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OBJECTIVE: To examine whether TTM treatment was aligned with predicted mortality risk in patients with resuscitated OHCA during a period when it was a class I guideline recommended therapy. METHODS: Within the Cardiac Arrest Registry to Enhance Survival for OHCA, we identified adult patients with OHCA who survived to hospital admission and were presumed eligible for TTM. Multivariable models were constructed using pre-hospital variables to predict in-hospital death in patients with shockable and non-shockable rhythms. Within each rhythm category, we divided patients into deciles of predicted mortality risk and examined TTM treatment rates across deciles. RESULTS: From 2013-2019, there were 25,882 successfully resuscitated patients with shockable rhythms and 43,414 patients with non-shockable rhythms presumed eligible for TTM. Of patients with shockable rhythms, predicted in-hospital mortality ranged from 16%-78% in deciles 1-10. TTM treatment increased from 44% in decile 1 to 59% in decile 10 (P for trend

BACKGROUND Whether initial invasive management in older vs younger adults with chronic coronary disease and moderate or severe ischemia improves health status or clinical outcomes is unknown. OBJECTIVES The goal of this study was to examine the impact of age on health status and clinical outcomes with invasive vs conservative management in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial. METHODS One-year angina-specific health status was assessed with the 7-item Seattle Angina Questionnaire (SAQ) (score range 0-100; higher scores indicate better health status). Cox proportional hazards models estimated the treatment effect of invasive vs conservative management as a function of age on the composite clinical outcome of cardiovascular death, myocardial infarction, or hospitalization for resuscitated cardiac arrest, unstable angina, or heart failure. RESULTS Among 4,617 participants, 2,239 (48.5%) were aged

AimsImproving the health status (symptoms, function, and quality of life) of patients with heart failure with reduced ejection fraction (HFrEF) is a primary treatment goal. Angiotensin receptor neprilysin inhibitors (ARNI) improve short-term health status in clinical practice, but the sustainability of these improvements is unknown.Methods and resultsIn CHAMP-HF, a multicentre observational study of outpatients with HFrEF, patients initiated on ARNI were propensity score matched 1:2 to patients not using ARNI with Cox regression modelling time to ARNI initiation, adjusted for sociodemographic and clinical variables, medical history, medications, and baseline Kansas City Cardiomyopathy Questionnaire (KCCQ) scores. Repeated measures models for the overall KCCQ score and each domain compared the health status trajectories of patients initiated on ARNI vs. not. Among 3930 participants, 746 (19.0%) began ARNI, of whom 576 were matched to 1152 non-ARNI patients. Prior to matching, participants initiated on ARNI were younger, non-Hispanic, had lower EFs, more commonly had a history of ventricular arrhythmia, were less likely to be taking an ACEI/ARB, and more likely to be treated with beta-blockers and mineralocorticoid receptor antagonists. There were no differences after matching. In the matched cohort, participants initiated on ARNI experienced improved health status by 3months that persisted through 12months [KCCQ Overall Summary Score (OSS)=73.4 vs. 70.8; P&nbsp

BackgroundAtrial fibrillation (AF) adversely impacts health-related quality of life (hrQoL). While some patients demonstrate improvements in hrQoL, the factors associated with large improvements in hrQoL are not well described.MethodsWe assessed factors associated with a 1-year increase in the Atrial Fibrillation Effect on Quality-of-Life score of 1 SD (≥18 points; 3× clinically important difference), among outpatients in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation I registry.ResultsOverall, 28% (181/636) of patients had such a hrQoL improvement. Compared with patients not showing large hrQoL improvement, they were of similar age (median 73 versus 74, P=0.3), equally likely to be female (44% versus 48%, P=0.3), but more likely to have newly diagnosed AF at baseline (18% versus 8%; P=0.0004), prior antiarrhythmic drug use (52% versus 40%, P=0.005), baseline antiarrhythmic drug use (34.8% versus 26.8%, P=0.045), and more likely to undergo AF-related procedures during follow-up (AF ablation: 6.6% versus 2.0%, P=0.003; cardioversion: 12.2% versus 5.9%, P=0.008). In multivariable analysis, a history of alcohol abuse (adjusted OR, 2.41; P=0.01) and increased baseline diastolic blood pressure (adjusted OR, 1.23 per 10-point increase and >65 mm Hg; P=0.04) were associated with large improvements in hrQoL at 1 year, whereas patients with prior stroke/transient ischemic attack, chronic obstructive pulmonary disease, and peripheral arterial disease were less likely to improve (P

Utstein-style reporting templates provide a structured framework with which to compare systems of care for cardiac arrest. The 2004 Utstein reporting template encompassed both out-of-hospital and in-hospital cardiac arrest. A 2015 update of the Utstein template focused on out-of-hospital cardiac arrest, which makes this update of the in-hospital template timely. Representatives of the International Liaison Committee on Resuscitation developed an updated in-hospital Utstein reporting template iteratively by meeting face-to-face, by teleconference, and by online surveys between 2013 and 2018. Data elements were grouped by hospital factors, patient variables, pre-event factors, cardiac arrest and postresuscitation processes, and outcomes. Elements were classified as core or supplemental by use of a modified Delphi process. Variables were described as core if they were considered essential. Core variables should enable reasonable comparisons between systems and are considered essential for quality improvement programs. Together with core variables, supplementary variables are considered useful for research.

