Journal: Circ Cardiovasc Qual Outcomes

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Abstract

Multiple Vulnerabilities to Health Disparities and Incident Heart Failure Hospitalization in the REGARDS Study.

Pinheiro LC, Reshetnyak E, Sterling MR, Levitan EB, Safford MM, Goyal P

Background Socially determined vulnerabilities (SDVs) to health disparities often cluster within the same individual. SDVs are separately associated with increased risk of heart failure (HF). The objective of this study was to determine the cumulative effect of SDVs to health disparities on incident HF hospitalization. Methods and Results Using the REGARDS (Reasons for Geographic and Racial Differences in Stroke) cohort study, we studied 25 790 participants without known HF and followed them for 10+ years. Our primary outcome was an incident HF hospitalization through December 31, 2016. Guided by the Healthy People 2020 framework for social determinants of health, we examined 10 potential SDVs. We retained SDVs associated with incident HF hospitalization (<0.10) and created an SDV count (0, 1, 2, 3+). Using the count, we estimated Cox proportional hazard models to examine associations with incident HF hospitalization, adjusting for potential confounders. Models were stratified by age (45-64, 65-74, and 75+ years) because past reports suggest greater disparities in HF incidence at younger ages. Participants were followed for a median of 10.1 years (interquartile range, 6.5-11.9). Black race, low educational attainment, low annual household income, zip code poverty, poor public health infrastructure, and lack of health insurance were associated with incident HF hospitalization. In adjusted models, among those 45 to 64 years, compared with having no SDV, having 1 SDV (hazard ratio, 1.85 [95% CI, 1.12-3.05]), 2 SDVs (hazard ratio, 2.12 [95% CI, 1.28-3.50]), and 3+ SDVs (hazard ratio, 2.45 [95% CI, 1.48-4.04]) were significantly associated with incident HF hospitalization ( for trend, 0.001). We observed no significant associations for older individuals. Conclusions A greater number of SDVs significantly increased risk of incident HF hospitalization among adults <65 years, which persisted after adjustment for cardiovascular risk factors. Using a simple SDV count that could be obtained from a social history during clinical assessment may identify younger individuals at increased risk.



Circ Cardiovasc Qual Outcomes: 23 Jul 2020:CIRCOUTCOMES119006438; epub ahead of print
Pinheiro LC, Reshetnyak E, Sterling MR, Levitan EB, Safford MM, Goyal P
Circ Cardiovasc Qual Outcomes: 23 Jul 2020:CIRCOUTCOMES119006438; epub ahead of print | PMID: 32703013
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Abstract

Rapid Diet Assessment Screening Tools for Cardiovascular Disease Risk Reduction Across Healthcare Settings: A Scientific Statement From the American Heart Association.

Vadiveloo M, Lichtenstein AH, Anderson C, Aspry K, ... Thorndike AN,

It is critical that diet quality be assessed and discussed at the point of care with clinicians and other members of the healthcare team to reduce the incidence and improve the management of diet-related chronic disease, especially cardiovascular disease. Dietary screening or counseling is not usually a component of routine medical visits. Moreover, numerous barriers exist to the implementation of screening and counseling, including lack of training and knowledge, lack of time, sense of futility, lack of reimbursement, competing demands during the visit, and absence of validated rapid diet screener tools with coupled clinical decision support to identify actionable modifications for improvement. With more widespread use of electronic health records, there is an enormous unmet opportunity to provide evidence-based clinician-delivered dietary guidance using rapid diet screener tools that must be addressed. In this scientific statement from the American Heart Association, we provide rationale for the widespread adoption of rapid diet screener tools in primary care and relevant specialty care prevention settings, discuss the theory- and practice-based criteria of a rapid diet screener tool that supports valid and feasible diet assessment and counseling in clinical settings, review existing tools, and discuss opportunities and challenges for integrating a rapid diet screener tool into clinician workflows through the electronic health record.



Circ Cardiovasc Qual Outcomes: 06 Aug 2020:HCQ0000000000000094; epub ahead of print
Vadiveloo M, Lichtenstein AH, Anderson C, Aspry K, ... Thorndike AN,
Circ Cardiovasc Qual Outcomes: 06 Aug 2020:HCQ0000000000000094; epub ahead of print | PMID: 32762254
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Abstract

Conflicting Perspectives on the Value of Neprilysin Inhibition in Heart Failure Revealed During Development of a Decision Aid Focusing on Patient Costs for Sacubitril/Valsartan.

Venechuk GE, Allen LA, Doermann Byrd K, Dickert N, Matlock DD
Background
Despite concerns about rising costs in health care, cost is rarely an issue discussed by patients and clinicians when making treatment decisions in a clinical setting. This study aimed to understand stakeholder perspectives on a patient decision aid (PtDA) meant to help patients with heart failure choose between a generic and relatively low-cost heart failure medication (ACE [angiotensin-converting enzyme] inhibitor or angiotensin II receptor blocker) and a newer, but more expensive, heart failure medication (angiotensin II receptor blocker neprilysin inhibitor).
Methods and results
Feedback on the PtDA was solicited from 26 stakeholders including patients, clinicians, and the manufacturer. Feedback was recorded and discussed among development team members until consensus regarding both the interpretation of the data and the appropriate changes to the PtDA was reached. Stakeholders found the PtDA sufficient in clarifying the different treatment options for heart failure. However, patients, physicians, and the manufacturer had different opinions on the importance of highlighting cost in a PtDA. Patients indicated issues of cost were crucial to the decision while physicians and manufacturers expressed that the cost issue was secondary and should be de-emphasized.
Conclusions
The stratified perspectives on the role of cost in medical decision-making expressed by our participants underscore the importance and challenge of having clear, frank discussions during clinic visits about treatment cost and perceived value.



Circ Cardiovasc Qual Outcomes: 19 Aug 2020:CIRCOUTCOMES119006255; epub ahead of print
Venechuk GE, Allen LA, Doermann Byrd K, Dickert N, Matlock DD
Circ Cardiovasc Qual Outcomes: 19 Aug 2020:CIRCOUTCOMES119006255; epub ahead of print | PMID: 32814457
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Abstract

Long-Term Bleeding Risk Prediction with Dual Antiplatelet Therapy After Acute Coronary Syndromes Treated Without Revascularization.

