrial appendage occlusion with the Watchman device for patients who are at increased stroke risk and are suitable for oral anticoagulation but who have an appropriate reason to seek a nondrug alternative. These broad criteria raise the question of their interpretation in clinical practice. There is a lack of studies comprehensively evaluating the indications for Watchman implantation among a large series of patients from contemporary, real-world practice in the United States.
Methods
We used the National Cardiovascular Data Registry Left Atrial Appendage Occlusion Registry to identify Watchman procedures performed between 2016 and 2018. We assessed procedural indications for Watchman implantation in the United States and evaluated the association between procedural indications and in-hospital adverse events.
Results
A total of 38 314 procedures were included. The mean patient age was 76.1±8.1 years, and 58.9% were men. The mean CHA2DS2-VASc score was 4.8±1.5, whereas the mean hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol (HAS-BLED) score was 3.0±1.1. Prior stroke or transient ischemic attack was reported in 40.2% and prior bleeding in 70.1%, with gastrointestinal bleeding being most common (41.9%). The most common site-reported procedural indications for Watchman implantation were increased thromboembolic risk (64.8%) and history of major bleed (64.3%), followed by high fall risk (35.5%). Most (71.9%) had ≥2 procedural indications. Patients with high fall risk had increased risk of in-hospital adverse events (adjusted OR, 1.12; P=0.025), but no other differences were found in the risk of in-hospital adverse events by procedural indication.
Conclusions
Among patients in the National Cardiovascular Data Registry Left Atrial Appendage Occlusion Registry, the most common procedural indications for Watchman implantation were increased thromboembolic risk, history of major bleed, and high fall risk. A majority of patients had multiple procedural indications. High fall risk conferred a modestly increased risk of in-hospital adverse events.



Circ Cardiovasc Qual Outcomes: 12 Aug 2022:101161CIRCOUTCOMES121008418; epub ahead of print
Daimee UA, Wang Y, Masoudi FA, Varosy PD, ... Curtis JP, Freeman JV
Circ Cardiovasc Qual Outcomes: 12 Aug 2022:101161CIRCOUTCOMES121008418; epub ahead of print | PMID: 35959677
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Abstract

County-Level Social Vulnerability is Associated With In-Hospital Death and Major Adverse Cardiovascular Events in Patients Hospitalized With COVID-19: An Analysis of the American Heart Association COVID-19 Cardiovascular Disease Registry.

Islam SJ, Malla G, Yeh RW, Quyyumi AA, ... Goyal A, Wadhera RK
Background
The COVID-19 pandemic has disproportionately affected low-income and racial/ethnic minority populations in the United States. However, it is unknown whether hospitalized patients with COVID-19 from socially vulnerable communities experience higher rates of death and/or major adverse cardiovascular events (MACEs). Thus, we evaluated the association between county-level social vulnerability and in-hospital mortality and MACE in a national cohort of hospitalized COVID-19 patients.
Methods
Our study population included patients with COVID-19 in the American Heart Association COVID-19 Cardiovascular Disease Registry across 107 US hospitals between January 14, 2020 to November 30, 2020. The Social Vulnerability Index (SVI), a composite measure of community vulnerability developed by Centers for Disease Control and Prevention, was used to classify the county-level social vulnerability of patients\' place of residence. We fit a hierarchical logistic regression model with hospital-level random intercepts to evaluate the association of SVI with in-hospital mortality and MACE.
Results
Among 16 939 hospitalized COVID-19 patients in the registry, 5065 (29.9%) resided in the most vulnerable communities (highest national quartile of SVI). Compared with those in the lowest quartile of SVI, patients in the highest quartile were younger (age 60.2 versus 62.3 years) and more likely to be Black adults (36.7% versus 12.2%) and Medicaid-insured (31.1% versus 23.0%). After adjustment for demographics (age, sex, race/ethnicity) and insurance status, the highest quartile of SVI (compared with the lowest) was associated with higher likelihood of in-hospital mortality (OR, 1.25 [1.03-1.53]; P=0.03) and MACE (OR, 1.26 [95% CI, 1.05-1.50]; P=0.01). These findings were not attenuated after accounting for clinical comorbidities and acuity of illness on admission.
Conclusions
Patients hospitalized with COVID-19 residing in more socially vulnerable communities experienced higher rates of in-hospital mortality and MACE, independent of race, ethnicity, and several clinical factors. Clinical and health system strategies are needed to improve health outcomes for socially vulnerable patients.



Circ Cardiovasc Qual Outcomes: 18 Jul 2022:101161CIRCOUTCOMES121008612; epub ahead of print
Islam SJ, Malla G, Yeh RW, Quyyumi AA, ... Goyal A, Wadhera RK
Circ Cardiovasc Qual Outcomes: 18 Jul 2022:101161CIRCOUTCOMES121008612; epub ahead of print | PMID: 35862003
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Abstract

Psychological Outcomes and Interventions for Individuals With Congenital Heart Disease: A Scientific Statement From the American Heart Association.