OBJECTIVE: To characterize the rapid response team activations, and the patients receiving them, in the American Heart Association-sponsored Get With The Guidelines Resuscitation- Medical Emergency Team cohort between 2005 and 2015. DESIGN: Retrospective multicenter cohort study. SETTING: Three hundred and sixty United States hospitals. PATIENTS: Consecutive adult patients experiencing rapid response team (RRT) activation. INTERVENTIONS: RRT activation. MEASUREMENTS AND MAIN RESULTS: The cohort included 402,023 RRT activations from 347,401 unique healthcare encounters. Respiratory (38.0%) and cardiac (37.4%) triggers were most common. The most frequent interventions – pulse oximetry (66.5%), other monitoring (59.6%), and supplemental oxygen (62.0%) – were non-invasive. Fluids were the most common medication ordered (19.3%) but new antibiotic orders were rare (1.2%). More than 10% of RRTs resulted in code status changes. Hospital mortality was over 14% and increased with subsequent rapid response activations. CONCLUSIONS: Although patients requiring RRT activation have high inpatient mortality, most RRT activations involve relatively few interventions, which may limit these teams’ ability to improve patient outcomes.

ObjectiveTo determine the use of epinephrine (adrenaline) before defibrillation for treatment of in-hospital cardiac arrest due to a ventricular arrhythmia and examine its association with patient survival.DesignPropensity matched analysis.Setting2000-18 data from 497 hospitals participating in the American Heart Association’s Get With The Guidelines-Resuscitation registry.ParticipantsAdults aged 18 and older with an index in-hospital cardiac arrest due to an initial shockable rhythm treated with defibrillation.InterventionsAdministration of epinephrine before first defibrillation.Main outcome measuresSurvival to discharge; favorable neurological survival, defined as survival to discharge with none, mild, or moderate neurological disability measured using cerebral performance category scores; and survival after acute resuscitation (that is, return of spontaneous circulation for >20 minutes). A time dependent, propensity matched analysis was performed to adjust for confounding due to indication and evaluate the independent association of epinephrine before defibrillation with study outcomes.ResultsAmong 34 820 patients with an initial shockable rhythm, 7054 (20.3%) were treated with epinephrine before defibrillation, contrary to current guidelines. In comparison with participants treated with defibrillation first, participants receiving epinephrine first were less likely to have a history of myocardial infarction or heart failure, but more likely to have renal failure, sepsis, respiratory insufficiency, and receive mechanical ventilation before in-hospital cardiac arrest (standardized differences >10% for all). Treatment with epinephrine before defibrillation was strongly associated with delayed defibrillation (median 4 minutesv0 minutes). In propensity matched analysis (6569 matched pairs), epinephrine before defibrillation was associated with lower odds of survival to discharge (22.4%v29.7%; adjusted odds ratio 0.69; 95% confidence interval 0.64 to 0.74; Pv21.6%; 0.68; 0.61 to 0.76; Pv69.5%; 0.73; 0.67 to 0.79; PConclusionsContrary to current guidelines that prioritize immediate defibrillation for in-hospital cardiac arrest due to a shockable rhythm, one in five patients are treated with epinephrine before defibrillation. Use of epinephrine before defibrillation was associated with worse survival outcomes.

ObjectiveTo describe self-reported disease understanding for newly diagnosed patients with atrial fibrillation (AF) and assess (1) how disease understanding changes over the first 6 months after diagnosis and (2) the relationship between patient understanding of therapies at baseline and treatment receipt at 6 months among treatment-naïve patients.MethodsWe analysed survey data from SATELLITE (Survey of Patient Knowledge and Personal Priorities for Treatment), a substudy of patients with new-onset AF enrolled in the national Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT) II registry across 56 US sites. Patients were surveyed at the baseline and 6-month follow-up clinic visits using Likert scales.ResultsAmong 1004 baseline survey responses, patients' confidence in their understanding of rhythm control, ablation, anticoagulation and cardioversion was suboptimal, with 'high' understanding ranging from 8.5% for left atrial appendage closure to 71.3% for rhythm therapy. Of medical history and demographic factors, education level was the strongest predictor of reporting 'high' disease understanding. Among the 786 patients with 6-month survey data, significant increases in the proportion reporting high understanding were observed (p

BackgroundNon-vitamin K antagonist oral anticoagulants (NOACs) are indicated for stroke prevention in atrial fibrillation (AF) but require lower doses in certain patients. We sought to describe the frequency, appropriateness (according to Food and Drug Administration labeling), and outcomes of patients prescribed reduced doses of NOACs in community practice.Methods and resultsWe analyzed data from the ORBIT-AF II (The Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II) registry, a prospective, national, observational registry of AF patients. Among 7925 AF patients receiving NOACs, we assessed patterns of use of reduced NOAC doses and associated cardiovascular and bleeding outcomes at median follow-up of 1year. Overall, 6636 patients (84%) received a NOAC at standard dose, which was consistent with US Food and Drug Administration labeling in 6376 (96%). Reduced NOAC dose was prescribed to 1289 (16% overall), which was consistent with Food and Drug Administration labeling in only 555 patients (43%). Compared with those whose NOAC dose was appropriately reduced, patients receiving inappropriate dose reductions were younger (median age 79 versus 84, P