Marquis-Gravel G, Neely ML, Valgimigli M, Costa F, ... Ohman EM, Roe MT

Background Longitudinal bleeding risk scores have been validated in patients treated with dual antiplatelet therapy (DAPT) following percutaneous coronary intervention. How these scores apply to the population of patients with acute coronary syndrome (ACS) treated without revascularization remains unknown. The objective was to evaluate and compare the performances of the PRECISE-DAPT, PARIS, and DAPT (bleeding component) bleeding risk scores in the medically managed patients with ACS treated with DAPT. Methods and Results TRILOGY ACS (Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes) was a double-blind, placebo-controlled randomized trial conducted from 2008 to 2012 over a median follow-up of 17.0 months in 966 sites (52 countries). High-risk patients with unstable angina or non-ST-segment-elevation myocardial infarction who did not undergo revascularization were randomized to prasugrel or clopidogrel. The PRECISE-DAPT, PARIS, and DAPT (bleeding component) risk scores were applied in the TRILOGY ACS population to evaluate their performance to predict adjudicated non-coronary artery bypass grafting-related GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) severe/life-threatening/moderate and TIMI (Thrombolysis in Myocardial Infarction) major/minor bleeding with time-dependent c-indices. Among the 9326 participants, median age was 66 years (interquartile range, 59-74 years), and 3650 were females (39.1%). A total of 158 (1.69%) GUSTO severe/life-threatening/moderate and 174 (1.87%) TIMI major/minor non-coronary artery bypass grafting bleeding events occurred. The c-indices (95% CI) of the PRECISE-DAPT, PARIS, and DAPT (bleeding component) scores through 12 months were 0.716 (0.677-0.758), 0.693 (0.658-0.733), and 0.674 (0.637-0.713), respectively, for GUSTO bleeding and 0.624 (0.582-0.666), 0.612 (0.578-0.651), and 0.608 (0.571-0.649), respectively, for TIMI bleeding. There was no significant difference in the c-indices of each score based upon pairwise comparisons. Conclusions Among medically managed patients with ACS treated with DAPT, the performances of the PRECISE-DAPT, PARIS, and DAPT (bleeding component) scores were reasonable and similar to their performances in the derivation percutaneous coronary intervention populations. Bleeding risk scores may be used to predict longitudinal bleeding risk in patients with ACS treated with DAPT without revascularization and help support shared decision making. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00699998.



Circ Cardiovasc Qual Outcomes: 30 Aug 2020:CIRCOUTCOMES120006582; epub ahead of print
Marquis-Gravel G, Neely ML, Valgimigli M, Costa F, ... Ohman EM, Roe MT
Circ Cardiovasc Qual Outcomes: 30 Aug 2020:CIRCOUTCOMES120006582; epub ahead of print | PMID: 32862694
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Abstract

Optimizing Atherosclerotic Cardiovascular Disease Risk Estimation for Veterans With Diabetes Mellitus.

Raghavan S, Ho YL, Vassy JL, Posner D, ... Wilson PWF, Cho K
Background
Estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk in diabetes mellitus patients is used to guide primary prevention, but the performance of risk estimators (2013 Pooled Cohort Equations [PCE] and Risk Equations for Complications of Diabetes [RECODe]) varies across populations. Data from electronic health records could be used to improve risk estimation for a health system\'s patients. We aimed to evaluate risk equations for initial ASCVD events in US veterans with diabetes mellitus and improve model performance in this population.
Methods and results
We studied 183 096 adults with diabetes mellitus and without prior ASCVD who received care in the Veterans Affairs Healthcare System (VA) from 2002 to 2016 with mean follow-up of 4.6 years. We evaluated model discrimination, using Harrell\'s C statistic, and calibration, using the reclassification χ test, of the PCE and RECODe equations to predict fatal or nonfatal myocardial infarction or stroke and cardiovascular mortality. We then tested whether model performance was affected by deriving VA-specific β-coefficients. Discrimination of ASCVD events by the PCE was improved by deriving VA-specific β-coefficients (C statistic increased from 0.560 to 0.597) and improved further by including measures of glycemia, renal function, and diabetes mellitus treatment (C statistic, 0.632). Discrimination by the RECODe equations was improved by substituting VA-specific coefficients (C statistic increased from 0.604 to 0.621). Absolute risk estimation by PCE and RECODe equations also improved with VA-specific coefficients; the calibrationincreased from <0.001 to 0.08 for PCE and from <0.001 to 0.005 for RECODe, where higherindicates better calibration. Approximately two-thirds of veterans would meet a guideline indication for high-intensity statin therapy based on the PCE versus only 10% to 15% using VA-fitted models.
Conclusions
Existing ASCVD risk equations overestimate risk in veterans with diabetes mellitus, potentially impacting guideline-indicated statin therapy. Prediction model performance can be improved for a health system\'s patients using readily available electronic health record data.



Circ Cardiovasc Qual Outcomes: 30 Aug 2020:CIRCOUTCOMES120006528; epub ahead of print
Raghavan S, Ho YL, Vassy JL, Posner D, ... Wilson PWF, Cho K
Circ Cardiovasc Qual Outcomes: 30 Aug 2020:CIRCOUTCOMES120006528; epub ahead of print | PMID: 32862698
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Abstract

Association of Hypertension and Arterial Blood Pressure on Limb and Cardiovascular Outcomes in Symptomatic Peripheral Artery Disease: The EUCLID Trial.

Fudim M, Hopley CW, Huang Z, Kavanagh S, ... Jones WS, Hiatt WR

Background Current guidelines recommend aggressive management of hypertension. Recent evidence suggested potential harm with low blood pressure targets in patients with peripheral artery disease. We investigated the association of a history of hypertension and office systolic blood pressure (SBP) with major adverse cardiovascular events (MACEs) and major adverse limb events (MALEs). Methods and Results The EUCLID trial (Examining the Use of Ticagrelor in Peripheral Artery Disease) included 13 885 participants with symptomatic peripheral artery disease; median follow-up was 30 months. Cox proportional hazards regression was used to calculate hazard ratios (HRs) for any MACE, MALE, and MALE including lower extremity revascularization. A clinical history of arterial hypertension was present in 10 857 (78%) participants, and these participants were older and more likely to be female when compared with the 3026 (22%) patients without hypertension. In patients with a history of hypertension, the adjusted hazard ratio for MACE was 0.94, 95% CI, 0.82-1.08; =0.39, and the adjusted hazard ratio for MALE was 1.08, 95% CI, 0.96-1.23; =0.21. During follow-up, average SBP was 135 mm Hg (125-145). Every 10 mmHg increase in SBP>125 mmHg was associated with an increased risk of MACE (HR, 1.10 [95% CI, 1.06-1.14]; <0.001), a marginally increased risk of MALE (HR, 1.07 [95% CI, 1.00-1.15]; =0.062), and an increased risk of MALE/lower extremity revascularization (HR, 1.08 [95% CI, 1.04-1.11]; <0.001). Every decrease in 10 mmHg SBP ≤125 mmHg was associated with an increased risk of MACE (HR, 1.19 [95% CI, 1.09-1.31]; <0.001) but not MALE or MALE/lower extremity revascularization (HR, 1.02 [95% CI, 0.84-1.23], =0.824; HR, 1.04 [95% CI, 0.95-1.13], =0.392, respectively). Conclusions History of hypertension was not associated with higher hazard for MACE or MALE in patients with peripheral artery disease. In contrast, there was a higher hazard of MACE in patients with out-of-target low and high SBP. High but not low SBP was associated with an increased risk of ischemic limb events. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01732822.