Kovacs AH, Brouillette J, Ibeziako P, Jackson JL, ... Kochilas LK, American Heart Association Council on Lifelong Congenital Heart Disease and Heart Health in the Young; and Stroke Council
Although resilience and high quality of life are demonstrated by many individuals with congenital heart disease, a range of significant psychological challenges exists across the life span for this growing patient population. Psychiatric disorders represent the most common comorbidity among people with congenital heart disease. Clinicians are becoming increasingly aware of the magnitude of this problem and its interplay with patients\' physical health, and many seek guidance and resources to improve emotional, behavioral\' and social outcomes. This American Heart Association scientific statement summarizes the psychological outcomes of patients with congenital heart disease across the life span and reviews age-appropriate mental health interventions, including psychotherapy and pharmacotherapy. Data from studies on psychotherapeutic, educational\' and pharmacological interventions for this population are scarce but promising. Models for the integration of mental health professionals within both pediatric and adult congenital heart disease care teams exist and have shown benefit. Despite strong advocacy by patients, families\' and health care professionals, however, initiatives have been slow to move forward in the clinical setting. It is the goal of this scientific statement to serve as a catalyst to spur efforts for large-scale research studies examining psychological experiences, outcomes, and interventions tailored to this population and for integrating mental health professionals within congenital heart disease interdisciplinary teams to implement a care model that offers patients the best possible quality of life.



Circ Cardiovasc Qual Outcomes: 14 Jul 2022:101161HCQ0000000000000110; epub ahead of print
Kovacs AH, Brouillette J, Ibeziako P, Jackson JL, ... Kochilas LK, American Heart Association Council on Lifelong Congenital Heart Disease and Heart Health in the Young; and Stroke Council
Circ Cardiovasc Qual Outcomes: 14 Jul 2022:101161HCQ0000000000000110; epub ahead of print | PMID: 35862009
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Abstract

Patients With Acute Coronary Syndromes Admitted to Contemporary Cardiac Intensive Care Units: Insights From the CCCTN Registry.

Fagundes A, Berg DD, Park JG, Baird-Zars VM, ... Bohula EA, CCCTN Investigators
Background
With the improvement in outcomes for acute coronary syndrome (ACS), the practice of routine admission to cardiac intensive care units (CICUs) is evolving. We aimed to describe the epidemiology of patients with ACS admitted to contemporary CICUs.
Methods
Using the CCCTN (Critical Care Cardiology Trials Network) Registry for consecutive medical CICU admissions across 26 advanced CICUs in North America between 2017 and 2020, we identified patients with a primary diagnosis of ACS at CICU admission and compared patient characteristics, resource utilization, and outcomes to patients admitted with a non-ACS diagnosis and across sub-populations of patients with ACS, including by indication for CICU admission.
Results
Of 10 118 CICU admissions, 29.4% (n=2978) were for a primary diagnosis of ACS, with significant interhospital variability (range, 13.4%-56.6%). Compared with patients admitted with a diagnosis other than ACS, patients with ACS had fewer comorbidities, lower acute severity of illness with less utilization of advanced CICU therapies (41.3% versus 66.1%, P<0.0001), and lower CICU mortality (5.4% versus 9.9%, P<0.0001). Monitoring alone, without another CICU indication at the time of admission, was the most frequent admission indication in patients with ACS (53.8%); less common indications in patients with ACS included respiratory insufficiency, shock, or the need for vasoactive therapy. Of patients with ACS admitted for monitoring alone, 94.8% did not subsequently require advanced intensive care unit therapies and had a low CICU length of stay (1.5 days [0.9-2.4] versus 2.6 [1.4-5.1], P<0.0001) and CICU mortality (0.6% versus 11.0%, P<0.0001), compared with patients with ACS with an admission indication beyond monitoring.
Conclusions
In a registry of tertiary care CICUs, ACS represent ≈1/3 of all admissions with significant variability across hospitals. More than half of the ACS admissions to the CICU were for routine monitoring alone, with a low rate of complications and mortality. This observation highlights an opportunity for prospective studies to refine triage strategies for lower risk patients with ACS.



Circ Cardiovasc Qual Outcomes: 05 Jul 2022:101161CIRCOUTCOMES121008652; epub ahead of print
Fagundes A, Berg DD, Park JG, Baird-Zars VM, ... Bohula EA, CCCTN Investigators
Circ Cardiovasc Qual Outcomes: 05 Jul 2022:101161CIRCOUTCOMES121008652; epub ahead of print | PMID: 35862019
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Impact:

This program is still in alpha version.