Some studies suggest that female practitioners are more likely to provide guideline-concordant care than male practitioners; however, little is known about the role of practitioner gender in cardiology.The aim of the study was to measure the association between practitioner gender and adherence to the cardiovascular performance measures in the American College of Cardiology's ambulatory Practice Innovation and Clinical Excellence Registry.Patients with at least 1 outpatient visit with a unique practitioner were included. Among eligible patients, adherence to 7 guideline-supported performance measures for coronary artery disease, heart failure, and atrial fibrillation over 12 months after registry entry was compared by practitioner gender using hierarchical models adjusting for practitioner type (physicians vs advance practice practitioners) and number of visits.The study cohort included 1493 individual practitioners who saw 769 139 patients; 80% of practitioners were men. Male practitioners were more often physicians compared with female practitioners (98.2% vs 43.7%, P.01). Accounting for practitioner category and visit frequency, guideline adherence rates were similar by practitioner gender for all measures with the exception of marginally higher rates for coronary artery disease performance measures for male practitioners compared with female practitioners (antiplatelet: rate ratio [RR] = 1.06; 95% confidence interval [CI], 1.03-1.09; β-blockers: RR = 1.06; 95% CI, 1.01-1.10; and lipid-lowering drug: RR = 1.07; 95% CI, 1.04-1.10) and atrial fibrillation (oral anticoagulants: RR = 1.05; 95% CI, 1.01-1.09).Male practitioners marginally outperformed their female counterparts in ambulatory practices enrolled in a voluntary cardiovascular performance improvement registry program. Overall low adherence to some performance measures suggests room for improvement among all practitioners.

In SPRINT (Systolic Blood Pressure Intervention Trial), patients with hypertension and high cardiovascular risk treated with intensive blood pressure (BP) control (120 mm Hg) had fewer major adverse cardiovascular events (MACE) and deaths but higher rates of treatment-related serious adverse events (SAE) than patients randomized to standard BP control (140 mm Hg). However, the degree of benefit or harm for an individual patient could vary because of heterogeneity in treatment effect.Using patient-level data from 9361 randomized patients in SPRINT, we developed models to predict risk for MACE or death and treatment-related SAE to allow for individualized BP treatment goals based on each patient's projected risk and benefit of intensive versus standard BP control. Models were internally validated using bootstrap resampling and externally validated on 4741 patients from the ACCORD-BP (The Action to Control Cardiovascular Risk in Diabetes blood pressure) trial. Among 9361 SPRINT patients, 755 patients (8.1%) had a MACE or death event and 338 patients (3.6%) had a treatment-related SAE during a median follow-up of 3.3 years. The MACE/death and the SAE model had C statistics of 0.72 and 0.70, respectively, in the derivation cohort and 0.69 and 0.65 in ACCORD. The MACE/death model had 10 variables including treatment interactions with age, baseline systolic BP, and diastolic BP, and the SAE model had 8 variables including treatment interaction with number of BP medications. Intensive BP treatment was associated with a mean 2.2±2.6% lower risk of MACE/death compared with standard treatment (range, 20.7% lower risk to 19.6% greater risk among individual patients) and a mean 2.2±1.2% higher risk for SAEs (range, 0.5%-15.8% more harm in individual patients).To translate the findings from SPRINT to clinical practice, we developed prediction models to tailor the intensity of BP control based on the projected risk and benefit for each unique patient. This approach should be prospectively tested to better engage patients in shared medical decision making and to improve outcomes.URL: https://clinicaltrials.gov. Unique identifier: NCT01206062.

BackgroundAs treatment options for atrial fibrillation (AF) increase, more attention is focused on patients' experiences and quality of life (QoL). However, little is known about the factors associated with these outcomes.MethodsThe Atrial Fibrillation Effect on QualiTy-of-life (AFEQT) is a disease-specific QoL tool for AF, with domain and summary scores ranging from 0 (the worst QoL) to 100. Using multivariable linear regression, we evaluated factors associated with baseline AFEQT Summary and Subscale Scores in ORBIT AF, a large, community-based AF registry. Independent associations were reported as coefficient estimates in scores and 95% confidence intervals (CI).ResultsOverall, AFEQT was assessed in 2007 AF outpatients from 99 sites. Median age (IQR) was 76 years (67-82) and 43% were female. The median AFEQT summary score was 82 (67-94). Female sex, younger age, new onset AF, higher heart rate, obstructive sleep apnea, symptomatic heart failure (HF), chronic obstructive pulmonary disease and coronary artery disease were all independently associated with reduced QoL. Female sex [Estimate -7.03, 95% CI (-9.31, -4.75)] and new onset versus permanent AF [Estimate -7.44, 95% CI (-11.03, -3.84)] were independently associated with increased symptoms. NYHA Class III or IV HF [Estimate -14.44, 95% CI (-19.46, -8.76)] and female sex [Estimate -7.91, 95% CI (-9.95, -5.88)] were most independently associated with impaired daily activities.ConclusionsQoL in patients with AF varies widely and is associated with several patient factors. Understanding patient factors independently associated with worse QoL can be a foundation for tailoring treatment.

As treatment options for atrial fibrillation (AF) increase, more attention is focused on patients' experiences and quality of life (QoL). However, little is known about the factors associated with these outcomes.The Atrial Fibrillation Effect on QualiTy-of-life (AFEQT) is a disease-specific QoL tool for AF, with domain and summary scores ranging from 0 (the worst QoL) to 100. Using multivariable linear regression, we evaluated factors associated with baseline AFEQT Summary and Subscale Scores in ORBIT AF, a large, community-based AF registry. Independent associations were reported as coefficient estimates in scores and 95% confidence intervals (CI).Overall, AFEQT was assessed in 2007 AF outpatients from 99 sites. Median age (IQR) was 76 years (67-82) and 43% were female. The median AFEQT summary score was 82 (67-94). Female sex, younger age, new onset AF, higher heart rate, obstructive sleep apnea, symptomatic heart failure (HF), chronic obstructive pulmonary disease and coronary artery disease were all independently associated with reduced QoL. Female sex [Estimate -7.03, 95% CI (-9.31, -4.75)] and new onset versus permanent AF [Estimate -7.44, 95% CI (-11.03, -3.84)] were independently associated with increased symptoms. NYHA Class III or IV HF [Estimate -14.44, 95% CI (-19.46, -8.76)] and female sex [Estimate -7.91, 95% CI (-9.95, -5.88)] were most independently associated with impaired daily activities.QoL in patients with AF varies widely and is associated with several patient factors. Understanding patient factors independently associated with worse QoL can be a foundation for tailoring treatment.