Circ Cardiovasc Qual Outcomes: 30 Aug 2020:CIRCOUTCOMES120006512; epub ahead of print
Fudim M, Hopley CW, Huang Z, Kavanagh S, ... Jones WS, Hiatt WR
Circ Cardiovasc Qual Outcomes: 30 Aug 2020:CIRCOUTCOMES120006512; epub ahead of print | PMID: 32862697
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Abstract

Impact of Medicare\'s Bundled Payments Initiative on Patient Selection, Payments, and Outcomes for Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting.

McNeely C, Orav EJ, Zheng J, Joynt Maddox KE

Background The Center for Medicare and Medicaid Innovation launched the Bundled Payments for Care Initiative (BPCI) in 2013. Its effect on payments and outcomes for percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) is unknown. Methods and Results We used Medicare inpatient files to identify index admissions for PCI and CABG from 2013 through 2016 at BPCI hospitals and matched control hospitals and difference in differences models to compare the 2 groups. Our primary outcome was the change in standardized Medicare-allowed payments per 90-day episode. Secondary outcomes included changes in patient selection, discharge to postacute care, length of stay, emergency department use, readmissions, and mortality. Forty-two hospitals joined BPCI for PCI and 46 for CABG. There were no differential changes in patient selection between BPCI and control hospitals. Baseline Medicare payments per episode for PCI were $20 164 at BPCI hospitals and $19 955 at control hospitals. For PCI, payments increased at both BPCI and control hospitals during the intervention period, such that there was no significant difference in differences (BPCI hospitals +$673, =0.048; control hospitals +$551, =0.022; difference in differences $122, =0.768). For CABG, payments at both BPCI and control hospitals decreased during the intervention period (BPCI baseline, $36 925, change -$2918, <0.001; control baseline, $36 877, change -$2618, <0.001; difference in differences, $300; =0.730). For both PCI and CABG, BPCI participation was not associated with changes in mortality, readmissions, or length of stay. Among BPCI hospitals, emergency department use differentially increased for patients undergoing PCI and decreased for patients undergoing CABG. Conclusions Participation in episode-based payment for PCI and CABG was not associated with changes in patient selection, payments, length of stay, or clinical outcomes.



Circ Cardiovasc Qual Outcomes: 31 Aug 2020:CIRCOUTCOMES119006171; epub ahead of print
McNeely C, Orav EJ, Zheng J, Joynt Maddox KE
Circ Cardiovasc Qual Outcomes: 31 Aug 2020:CIRCOUTCOMES119006171; epub ahead of print | PMID: 32867514
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Abstract

Trajectory of Risk-Standardized Survival Rates for In-Hospital Cardiac Arrest.

Qazi AH, Chan PS, Zhou Y, Vaughan-Sarrazin M, Girotra S
Background
A hospital\'s risk-standardized survival rate (RSSR) for in-hospital cardiac arrest has emerged as an important metric to benchmark and incentivize hospital resuscitation quality. We examined whether hospital performance on the RSSR metric was stable or dynamic year-over-year and whether low-performing hospitals were able to improve survival outcomes over time.
Methods and results
We used data from 84 089 adult patients with an in-hospital cardiac arrest from 166 hospitals with continuous participation in Get With The Guidelines-Resuscitation from 2012 to 2017. A 2-level hierarchical regression model was used to compute RSSRs during a baseline (2012-2013) and two follow-up periods (2014-2015 and 2016-2017). At baseline, hospitals were classified as top-, middle-, and bottom-performing if they ranked in the top 25%, middle 50%, and bottom 25%, respectively, on their RSSR metric during 2012 to 2013. We compared hospital performance on RSSR during follow-up between top, middle, and bottom-performing hospitals\' at baseline. During 2012 to 2013, 42 hospitals were identified as top-performing (median RSSR, 31.7%), 82 as middle-performing (median RSSR, 24.6%), and 42 as bottom-performing (median RSSR, 18.7%). During both follow-up periods, >70% of top-performing hospitals ranked in the top 50%, a substantial proportion remained in the top 25% of RSSR during 2014 to 2015 (54.6%) and 2016 to 2017 (40.4%) follow-up periods. Likewise, nearly 75% of bottom-performing hospitals remained in the bottom 50% during both follow-up periods, with 50.0% in the bottom 25% of RSSR during 2014 to 2015 and 40.5% in the bottom 25% during 2016 to 2017. While percentile rankings were generally consistent over time at ≈45% of study hospitals, ≈1 in 5 (21.4%) bottom-performing hospitals showed large improvement in percentile rankings over time and a similar proportion (23.7%) of top-performing hospitals showed large decline in percentile rankings compared with baseline.
Conclusions
Hospital performance on RSSR during baseline period was generally consistent over 4 years of follow-up. However, 1 in 5 bottom-performing hospitals had large improvement in survival over time. Identifying care and quality improvement innovations at these sites may provide opportunities to improve in-hospital cardiac arrest care at other hospitals.



Circ Cardiovasc Qual Outcomes: 09 Sep 2020:CIRCOUTCOMES120006514; epub ahead of print
Qazi AH, Chan PS, Zhou Y, Vaughan-Sarrazin M, Girotra S
Circ Cardiovasc Qual Outcomes: 09 Sep 2020:CIRCOUTCOMES120006514; epub ahead of print | PMID: 32907387
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Abstract

Transcatheter Aortic Valve Replacement in Low-Population Density Areas: Assessing Healthcare Access for Older Adults With Severe Aortic Stenosis.