OBJECTIVES: We sought to investigate the prevalence and predictors of oral anticoagulation prescription among patients with atrial fibrillation (AF) at the lowest risk for thromboembolism, despite contemporary consensus guidelines that do not recommend anticoagulation therapy in this population. BACKGROUND: In young and healthy AF patients without significant thromboembolic risk factors, anticoagulant treatment carries bleeding risks that outweigh stroke prevention benefit. METHODS: Within a large contemporary registry of cardiology outpatients, we identified low-risk patients with AF meeting criteria for a contemporary consensus guideline class III indication against use of anticoagulation (age < 60 years, CHADS2 Score=0, and no structural heart disease) between 2008–2012, and a second cohort with the same criteria and a CHA2DS2-VASc Score of 0. Using hierarchical modified Poisson regression models adjusted for patient characteristics, we examined predictors of oral anticoagulation treatment in these low thromboembolic risk AF patients. RESULTS: Oral anticoagulation was prescribed in a total of 2,561 of 10,995 (23.2%) AF patients with a CHADS2 score of 0 and 1,787 of 6,730 (26.6%) AF patients with a CHA2DS2-VASc score of 0. In multivariable analysis, older age (RR 1.48 per 10 years; 95% CI, 1.41–1.56; p

American research demonstrated that 1 out of 4 patients undergoes diagnostic coronary angiography without clear evidence of symptoms or objective signs of ischaemia, leading to unnecessary angioplasties in a substantial number of patients. A second study, published simultaneously, demonstrated that proper patient education could decrease the rates of angioplasty in patients with stable coronary artery disease significantly. In the present editorial we critically assess both publications and put them in perspective to current clinical practice in the Netherlands along with the European guidelines for myocardial revascularization.

ObjectivesCHARISMA was a landmark randomized clinical trial that failed to demonstrate a benefit of dual antiplatelet therapy (DAPT) over aspirin alone for preventing cardiovascular events. However, subgroup analyses of the trial found fewer major adverse cardiovascular events (MACEs) for patients with established cardiovascular disease but more MACEs for patients with multiple risk factors without established cardiovascular disease. Our objective was to examine DAPT use in contemporary clinical practice after publication of CHARISMA results.Study designRetrospective analysis of a large clinical registry of outpatient cardiovascular visits to over 1000 physicians that collected data on patient clinical history, symptoms, vital signs, and medications.MethodsClinical characteristics and prescription rates of aspirin and clopidogrel were compared for patients with established cardiovascular disease and for patients with only multiple cardiovascular risk factors. Prescription of DAPT by calendar quarter was evaluated from 2008 to 2011 using multivariable Poisson regression models.ResultsOf 167,839 patients with established cardiovascular disease, 20.5% were prescribed both aspirin and clopidogrel. Of 20,478 patients with multiple risk factors but no known cardiovascular disease, 3.5% were prescribed both aspirin and clopidogrel. Across 14 calendar quarters, prescription rates of DAPT did not change significantly for patients with established CVD but decreased for patients with multiple risk factors with an incidence rate ratio of 0.77.ConclusionsUse of DAPT is modest in patients with established cardiovascular disease, for whom the CHARISMA trial suggested decreased MACEs, and prescription rates have remained stable over time. Use of DAPT in patients with multiple risk factors only, for whom CHARISMA suggested that DAPT may lead to increased MACE, was low and decreased over time.

CHARISMA was a landmark randomized clinical trial that failed to demonstrate a benefit of dual antiplatelet therapy (DAPT) over aspirin alone for preventing cardiovascular events. However, subgroup analyses of the trial found fewer major adverse cardiovascular events (MACEs) for patients with established cardiovascular disease but more MACEs for patients with multiple risk factors without established cardiovascular disease. Our objective was to examine DAPT use in contemporary clinical practice after publication of CHARISMA results.Retrospective analysis of a large clinical registry of outpatient cardiovascular visits to over 1000 physicians that collected data on patient clinical history, symptoms, vital signs, and medications.Clinical characteristics and prescription rates of aspirin and clopidogrel were compared for patients with established cardiovascular disease and for patients with only multiple cardiovascular risk factors. Prescription of DAPT by calendar quarter was evaluated from 2008 to 2011 using multivariable Poisson regression models.Of 167,839 patients with established cardiovascular disease, 20.5% were prescribed both aspirin and clopidogrel. Of 20,478 patients with multiple risk factors but no known cardiovascular disease, 3.5% were prescribed both aspirin and clopidogrel. Across 14 calendar quarters, prescription rates of DAPT did not change significantly for patients with established CVD but decreased for patients with multiple risk factors with an incidence rate ratio of 0.77.Use of DAPT is modest in patients with established cardiovascular disease, for whom the CHARISMA trial suggested decreased MACEs, and prescription rates have remained stable over time. Use of DAPT in patients with multiple risk factors only, for whom CHARISMA suggested that DAPT may lead to increased MACE, was low and decreased over time.