Damluji AA, Fabbro M, Epstein RH, Rayer S, ... O\'Connor CM, Batchelor W
Background
Restricting transcatheter aortic valve replacement (TAVR) to centers based on volume thresholds alone can potentially create unintended disparities in healthcare access. We aimed to compare the influence of population density in state of Florida in regard to access to TAVR, TAVR utilization rates, and in-hospital mortality.
Methods and results
From 2011 to 2016, we used data from the Agency for Health Care Administration to calculate travel time and distance for each TAVR patient by comparing their home address to their TAVR facility ZIP code. Travel time and distance, TAVR rates, and mortality were compared across categories of low to high population density (population per square miles of land). Of the 6531 patients included, the mean (SD) age was 82 (9) years, 43% were female and 91% were White. Patients residing in the lowest category (<50/square miles) were younger, more likely to be men, and less likely to be a racial minority. Those residing in the lowest category density faced a longer unadjusted driving distances and times to their TAVR center (mean extra distance [miles]=43.5 [95% CI, 35.6-51.4]; <0.001; mean extra time (minutes)=45.6 [95% CI, 38.3-52.9], <0.001). This association persisted regardless of the methods used to determine population density. Excluding uninhabitable land, there was a 7-fold difference in TAVR utilization rates in the lowest versus highest population density regions (7 versus 45 per 100 000, -for-pairwise-comparisons <0.001) and increase in TAVR in-hospital mortality (adjusted OR, 6.13 [95% CI, 1.97-19.1]; <0.001).
Conclusions
Older patients living in rural counties in Florida face (1) significantly longer travel distances and times for TAVR, (2) lower TAVR utilization rates, and (3) higher adjusted TAVR mortality. These findings suggest that there are trade-offs between access to TAVR, its rate of utilization, and procedural mortality, all of which are important considerations when defining institutional and operator requirements for TAVR across the country.



Circ Cardiovasc Qual Outcomes: 30 Jul 2020; 13:e006245
Damluji AA, Fabbro M, Epstein RH, Rayer S, ... O'Connor CM, Batchelor W
Circ Cardiovasc Qual Outcomes: 30 Jul 2020; 13:e006245 | PMID: 32813564
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Abstract

The Heart Failure Readmission Intervention by Variable Early Follow-up (THRIVE) Study: A Pragmatic Randomized Trial.

Lee KK, Thomas RC, Tan TC, Leong TK, Steimle A, Go AS
Background
In-person clinic follow-up within 7 days after discharge from a heart failure hospitalization is associated with lower 30-day readmission. However, health systems and patients may find it difficult to complete an early postdischarge clinic visit, especially during the current pandemic. We evaluated the effect on 30-day readmission and death of follow-up within 7 days postdischarge guided by an initial structured nonphysician telephone visit compared with follow-up guided by an initial clinic visit with a physician.
Methods and results
We conducted a pragmatic randomized trial in a large integrated healthcare delivery system. Adults being discharged home after hospitalization for heart failure were randomly assigned to either an initial telephone visit with a nurse or pharmacist to guide follow-up or an initial in-person clinic appointment with primary care physicians providing usual care within the first 7 days postdischarge. Telephone appointments included a structured protocol enabling medication titration, laboratory ordering, and booking urgent clinic visits as needed under physician supervision. Outcomes included 30-day readmissions and death and frequency and type of completed follow-up within 7 days of discharge. Among 2091 participants (mean age 78 years, 44% women), there were no significant differences in 30-day heart failure readmission (8.6% telephone, 10.6% clinic, =0.11), all-cause readmission (18.8% telephone, 20.6% clinic, =0.30), and all-cause death (4.0% telephone, 4.6% clinic, =0.49). Completed 7-day follow-up was higher in 1027 patients randomized to telephone follow-up (92%) compared with 1064 patients assigned to physician clinic follow-up (79%, <0.001). Overall frequency of clinic visits during the first 7 days postdischarge was lower in participants assigned to nonphysician telephone guided follow-up (48%) compared with physician clinic-guided follow-up (77%, <0.001).
Conclusions
Early, structured telephone follow-up after hospitalization for heart failure can increase 7-day follow-up and reduce in-person visits with comparable 30-day clinical outcomes within an integrated care delivery framework.
Registration
URL: https://www.clinicaltrials.gov; Unique identifier: NCT03524534.



Circ Cardiovasc Qual Outcomes: 23 Sep 2020:CIRCOUTCOMES120006553; epub ahead of print
Lee KK, Thomas RC, Tan TC, Leong TK, Steimle A, Go AS
Circ Cardiovasc Qual Outcomes: 23 Sep 2020:CIRCOUTCOMES120006553; epub ahead of print | PMID: 32967439
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Abstract

Characteristics and Outcomes of In-Hospital Cardiac Arrest Events During the COVID-19 Pandemic: A Single Center Experience from a New York City Public Hospital.

Miles JA, Mejia Saldarriaga M, Rios S, Sokol SI, ... Bradley SM, Faillace RT

: Patients hospitalized for severe COVID-19 infection are at risk for in-hospital cardiac arrest (IHCA). It is unknown whether certain characteristics of cardiac arrest care and outcomes of IHCAs during the COVID-19 pandemic differed compared to a pre-COVID-19 period. : All patients who experienced an IHCA at our hospital from March 1st through May 15th 2020, during the peak of the COVID-19 pandemic, and those who had an IHCA from January 1st 2019 to December 31st 2019 were identified. All patient data was extracted from our hospital\'s Get With The Guidelines-Resuscitation (GWTG-R) registry, a prospective hospital-based archive of IHCA data. Baseline characteristics of patients, interventions and overall outcomes of IHCAs during the COVID-19 pandemic were compared to IHCAs in 2019, prior to the COVID-19 pandemic. : There were 125 IHCAs during a 2.5-month period at our hospital during the peak of the COVID-19 pandemic compared to 117 IHCAs in all of 2019. IHCAs during the COVID-19 pandemic occurred more often on general medicine wards than in intensive care units (46% vs 33%; 19% vs 60% in 2019, p<0.001), were overall shorter in duration (median time of 11 min (8.5-26.5) vs 15 min (7.0-20.0), p=0.001), led to fewer endotracheal intubations (52% vs 85%, p<0.001) and had overall worse survival rates (3% vs 13%, p=0.007) compared to IHCAs prior to the COVID-19 pandemic. : Patients who experienced an IHCA during the COVID-19 pandemic had overall worse survival compared to those who had an IHCA prior to the COVID-19 pandemic. Our findings highlight important differences between these two time periods. Further study is needed on cardiac arrest care in patients with COVID-19.