Whereas statins are considered the cornerstone of prevention after acute myocardial infarction (AMI), concerns about worsening depression in association with their use have been raised.Using data from 2 prospective AMI registries (PREMIER and TRIUMPH), we examined the change in depressive symptoms from baseline and at 1, 6 and 12 months among statin-naïve patients who were and were not discharged on a statin. Depressive symptoms were assessed with the 8-item Patient Health Questionnaire (PHQ-8). Within-group change in PHQ-8 scores from baseline to each follow-up period was assessed using paired t tests. A repeated-measures propensity-matched analysis examined whether changes in PHQ-8 scores from baseline were different between statin-treated and statin-untreated patients.Of 3,675 patients not previously treated with statins, 3,050 (83%) were discharged on a statin and 625 (17%) were not. Scores of PHQ-8 in the statin group decreased from baseline by a mean (± SD) of 0.9 (± 5.1), 1.2 (± 5), and 1.1 (± 5.1) at 1, 6, and 12 months, respectively. Corresponding changes in the nonstatin group were 0.9 (± 5.2), 1.3 (± 5.1), and 1.5 (± 5.8), respectively (P.0001 for all comparisons). After propensity matching, 451 patients not discharged on statins with 1,240 patients discharged on statins, the mean change in PHQ-8 scores between baseline and the 3 follow-up time points was not significantly different between groups (mean between-group difference at 1 month: -0.13, 95% CI [-0.69 to 0.43], P = .65; at 6 months: -0.07, 95% CI [-0.66 to 0.52], P = .82; and at 12 months: -0.05, 95% CI [-0.67 to 0.58], P = .88).Initiation of statins after AMI was not associated with worsening depression.

This study assessed practice variations in secondary prevention medication prescriptions among coronary artery disease (CAD) patients treated in outpatient practices participating in the National Cardiovascular Data Registry (NCDR) Practice Innovation and Clinical Excellence (PINNACLE) registry.Among patients with CAD, secondary prevention with a combination of beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and statins reduces cardiac mortality and myocardial infarction (MI). Accordingly, every CAD patient should receive the combination of these medications for which they are eligible. However, little is known about current prescription patterns of these medications and the variation in use among outpatient cardiology clinics.Using data from NCDR PINNACLE registry, a national outpatient cardiology practice registry, we assessed medication prescription patterns among eligible CAD patients, between July 2008 and December 2010. Overall rates of prescription and variation by practice were calculated, adjusting for patient characteristics.Among 156,145 CAD patients in 58 practices, 103,830 (66.5%) patients were prescribed the optimal combination of medications for which they were eligible. The median rate of optimal combined prescription by practice was 73.5% and varied from 28.8% to 100%. After adjustment for patient factors, the practice median rate ratio for prescription was 1.25 (95% confidence interval: 1.20 to 1.32), indicating a 25% likelihood that 2 random practices would differ in treating identical CAD patients.Among a national registry of CAD patients treated in outpatient cardiology practices, over one-third of patients failed to receive their optimal combination of secondary prevention medications. Significant variation was observed across practices, even after adjusting for patient characteristics, suggesting that quality improvement efforts may be needed to support more uniform practice.

Somatic depressive symptoms and certain biomarkers are each associated with worse acute myocardial infarction (AMI) prognosis, but the relationship between depressive symptom domains and inflammatory, neurohormonal, and coagulation markers is unknown.We examined the relationship between depressive symptoms and 1-month biomarker levels (high-sensitivity C-reactive protein [hs-CRP], N-terminal pro-brain natriuretic peptide [NT-proBNP], white blood cell [WBC], platelet counts) in 1265 AMI patients. Depressive symptoms (9-item Patient Health Questionnaire) were assessed during index hospitalization and categorized as somatic or cognitive. Using median regression models, the upper quartile of somatic and cognitive depression scores and each biomarker were compared with the lower three quartiles, adjusting for site, demographics, and clinical characteristics.Although hs-CRP values were higher in patients with somatic symptoms, this association was attenuated after adjustment (B(per SD increase) = .02, 95% confidence interval: .00; .05, p = .07). WBC count was independently associated with somatic depressive symptoms (B(per SD increase) = .28, 95% confidence interval: .12; .44, p.001). Cognitive depressive symptoms were not associated with hs-CRP or WBC count. Neither dimension was associated with NT-proBNP or platelet levels. For each biomarker, the depression dimensions explained1% of their variation.Neither somatic nor cognitive depressive symptoms were meaningfully associated with hs-CRP, NT-proBNP, WBC, or platelet counts 1 month after AMI, suggesting that the association between depression and long-term outcomes may be unrelated to these biomarkers. Future research should explore other biomarkers to better illuminate pathways by which depression adversely impacts AMI prognosis.

Assistive listening devices allow hearing impaired listeners to achieve higher comprehension than with hearing aids alone in difficult listening conditions which occurs during business meetings, lectures, and presentations. These devices minimize the acoustic pathway between the speaker and listener by using some form of electromagnetic transmission. A major problem with existing assistive listening devices is that they provide little security for the users, as the signal may be picked up by unauthorized listeners outside the confines of the meeting room or hall. The design, implementation, and testing of a secure radio-frequency assistive listening device are described in this thesis. The device combines digital voice encoding technology with the direct sequence spread spectrum technique to provide a secure digital voice communication channel for hearing impaired people. It is shown that the CCITT 0.722 and the digital voice encoding algorithms are acceptable for hearing impaired listeners. A transmitter and receiver based on the Arlan 650Tm wireless network card is implemented. Digitized speech samples are grouped into packets and transmitted using the TCP/IP protocol. The packet error rates of the device measured under some typical environment are presented. The degradation of intelligibility under packet loss conditions is also presented. It is shown that speech intelligibility decreases as the number of lost speech segments increases and the lost speech segments are replaced by two simple packet loss replacement methods.