Circ Cardiovasc Qual Outcomes: 24 Sep 2020; epub ahead of print
Miles JA, Mejia Saldarriaga M, Rios S, Sokol SI, ... Bradley SM, Faillace RT
Circ Cardiovasc Qual Outcomes: 24 Sep 2020; epub ahead of print | PMID: 32975134
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Abstract

Evidence-Based Policy Making for Public Health Interventions in Cardiovascular Diseases: Formally Assessing the Feasibility of Clinical Trials.

Foti K, Foraker RE, Martyn-Nemeth P, Anderson CAM, ... Whitsel LP, Appel LJ

Implementation of prevention policies has often been impeded or delayed due to the lack of randomized controlled trials (RCTs) with hard clinical outcomes (eg, incident disease, mortality). Despite the prominent role of RCTs in health care, it may not always be feasible to conduct RCTs of public health interventions with hard outcomes due to logistical and ethical considerations. RCTs may also lack external validity and have limited generalizability. Currently, there is insufficient guidance for policymakers charged with establishing evidence-based policy to determine whether an RCT with hard outcomes is needed before policy recommendations. In this context, the purpose of this article is to assess, in a case study, the feasibility of conducting an RCT of the oft-cited issue of sodium reduction on cardiovascular outcomes and then propose a framework for decision-making, which includes an assessment of the feasibility of conducting an RCT with hard clinical outcomes when such trials are unavailable. We designed and assessed the feasibility of potential individual- and cluster-randomized trials of sodium reduction on cardiovascular outcomes. Based on our assumptions, a trial using any of the designs considered would require tens of thousands of participants and cost hundreds of millions of dollars, which is prohibitively expensive. Our estimates may be conservative given several key challenges, such as the unknown costs of sustaining a long-term difference in sodium intake, the effect of differential cotreatment with antihypertensive medications, and long lag time to clinical outcomes. Thus, it would be extraordinarily difficult to conduct such a trial, and despite the high costs, substantial risk for a spuriously null result. A robust framework, such as the one we developed, should be used to guide policymakers when establishing evidence-based public health interventions in the absence of trials with hard clinical outcomes.



Circ Cardiovasc Qual Outcomes: 27 Sep 2020:CIRCOUTCOMES119006378; epub ahead of print
Foti K, Foraker RE, Martyn-Nemeth P, Anderson CAM, ... Whitsel LP, Appel LJ
Circ Cardiovasc Qual Outcomes: 27 Sep 2020:CIRCOUTCOMES119006378; epub ahead of print | PMID: 32981337
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Abstract

Kidney Function and Potassium Monitoring After Initiation of Renin-Angiotensin-Aldosterone System Blockade Therapy and Outcomes in 2 North American Populations.

Parikh RV, Nash DM, Brimble KS, Markle-Reid M, ... Garg AX, Go AS
Background
Clinical practice guidelines recommend routine kidney function and serum potassium testing within 30 days of initiating ACE (angiotensin-converting enzyme) inhibitor or angiotensin II receptor blocker therapy. However, evidence is lacking about whether follow-up testing reduces therapy-related adverse outcomes.
Methods and results
We conducted 2 population-based retrospective cohort studies in Kaiser Permanente Northern California and Ontario, Canada. Patients with outpatient serum creatinine and potassium tests in the 30 days after starting ACE inhibitor or angiotensin II receptor blocker therapy were matched 1:1 to patients without follow-up tests. We evaluated the association of follow-up testing with 30-day all-cause mortality and hospitalization with acute kidney injury or hyperkalemia using Cox regression. We also developed and externally validated a risk score to identify patients at risk of having abnormally high serum creatinine and potassium values in follow-up. We identified 75 251 matched pairs initiating ACE inhibitor or angiotensin II receptor blocker therapy between January 1, 2007, and December 31, 2017, in Kaiser Permanente Northern California. Follow-up testing was not significantly associated with 30-day all-cause mortality in Kaiser Permanente Northern California (hazard ratio, 0.75 [95% CI, 0.54-1.06]) and was associated with higher mortality in 84 905 matched pairs in Ontario (hazard ratio, 1.32 [95% CI, 1.07-1.62]). In Kaiser Permanente Northern California, follow-up testing was significantly associated with higher rates of hospitalization with acute kidney injury (hazard ratio, 1.66 [95% CI, 1.10-2.22]) and hyperkalemia (hazard ratio, 3.36 [95% CI, 1.08-10.41]), as was observed in Ontario. The risk score for abnormal potassium provided good discrimination (area under the curve [AUC], 0.75) and excellent calibration of predicted risks, while the risk score for abnormal serum creatinine provided moderate discrimination (AUC, 0.62) but excellent calibration.
Conclusions
Routine laboratory monitoring after ACE inhibitor or angiotensin II receptor blocker initiation was not associated with a lower risk of 30-day mortality. We identified patient subgroups in which targeted testing may be effective in identifying therapy-related changes in serum potassium or kidney function.



Circ Cardiovasc Qual Outcomes: 30 Aug 2020; 13:e006415
Parikh RV, Nash DM, Brimble KS, Markle-Reid M, ... Garg AX, Go AS
Circ Cardiovasc Qual Outcomes: 30 Aug 2020; 13:e006415 | PMID: 32873054
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Abstract

Screening for Intracranial Aneurysms in Coarctation of the Aorta: A Decision and Cost-Effectiveness Analysis.

Pickard SS, Prakash A, Newburger JW, Malek AM, Wong JB
Background
Patients with coarctation of the aorta have a high prevalence of intracranial aneurysms (IA) and suffer subarachnoid hemorrhage (SAH) at younger ages than the general population. American Heart Association/American College of Cardiology guidelines recommend IA screening, but appropriate age and interval of screening and its effectiveness remain a critical knowledge gap.
Methods and results
To evaluate the benefits and cost-effectiveness of magnetic resonance angiography screening for IA in patients with coarctation of the aorta, we developed and calibrated a Markov model to match published IA prevalence estimates. The primary outcome was the incremental cost-effectiveness ratio. Secondary outcomes included lifetime cumulative incidence of prophylactic IA treatment and mortality and SAH deaths prevented. Using a payer perspective, a lifetime horizon, and a willingness-to-pay of $150 000 per quality-adjusted life-year gained, we applied a 3% annual discounting rate to costs and effects and performed 1-way, 2-way, and probabilistic sensitivity analyses. In a simulated cohort of 10 000 patients, no screening resulted in a 10.1% lifetime incidence of SAH and 183 SAH-related deaths. Screening at ages 10, 20, and 30 years led to 978 prophylactic treatments for unruptured aneurysms, 19 procedure-related deaths, and 65 SAH-related deaths. Screening at ages 10, 20, and 30 years was cost-effective compared with screening at ages 10 and 20 years (incremental cost-effectiveness ratio $106 841/quality-adjusted life-year). Uncertainty in the outcome after aneurysm treatment and quality of life after SAH influenced the preferred screening strategy. In probabilistic sensitivity analysis, screening at ages 10, 20, and 30 years was cost-effective in 41% of simulations and at ages 10 and 20 in 59% of simulations.
Conclusions
Our model supports the American Heart Association/American College of Cardiology recommendation to screen patients with coarctation of the aorta for IA and suggests screening at ages 10 and 20 or at 10, 20, and 30 years would extend life and be cost-effective.