ObjectivesTo investigate the generalizability of the reduction in mortality posed by implantable cardioverter-defibrillators, we examined the effectiveness of defibrillators as applied in routine medical practice.BackgroundImplantable cardioverter-defibrillators have been shown to be efficacious in the primary and secondary prevention of overall and cardiovascular mortality in clinical trials.MethodsUsing the National Veterans Administration database, we identified a cohort of 6,996 patients from 1995 to 1999 with new-onset ventricular arrhythmia and pre-existing ischemic heart disease and congestive heart failure, of which 1,442 received a defibrillator, and followed them for three years to determine rates of mortality. With multivariate logistic regression analyses that adjusted for demographics, illness severity, and comorbidity, we assessed overall, cardiovascular, and noncardiovascular rates of mortality. To further address potential confounding, we also stratified the cohort by quintiles using a multivariable propensity score for each patient and determined mortality rates.ResultsFor the overall cohort, multivariate regression showed that those who received defibrillators had significantly lower all-cause (odds ratio [OR] 0.52; 95% confidence interval [CI] 0.45 to 0.60) and cardiovascular (OR 0.56; 95% CI 0.49 to 0.65)] rates of mortality at three years. No significant differences were noted between groups in their rates of noncardiovascular mortality (OR 0.92; 95% CI 0.77 to 1.10). Propensity score analysis demonstrated similar mortality reduction benefits at three years: risk ratio (RR) 0.72 (95% CI 0.69 to 0.79) for all-cause; RR 0.70 (95% CI 0.63 to 0.78) for cardiovascular; and RR 0.95 (95% CI 0.83 to 1.08) for noncardiovascular rates of mortality. These results suggest that one death is prevented in this patient population for every four to five patients receiving a defibrillator for three years.ConclusionsImplantable cardioverter-defibrillators in routine medical practice significantly reduce cardiovascular and all-cause rates of mortality at levels similar to secondary prevention trials.

ObjectivesThe aim of this study was to examine the prescribing patterns of medications quantified by the performance measures for acute myocardial infarction (AMI).BackgroundCurrent performance measures for AMI are designed to improve quality by quantifying the use of evidence-based treatments. However, these measures only assess medication prescription. Whether patients receive optimal dosing of secondary prevention medications at the time of and after discharge after AMI is unknown.MethodsWe assessed treatment doses of beta-blockers, statins, and angiotensin-converting enzyme inhibitors (ACEI)/angiotensin II receptor blockers (ARBs) at discharge and 12 months after AMI among 6,748 patients from 31 hospitals enrolled in 2 U.S. registries (2003 to 2008). Prescribed doses were categorized as none, low (87%) were prescribed some dose of each medication at discharge, although only 1 in 3 patients were prescribed these medications at goal doses. Of patients not discharged on goal doses, up-titration during follow-up occurred infrequently (approximately 25% of patients for each medication). At 12 months, goal doses of beta-blockers, statins, and ACEI/ARBs were achieved in only 12%, 26%, and 32% of eligible patients, respectively. After multivariable adjustment, prescription of goal dose at discharge was strongly associated with being at goal dose at follow-up: beta-blockers, adjusted odds ratio (OR): 6.08 (95% confidence interval [CI]: 3.70 to 10.01); statins, adjusted OR: 8.22 (95% CI: 6.20 to 10.90); ACEI/ARBs, adjusted OR: 5.80 (95% CI: 2.56 to 13.16); p < 0.001 for each.ConclusionsAlthough nearly all patients after an AMI are discharged on appropriate secondary prevention medications, dose increases occur infrequently, and most patients are prescribed doses below those with proven efficacy in clinical trials. Integration of dose intensity into performance measures might help improve the use of optimal medical therapy after AMI.

ObjectivesThe authors sought to study the characteristics and outcomes of patients with contralateral carotid artery occlusions (CCOs) undergoing elective carotid artery stenting (CAS).BackgroundCCOs are associated with adverse neurological events following carotid endarterectomy.MethodsIn-hospital outcomes were examined in patients with and without CCO undergoing elective CAS in the Carotid Artery Revascularization and Endarterectomy (CARE) registry. A CCO was defined as a 100% occlusion of the contralateral internal carotid artery. To minimize differences in measured comorbidities, a 3:1 propensity matching analysis was performed comparing 42 clinical and demographic variables between CCO and non-CCO patients from the CARE registry. The primary endpoint was a composite of in-hospital death, nonfatal myocardial infarction, and nonfatal stroke.ResultsBetween April 2005 and January 2012, 13,993 eligible patients underwent elective CAS, of whom 1,450 (10%) had CCO. There were 5,500 CAS procedures (1,375 CCO and 4,125 non-CCO) identified in the propensity analysis. The primary composite endpoint occurred in 29 (2.1%) and 107 (2.6%) patients with and without CCO, respectively (adjusted odds ratio: 0.81, 95% confidence interval: 0.53 to 1.23, p = 0.316).ConclusionsIn the CARE registry, there was no evidence that the presence of a CCO was associated with an increased risk of in-hospital death, nonfatal myocardial infarction, or nonfatal stroke in patients undergoing elective CAS. These findings may have implications on the selection of carotid revascularization procedures for such patients.