Circ Cardiovasc Qual Outcomes: 30 Jul 2020; 13:e006406
Pickard SS, Prakash A, Newburger JW, Malek AM, Wong JB
Circ Cardiovasc Qual Outcomes: 30 Jul 2020; 13:e006406 | PMID: 32762482
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Abstract

Comparative Methodological Assessment of the Randomized GLOBAL LEADERS Trial Using Total Ischemic and Bleeding Events.

Hara H, van Klaveren D, Takahashi K, Kogame N, ... Serruys PW,
Background
Time-to-first-event analysis considers only the first event irrespective of its severity. There are several methods to assess trial outcomes beyond time-to-first-event analysis, such as analyzing total events and ranking outcomes. In the GLOBAL LEADERS study, time-to-first-event analysis did not show superiority of ticagrelor monotherapy following one-month dual antiplatelet therapy (DAPT) after percutaneous coronary intervention to conventional 12-month DAPT followed by aspirin monotherapy in the reduction of the primary composite end point of all-cause mortality or new Q-wave myocardial infarction. This study sought to explore various analytical approaches in assessing total ischemic and bleeding events after percutaneous coronary intervention in the GLOBAL LEADERS study.
Methods and results
Total ischemic and bleeding events were defined as all-cause mortality, any stroke, any myocardial infarction, any revascularization, or Bleeding Academic Research Consortium grade 2 or 3 bleeding. We used various analytical approaches to analyze the benefit of ticagrelor monotherapy over conventional DAPT. For ischemic and bleeding events at 2 years after percutaneous coronary intervention, ticagrelor monotherapy demonstrated a 6% risk reduction, compared with conventional 12-month DAPT in time-to-first-event analysis (hazard ratio, 0.94 [95% CI, 0.88-1.01]; log-rank =0.10). In win ratio analysis, win ratio was 1.05 (95% CI, 0.97-1.13; =0.20). Negative binomial regression and Andersen-Gill analyses which include repeated events showed statistically significant advantage for ticagrelor monotherapy (rate ratio, 0.92 [95% CI, 0.85-0.99; =0.020] and hazard ratio, 0.92 [95% CI, 0.85-0.99; =0.028], respectively), although in weighted composite end point analysis, the hazard ratio was 0.93 (95% CI, 0.84-1.04; log-rank =0.22).
Conclusions
Statistical analyses considering repeated events or event severity showed that ticagrelor monotherapy consistently reduced ischemic and bleeding events by 5% to 8%, compared with conventional 1-year DAPT. Applying multiple statistical methods could emphasize the multiple facets of a trial and result in accurate and more appropriate analyses. Considering the recurrence of ischemic and bleeding events, ticagrelor monotherapy appeared to be beneficial after percutaneous coronary intervention. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01813435.



Circ Cardiovasc Qual Outcomes: 30 Jul 2020; 13:e006660
Hara H, van Klaveren D, Takahashi K, Kogame N, ... Serruys PW,
Circ Cardiovasc Qual Outcomes: 30 Jul 2020; 13:e006660 | PMID: 32762446
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Abstract

Comparative Effectiveness and Safety of Oral Anticoagulants Across Kidney Function in Patients With Atrial Fibrillation.

Yao X, Inselman JW, Ross JS, Izem R, ... Shah ND, Noseworthy PA

Background Patients with atrial fibrillation and severely decreased kidney function were excluded from the pivotal non-vitamin K antagonist oral anticoagulants (NOAC) trials, thereby raising questions about comparative safety and effectiveness in patients with reduced kidney function. The study aimed to compare oral anticoagulants across the range of kidney function in patients with atrial fibrillation. Methods and Results Using a US administrative claims database with linked laboratory data, 34 569 new users of oral anticoagulants with atrial fibrillation and estimated glomerular filtration rate ≥15 mL/(min·1.73 m) were identified between October 1, 2010 to November 29, 2017. The proportion of patients using NOACs declined with decreasing kidney function-73.5%, 69.6%, 65.4%, 59.5%, and 45.0% of the patients were prescribed a NOAC in estimated glomerular filtration rate ≥90, 60 to 90, 45 to 60, 30 to 45, 15 to 30 mL/min per 1.73 m groups, respectively. Stabilized inverse probability of treatment weighting was used to balance 4 treatment groups (apixaban, dabigatran, rivaroxaban, and warfarin) on 66 baseline characteristics. In comparison to warfarin, apixaban was associated with a lower risk of stroke (hazard ratio [HR], 0.57 [0.43-0.75]; <0.001), major bleeding (HR, 0.51 [0.44-0.61]; <0.001), and mortality (HR, 0.68 [0.56-0.83]; <0.001); dabigatran was associated with a similar risk of stroke but a lower risk of major bleeding (HR, 0.57 [0.43-0.75]; <0.001) and mortality (HR, 0.68 [0.48-0.98]; =0.04); rivaroxaban was associated with a lower risk of stroke (HR, 0.69 [0.51-0.94]; =0.02), major bleeding (HR, 0.84 [0.72-0.99]; =0.04), and mortality (HR, 0.73 [0.58-0.91]; =0.006). There was no significant interaction between treatment and estimated glomerular filtration rate categories for any outcome. When comparing one NOAC to another NOAC, there was no significant difference in mortality, but some differences existed for stroke or major bleeding. No relationship between treatments and falsification end points was found, suggesting no evidence for substantial residual confounding. Conclusions Relative to warfarin, NOACs are used less frequently as kidney function declines. However, NOACs appears to have similar or better comparative effectiveness and safety across the range of kidney function.



Circ Cardiovasc Qual Outcomes: 04 Oct 2020:CIRCOUTCOMES120006515; epub ahead of print
Yao X, Inselman JW, Ross JS, Izem R, ... Shah ND, Noseworthy PA
Circ Cardiovasc Qual Outcomes: 04 Oct 2020:CIRCOUTCOMES120006515; epub ahead of print | PMID: 33012172
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Abstract

Individual Psychosocial Resilience, Neighborhood Context, and Cardiovascular Health in Black Adults: A Multilevel Investigation From the Morehouse-Emory Cardiovascular Center for Health Equity Study.

Kim JH, Islam SJ, Topel ML, Ko YA, ... Baltrus P, Lewis TT
Background
Despite well-documented cardiovascular disparities between racial groups, within-race determinants of cardiovascular health among Black adults remain understudied. Factors promoting cardiovascular resilience among Black adults in particular warrant further investigation. Our objective was to examine whether individual psychosocial resilience and neighborhood-level cardiovascular resilience were associated with better cardiovascular health in Black adults, measured utilizing Life\'s Simple 7 (LS7) scores.
Methods
We assessed LS7 scores in 389 Black adults (mean age, 53±10 years; 39% men ) living in Atlanta, Georgia. A composite score of individual psychosocial resilience was created by assessing environmental mastery, purpose in life, optimism, resilient coping, and depressive symptoms. Neighborhood-level cardiovascular resilience was separately determined by the census tract-level rates of cardiovascular mortality/morbidity events. Generalized linear mixed regression models were used to examine the association between individual psychosocial resilience, neighborhood cardiovascular resilience, and LS7 scores.
Results
Higher individual psychosocial resilience was significantly associated with higher LS7 (β=0.38 [0.16-0.59] per 1 SD) after adjustment for sociodemographic factors. Similarly, higher neighborhood-level cardiovascular resilience was significantly associated with higher LS7 (β=0.23 [0.02-0.45] per 1 SD). When jointly examined, high individual psychosocial resilience (>median) was independently associated with higher LS7 (β=0.73 [0.31-1.17]), whereas living in high-resilience neighborhoods (>median) was not. The largest difference in LS7 score was between those with high and low psychosocial resilience living in low-resilience neighborhoods (8.38 [7.90-8.86] versus 7.42 [7.04-7.79]).
Conclusions
Individual psychosocial resilience in Black adults is associated with better cardiovascular health.



Circ Cardiovasc Qual Outcomes: 06 Oct 2020:CIRCOUTCOMES120006638; epub ahead of print
Kim JH, Islam SJ, Topel ML, Ko YA, ... Baltrus P, Lewis TT
Circ Cardiovasc Qual Outcomes: 06 Oct 2020:CIRCOUTCOMES120006638; epub ahead of print | PMID: 33023334
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Abstract

Importance of Housing and Cardiovascular Health and Well-Being: A Scientific Statement From the American Heart Association.

Sims M, Kershaw KN, Breathett K, Jackson EA, ... Suglia SF,

Cardiovascular disease disparities are shaped by differences in risk factors across racial and ethnic groups. Housing remains an important social determinant of health. The objective of this statement is to review and summarize research that has examined the associations of housing status with cardiovascular health and overall health. PubMed/Medline, Centers for Disease Control and Prevention data, US Census data, Cochrane Library reviews, and the annual Heart Disease and Stroke Statistics report from the American Heart Association were used to identify empirical research studies that examined associations of housing with cardiovascular health and overall well-being. Health is affected by 4 prominent dimensions of housing: stability, quality and safety, affordability and accessibility, and neighborhood environment. Vulnerable and underserved populations are adversely affected by housing insecurity and homelessness, are at risk for lower-quality and unsafe housing conditions, confront structural barriers that limit access to affordable housing, and are at risk for living in areas with substandard built environment features that are linked to cardiovascular disease. Research linking select pathways to cardiovascular health is relatively strong, but research gaps in other housing pathways and cardiovascular health remain. Efforts to eliminate cardiovascular disease disparities have recently emphasized the importance of social determinants of health. Housing is a prominent social determinant of cardiovascular health and well-being and should be considered in the evaluation of prevention efforts to reduce and eliminate racial/ethnic and socioeconomic disparities.



Circ Cardiovasc Qual Outcomes: 30 Jul 2020; 13:e000089
Sims M, Kershaw KN, Breathett K, Jackson EA, ... Suglia SF,
Circ Cardiovasc Qual Outcomes: 30 Jul 2020; 13:e000089 | PMID: 32673512
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Abstract

Effectiveness of Stroke Early Supported Discharge: Analysis From a National Stroke Registry.

Fisher RJ, Byrne A, Chouliara N, Lewis S, ... Langhorne P, Walker MF
Background
Implementation of stroke early supported discharge (ESD) services has been recommended in many countries\' clinical guidelines, based on clinical trial evidence. This is the first observational study to investigate the effectiveness of ESD service models operating in real-world conditions, at scale.
Methods and results
Using historical prospective data from the United Kingdom Sentinel Stroke National Audit Programme (January 1, 2016-December 31, 2016), measures of ESD effectiveness were \"days to ESD\" (number of days from hospital discharge to first ESD contact; n=6222), \"rehabilitation intensity\" (total number of treatment days/total days with ESD; n=5891), and stroke survivor outcome (modified Rankin scale at ESD discharge; n=6222). ESD service models (derived from Sentinel Stroke National Audit Programme postacute organizational audit data) were categorized with a 17-item score, reflecting adoption of ESD consensus core components (evidence-based criteria). Multilevel modeling analysis was undertaken as patients were clustered within ESD teams across the Midlands, East, and North of England (n=31). A variety of ESD service models had been adopted, as reflected by variability in the ESD consensus score. Controlling for patient characteristics and Sentinel Stroke National Audit Programme hospital score, a 1-unit increase in ESD consensus score was significantly associated with a more responsive ESD service (reduced odds of patient being seen after ≥1 day of 29% [95% CI, 1%-49%] and increased treatment intensity by 2% [95% CI, 0.3%-4%]). There was no association with stroke survivor outcome measured by the modified Rankin Scale.
Conclusions
This study has shown that adopting defined core components of ESD is associated with providing a more responsive and intensive ESD service. This shows that adherence to evidence-based criteria is likely to result in a more effective ESD service as defined by process measures. Registration: URL: http://www.isrctn.com/; Unique identifier: ISRCTN15568163.



Circ Cardiovasc Qual Outcomes: 30 Jul 2020; 13:e006395
Fisher RJ, Byrne A, Chouliara N, Lewis S, ... Langhorne P, Walker MF
Circ Cardiovasc Qual Outcomes: 30 Jul 2020; 13:e006395 | PMID: 32674640
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Abstract

Development of a Portable Tool to Identify Patients With Atrial Fibrillation Using Clinical Notes From the Electronic Medical Record.