BackgroundIn a significant update, the 2013 American College of Cardiology/American Heart Association (ACC/AHA) cholesterol guidelines recommend fixed-dose statin therapy for those at risk and do not recommend nonstatin therapies or treatment to target low-density lipoprotein cholesterol (LDL-C) levels, limiting the need for repeated LDL-C testing.ObjectivesThe goal of this study was to examine the impact of the 2013 ACC/AHA cholesterol guidelines on current U.S. cardiovascular practice.MethodsUsing the NCDR PINNACLE (National Cardiovascular Data Registry Practice Innovation and Clinical Excellence) registry data from 2008 to 2012, we assessed current practice patterns as a function of the 2013 cholesterol guidelines. Lipid-lowering therapies and LDL-C testing patterns by patient risk group (atherosclerotic cardiovascular disease [ASCVD], diabetes, LDL-C ≥190 mg/dl, or an estimated 10-year ASCVD risk ≥7.5%) were described.ResultsAmong a cohort of 1,174,545 patients, 1,129,205 (96.1%) were statin-eligible (91.2% ASCVD, 6.6% diabetes, 0.3% off-treatment LDL-C ≥190 mg/dl, 1.9% estimated 10-year ASCVD risk ≥7.5%). There were 377,311 patients (32.4%) not receiving statin therapy and 259,143 (22.6%) receiving nonstatin therapies. During the study period, 20.8% of patients had 2 or more LDL-C assessments, and 7.0% had more than 4.ConclusionsIn U.S. cardiovascular practices, 32.4% of statin-eligible patients, as defined by the 2013 ACC/AHA cholesterol guidelines, were not currently receiving statins. In addition, 22.6% were receiving nonstatin lipid-lowering therapies and 20.8% had repeated LDL-C testing. Achieving concordance with the new cholesterol guidelines in patients treated in U.S. cardiovascular practices would result in significant increases in statin use, as well as significant reductions in nonstatin therapies and laboratory testing.

ObjectivesThe aim of this paper was to examine disparities in the use of cardioprotective medications in the treatment of peripheral artery disease (PAD) by socioeconomic status (SES).BackgroundPAD is associated with increased cardiovascular risk and is more prevalent among those of lower SES. However, the use of guideline-recommended secondary preventive measures for the treatment of PAD across diverse income subgroups and the influence of practice site on potential treatment disparities by SES are unknown.MethodsWithin the National Cardiovascular Disease Registry (NCDR) PINNACLE Registry, 62,690 patients with PAD were categorized into quintiles of SES, as defined by the median income of each patient's zip code. The association between SES and secondary preventive treatment with antiplatelet and statin medications was evaluated using sequential hierarchical modified Poison models, adjusting first for practice site and then for clinical variables.ResultsCompared with the highest SES quintile (median income: >$60,868), PAD patients in the lowest SES quintile (median income

ObjectivesThis study assessed practice variations in secondary prevention medication prescriptions among coronary artery disease (CAD) patients treated in outpatient practices participating in the National Cardiovascular Data Registry (NCDR) Practice Innovation and Clinical Excellence (PINNACLE) registry.BackgroundAmong patients with CAD, secondary prevention with a combination of beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and statins reduces cardiac mortality and myocardial infarction (MI). Accordingly, every CAD patient should receive the combination of these medications for which they are eligible. However, little is known about current prescription patterns of these medications and the variation in use among outpatient cardiology clinics.MethodsUsing data from NCDR PINNACLE registry, a national outpatient cardiology practice registry, we assessed medication prescription patterns among eligible CAD patients, between July 2008 and December 2010. Overall rates of prescription and variation by practice were calculated, adjusting for patient characteristics.ResultsAmong 156,145 CAD patients in 58 practices, 103,830 (66.5%) patients were prescribed the optimal combination of medications for which they were eligible. The median rate of optimal combined prescription by practice was 73.5% and varied from 28.8% to 100%. After adjustment for patient factors, the practice median rate ratio for prescription was 1.25 (95% confidence interval: 1.20 to 1.32), indicating a 25% likelihood that 2 random practices would differ in treating identical CAD patients.ConclusionsAmong a national registry of CAD patients treated in outpatient cardiology practices, over one-third of patients failed to receive their optimal combination of secondary prevention medications. Significant variation was observed across practices, even after adjusting for patient characteristics, suggesting that quality improvement efforts may be needed to support more uniform practice.

ObjectivesWe examined compliance with performance measures for 14,464 patients enrolled from July 2008 through June 2009 into the American College of Cardiology's PINNACLE (Practice Innovation And Clinical Excellence) program to provide initial insights into the quality of outpatient cardiac care.BackgroundLittle is known about the quality of care of outpatients with coronary artery disease (CAD), heart failure, and atrial fibrillation, and whether sex and racial disparities exist in the treatment of outpatients.MethodsThe PINNACLE program is the first, national, prospective office-based quality improvement program of cardiac patients designed, in part, to capture, report, and improve outpatient performance measure compliance. We examined the proportion of patients whose care was compliant with established American College of Cardiology, American Heart Association, and American Medical Association-Physician Consortium for Performance Improvement (ACC/AHA/PCPI) performance measures for CAD, heart failure, and atrial fibrillation.ResultsThere were 14,464 unique patients enrolled from 27 U.S. practices, accounting for 18,021 clinical visits. Of these, 8,132 (56.4%) had CAD, 5,012 (34.7%) had heart failure, and 2,786 (19.3%) had nonvalvular atrial fibrillation. Data from the PINNACLE program were feasibly collected for 24 of 25 ACC/AHA/PCPI performance measures. Compliance with performance measures ranged from being very low (e.g., 13.3% of CAD patients screened for diabetes mellitus) to very high (e.g., 96.7% of heart failure patients with blood pressure assessments), with moderate (70% to 90%) compliance observed for most performance measures. For 3 performance measures, there were small differences in compliance rates by race or sex.ConclusionsFor more than 14,000 patients enrolled from 27 practices in the outpatient PINNACLE program, we found that compliance with performance measures was variable, even after accounting for exclusion criteria, suggesting an important opportunity to improve the quality of outpatient care.