Shah RU, Mutharasan RK, Ahmad FS, Rosenblatt AG, ... Mukherjee R, Lloyd-Jones DM
Background
The electronic medical record contains a wealth of information buried in free text. We created a natural language processing algorithm to identify patients with atrial fibrillation (AF) using text alone.
Methods and results
We created 3 data sets from patients with at least one AF billing code from 2010 to 2017: a training set (n=886), an internal validation set from site no. 1 (n=285), and an external validation set from site no. 2 (n=276). A team of clinicians reviewed and adjudicated patients as AF present or absent, which served as the reference standard. We trained 54 algorithms to classify each patient, varying the model, number of features, number of stop words, and the method used to create the feature set. The algorithm with the highest F-score (the harmonic mean of sensitivity and positive predictive value) in the training set was applied to the validation sets. F-scores and area under the receiver operating characteristic curves were compared between site no. 1 and site no. 2 using bootstrapping. Adjudicated AF prevalence was 75.1% at site no. 1 and 86.2% at site no. 2. Among 54 algorithms, the best performing model was logistic regression, using 1000 features, 100 stop words, and term frequency-inverse document frequency method to create the feature set, with sensitivity 92.8%, specificity 93.9%, and an area under the receiver operating characteristic curve of 0.93 in the training set. The performance at site no. 1 was sensitivity 92.5%, specificity 88.7%, with an area under the receiver operating characteristic curve of 0.91. The performance at site no. 2 was sensitivity 89.5%, specificity 71.1%, with an area under the receiver operating characteristic curve of 0.80. The F-score was lower at site no. 2 compared with site no. 1 (92.5% [SD, 1.1%] versus 94.2% [SD, 1.1%]; <0.001).
Conclusions
We developed a natural language processing algorithm to identify patients with AF using text alone, with >90% F-score at 2 separate sites. This approach allows better use of the clinical narrative and creates an opportunity for precise, high-throughput cohort identification.



Circ Cardiovasc Qual Outcomes: 13 Oct 2020:e006516; epub ahead of print
Shah RU, Mutharasan RK, Ahmad FS, Rosenblatt AG, ... Mukherjee R, Lloyd-Jones DM
Circ Cardiovasc Qual Outcomes: 13 Oct 2020:e006516; epub ahead of print | PMID: 33079591
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Abstract

Recommendations for Reporting Machine Learning Analyses in Clinical Research.

Stevens LM, Mortazavi BJ, Deo RC, Curtis L, Kao DP

Use of machine learning (ML) in clinical research is growing steadily given the increasing availability of complex clinical data sets. ML presents important advantages in terms of predictive performance and identifying undiscovered subpopulations of patients with specific physiology and prognoses. Despite this popularity, many clinicians and researchers are not yet familiar with evaluating and interpreting ML analyses. Consequently, readers and peer-reviewers alike may either overestimate or underestimate the validity and credibility of an ML-based model. Conversely, ML experts without clinical experience may present details of the analysis that are too granular for a clinical readership to assess. Overwhelming evidence has shown poor reproducibility and reporting of ML models in clinical research suggesting the need for ML analyses to be presented in a clear, concise, and comprehensible manner to facilitate understanding and critical evaluation. We present a recommendation for transparent and structured reporting of ML analysis results specifically directed at clinical researchers. Furthermore, we provide a list of key reporting elements with examples that can be used as a template when preparing and submitting ML-based manuscripts for the same audience.



Circ Cardiovasc Qual Outcomes: 13 Oct 2020:e006556; epub ahead of print
Stevens LM, Mortazavi BJ, Deo RC, Curtis L, Kao DP
Circ Cardiovasc Qual Outcomes: 13 Oct 2020:e006556; epub ahead of print | PMID: 33079589
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Abstract

Sudden Cardiac Death in the Young: Incidence, Trends, and Risk Factors in a Nationwide Study.

Ha FJ, Han HC, Sanders P, Fendel K, ... Farouque O, Lim HS
Background
Sudden cardiac death (SCD) in the young is devastating. Contemporary incidence remains unclear with few recent nationwide studies and limited data addressing risk factors for causes. We aimed to determine incidence, trends, causes, and risk factors for SCD in the young.
Methods and results
The National Coronial Information System registry was reviewed for SCD in people aged 1 to 35 years from 2000 to 2016 in Australia. Subjects were identified by the ,code relating to circulatory system diseases (I00-I99) from coronial reports. Baseline demographics, circumstances, and cause of SCD were obtained from coronial and police reports, alongside autopsy and toxicology analyses where available. During the study period, 2006 cases were identified (median age, 28±7 years; men, 75%; mean body mass index, 29±8 kg/m). Annual incidence ranged from 0.91 to 1.48 per 100 000 age-specific person-years, which was the lowest in 2013 to 2015 compared with previous 3-year intervals on Poisson regression model (=0.001). SCD incidence was higher in nonmetropolitan versus metropolitan areas (0.99 versus 0.53 per 100 000 person-years; <0.001). The most common cause of SCD was coronary artery disease (40%), followed by sudden arrhythmic death syndrome (14%). Incidence of coronary artery disease-related SCD decreased from 2001-2003 to 2013-2015 (<0.001). Proportion of SCD related to sudden arrhythmic death syndrome increased during the study period (=0.02) although overall incidence was stable (=0.22). Residential remoteness was associated with coronary artery disease-related SCD (odds ratio, 1.44 [95% CI, 1.24-1.67]; <0.001). For every 1-unit increase, body mass index was associated with increased likelihood of SCD from cardiomegaly (odds ratio, 1.08 [95% CI, 1.05-1.11]; <0.001) and dilated cardiomyopathy (odds ratio, 1.04 [95% CI, 1.01-1.06]; =0.005).
Conclusions
Incidence of SCD in the young and specifically coronary artery disease-related SCD has declined in recent years. Proportion of SCD related to sudden arrhythmic death syndrome increased over the study period. Geographic remoteness and obesity are risk factors for specific causes of SCD in the young.



Circ Cardiovasc Qual Outcomes: 13 Oct 2020:e006470; epub ahead of print
Ha FJ, Han HC, Sanders P, Fendel K, ... Farouque O, Lim HS
Circ Cardiovasc Qual Outcomes: 13 Oct 2020:e006470; epub ahead of print | PMID: 33079584
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This program is still in alpha version.