ObjectivesThis study sought to assess the prognostic utility of echocardiographic dyssynchrony for health status improvement after cardiac resynchronization therapy (CRT).BackgroundEchocardiographic measures of dyssynchrony have been proposed for patient selection for CRT, but prospective validation studies are lacking.MethodsA prospective cohort of 324 patients from 53 centers with moderate to severe heart failure, left ventricular dysfunction, QRS ≥130 ms, and available echocardiographic and health status information were identified from the PROSPECT (Predictors of Response to Cardiac Re-Synchronization Therapy) trial, which evaluated the prognostic utility of dyssynchrony measures in CRT recipients. The association of 12 echocardiographic dyssynchrony parameters with 6-month improvement in health status, as measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ), was assessed both as a continuous variable and by responder status (ΔKCCQ ≥+10 points reflecting moderate to large improvement).ResultsOf 12 pre-defined dyssynchrony parameters, only 3 were consistently reported: interventricular mechanical delay (IVMD), left ventricular filling time relative to the cardiac cycle (LVFT), and left ventricular pre-ejection interval. After multivariable adjustment, IVMD (+5.18, 95% confidence interval [CI]: +0.76 to +9.60; p = 0.02) and LVFT (+5.19, 95% CI: +0.45 to +0.94; p = 0.03) were independently associated with 6-month improvements in KCCQ. Patients with 6-month improvements in KCCQ had lower subsequent mortality (adjusted hazard ratio [HR] for each 5-point improvement: 0.83; 95% CI: 0.72 to 0.93; p = 0.03). Additionally, IVMD was associated with CRT responder status (for ΔKCCQ ≥+10 points: odds ratio [OR]: 1.85; 95% CI: 1.12 to 3.05; p = 0.03), whereas LVFT was not (OR: 1.63; 95% CI: 0.85 to 3.11; p = 0.14). Patients classified as health status responders had a 76% lower subsequent risk of all-cause mortality (adjusted HR: 0.24; 95% CI: 0.07 to 0.84; p = 0.03).ConclusionsThe presence of pre-implantation IVMD and LVFT was associated with 6-month health status improvement, and IVMD was associated with a significant CRT response. These echocardiographic factors may help clinicians counsel patients regarding their likelihood of symptomatic improvement with CRT. (PROSPECT: Predictors of Response to Cardiac Re-Synchronization Therapy; NCT00253357)

BackgroundThe current number of physicians will not be sufficient to accommodate 30 to 40 million Americans expected to secure health coverage with Affordable Care Act implementation. One proposed solution is to use advanced practice providers (APPs) (nurse practitioners and physician assistants).ObjectivesThis study sought to determine whether there were clinically meaningful differences in the quality of care delivered by APPs versus physicians in a national sample of cardiology practices.MethodsWithin the American College of Cardiology’s PINNACLE Registry, we compared quality of coronary artery disease (CAD), heart failure, and atrial fibrillation care delivered by physicians and APPs for outpatient visits between January 1, 2012, and December 31, 2012. We performed hierarchical regression adjusting for provider sex; panel size; duration of participation in registry; and patient’s age, sex, insurance, number of outpatient visits, history of hypertension, diabetes, myocardial infarction, and percutaneous coronary intervention or coronary artery bypass grafting in the preceding 12 months.ResultsWe included 883 providers (716 physicians and 167 APPs) in 41 practices who cared for 459,669 patients. Mean number of patients seen by APPs (260.7) was lower compared with that seen by physicians (581.2). Compliance with most CAD, heart failure, and atrial fibrillation measures was comparable, except for a higher rate of smoking cessation screening and intervention (adjusted rate ratio: 1.14; 95% confidence interval: 1.03 to 1.26) and cardiac rehabilitation referral (rate ratio: 1.40; 95% confidence interval: 1.16 to 1.70) among CAD patients receiving care from APPs. Compliance with all eligible CAD measures was low for both (12.1% and 12.2% for APPs and physicians, respectively) with no significant difference. Results were consistent when comparing practices with both physicians and APPs (n = 41) and physician-only practices (n = 49).ConclusionsApart from minor differences, a collaborative care delivery model, using both physicians and APPs, may deliver an overall comparable quality of outpatient cardiovascular care compared with a physician-only model.

ObjectivesThis study examined the association between insurance status and physicians' adherence with providing evidence-based treatments for coronary artery disease (CAD).MethodsWithin the PINNACLE (Practice Innovation and Clinical Excellence) registry of the NCDR (National Cardiovascular Data Registry), the authors identified 60,814 outpatients with CAD from 30 U.S. practices. Hierarchical modified Poisson regression models with practice site as a random effect were used to study the association between health insurance (no insurance, public, or private health insurance) and 5 CAD quality measures.ResultsOf 60,814 patients, 5716 patients (9.4%) were uninsured and 11,962 patients (19.7%) had public insurance, whereas 43,136 (70.9%) were privately insured. After accounting for exclusions, uninsured patients with CAD were 9%, 12%, and 6% less likely to receive treatment with a beta-blocker, an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker (ACE-I/ARB), and lipid-lowering therapy, respectively, than privately insured patients, and patients with public insurance were 9% less likely to be prescribed ACE-I/ARB therapy. Most differences by insurance status were attenuated after adjusting for the site providing care. For example, whereas uninsured patients with left ventricular dysfunction and CAD were less likely to receive ACE-I/ARB therapy (unadjusted RR: 0.88; 95% CI: 0.84 to 0.93), this difference was eliminated after adjustment for site (adjusted RR: 0.95; 95% CI: 0.88 to 1.03; p = 0.18).ConclusionsWithin this national outpatient cardiac registry, uninsured patients were less likely to receive evidence-based medications for CAD. These disparities were explained by the site providing care. Efforts to reduce treatment differences by insurance status among cardiac outpatients may additionally need to focus on improving the rates of evidence-based treatment at sites with high proportions of uninsured patients.