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Background Persistence to P2Y12 inhibitors after myocardial infarction (MI) remains low. Out-of-pocket cost is cited as a factor affecting medication compliance. We examined whether a copayment intervention affected 1-year persistence to P2Y12 inhibitors and clinical outcomes. Methods and Results In an analysis of ARTEMIS (Affordability and Real-World Antiplatelet Treatment Effectiveness After Myocardial Infarction Study), patients with MI discharged on a P2Y12 inhibitor were stratified by baseline out-of-pocket medication burden: low ($0-$49 per month), intermediate ($50-$149 per month), and high (≥$150 per month). The impact of the voucher intervention on 1-year P2Y12 inhibitor persistence was examined using a logistic regression model with generalized estimating equations. We assessed the rates of major adverse cardiovascular events among the groups using a Kaplan-Meier estimator. Among 7351 MI-treated patients at 282 hospitals, 54.2% patients were in the low copay group, 32.0% in the middle copay group, and 13.8% in the high copay group. Patients in higher copay groups were more likely to have a history of prior MI, heart failure, and diabetes compared with the low copay group (all P

BackgroundAmong patients with acute myocardial infarction (MI) who have multivessel disease, it is unclear if multivessel percutaneous coronary intervention (PCI) improves clinical and quality-of-life outcomes compared with culprit-only intervention. We sought to compare clinical and quality-of-life outcomes between multivessel and culprit-only PCI.Methods and resultsAmong 6061 patients with acute MI who have multivessel disease in the TRANSLATE-ACS (Treatment With Adenosine Diphosphate Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome) study, we used inverse probability-weighted propensity adjustment to study the associations between multivessel and culprit-only intervention during the index PCI and major adverse cardiovascular events, unplanned all-cause readmission, and angina frequency at 6weeks and 1year. Multivessel PCI was performed in 1208 (20%) of patients with MI who had multivessel disease. Relative to the culprit-only intervention, patients receiving multivessel PCI were similarly aged and more likely to be seen with non-ST-segment elevation MI or cardiogenic shock. At 6weeks, the initial multivessel PCI strategy was associated with lower major adverse cardiovascular events and unplanned readmission risks, whereas angina frequency was not significantly different between multivessel and culprit-only PCI. At 1year, major adverse cardiovascular event risk was persistently lower in the multivessel PCI group (adjusted hazard ratio, 0.84; 95% confidence interval, 0.72-0.99), whereas long-term readmission risk (adjusted hazard ratio, 0.94; 95% confidence interval, 0.84-1.04) and angina frequency were similar between groups (adjusted odds ratio, 1.01; 95% confidence interval, 0.82-1.24). Similar associations were seen when patients with ST-segment elevation MI and non-ST-segment elevation MI were examined separately.ConclusionsAmong patients with acute MI who have multivessel disease, multivessel PCI was associated with lower risk of all-cause readmission at 6weeks and lower risk of major adverse cardiovascular events at 6weeks and 1year. However, similarshort- and long-term angina frequencies were noted.

ObjectivesThe purpose of this study was to examine use and describe outcomes of radial access for percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI).BackgroundTransradial PCI (TRI) is associated with reduced risk of bleeding and vascular complications, as compared with femoral access PCI (FPCI). Studies have suggested that TRI may reduce mortality among patients with STEMI.MethodsWe examined 294,769 patients undergoing PCI for STEMI at 1,204 hospitals in the CathPCI Registry between 2007 and 2011. Patients were grouped according to access site used for PCI. The temporal trend in the rate of radial versus femoral approach was determined. For minimization of confounding, an inverse probability weighting analysis incorporating propensity scores was used to compare procedural success, post-PCI bleeding, door-to-balloon times, and in-hospital mortality between radial and femoral access.ResultsOver the 5-year period, the use of TRI versus FPCI in STEMI increased from 0.9% to 6.4% (p < 0.0001). There was no difference in procedural success. TRI was associated with longer median door-to-balloon time (78 vs. 74 min; p < 0.0001) but lower adjusted risk of bleeding (odds ratio [OR]: 0.62; 95% CI: 0.53 to 0.72; p < 0.0001) and lower adjusted risk of in-hospital mortality (OR: 0.76; 95% CI: 0.57 to 0.99; p = 0.0455).ConclusionsIn this large national database, use of radial access for PCI in STEMI increased over the study period. Despite longer door-to-balloon times, the radial approach was associated with lower bleeding rate and reduced in-hospital mortality. These data provide support to execute an adequately powered randomized controlled trial comparing radial and femoral approaches for PCI in STEMI.

To determine the proportion of patients who achieved blood pressure control during the 2 years following new diabetes diagnosis.A retrospective cohort of veterans ≥ 18 years with hypertension who initiated a diabetes medication from 2000 to 2007 in the Veterans Administration Mid-South Network was assembled. Blood pressure control at diabetes treatment initiation (baseline) was compared with blood pressure control 6, 12, 18 and 24 months later. The Veterans Affairs and American Diabetes Association definitions of control, ≤ 140/90 and ≤ 130/80 mmHg, respectively, were primary and secondary outcomes.At baseline, 59.5% of 16,182 patients had controlled blood pressure according to the Veterans Affairs guideline (31.5% using American Diabetes Association definition). Six months following initiation of diabetes treatment, 65.7% had their blood pressure controlled (P0.001). Blood pressure control was sustained but not further improved between 6 months and 2 years, with 66.5% controlled at 2 years following baseline. Higher initial systolic blood pressure, black race and hospitalization in the previous year were associated with higher likelihood of uncontrolled blood pressure at 6 months; whereas baseline cardiovascular disease, baseline dementia and later year of cohort entry were associated with lower likelihood of uncontrolled blood pressure.We found an increase in blood pressure control in the 6 months following initiation of diabetes treatment. However, overall blood pressure control remained suboptimal and with no further improvement over the next 18 months.

ObjectivesThe goal of this study was to characterize nonsystem reasons for delay in door-to-balloon time (D2BT) and the impact on in-hospital mortality.BackgroundStudies have evaluated predictors of delay in D2BT, highlighting system-related issues and patient demographic characteristics. Limited data exist, however, for nonsystem reasons for delay in D2BT.MethodsWe analyzed nonsystem reasons for delay in D2BT among 82,678 ST-segment elevation myocardial infarction patients who underwent primary percutaneous coronary intervention within 24 h of symptom onset in the CathPCI Registry from January 1, 2009, to June 30, 2011.ResultsNonsystem delays occurred in 14.7% of patients (n = 12,146). Patients with nonsystem delays were more likely to be older, female, African American, and have greater comorbidities. The in-hospital mortality for patients treated without delay was 2.5% versus 15.1% for those with delay (p < 0.01). Nonsystem delay reasons included delays in providing consent (4.4%), difficult vascular access (8.4%), difficulty crossing the lesion (18.8%), “other” (31%), and cardiac arrest/intubation (37.4%). Cardiac arrest/intubation delays had the highest in-hospital mortality (29.9%) despite the shortest time delay (median D2BT: 84 min; 25th to 75th percentile: 64 to 108 min); delays in providing consent had a relatively lower in-hospital mortality rate (9.4%) despite the longest time delay (median D2BT: 100 min; 25th to 75th percentile: 80 to 131 min). Mortality for delays due to difficult vascular access, difficulty crossing a lesion, and other was also higher (8.0%, 5.6%, and 5.9%, respectively) compared with nondelayed patients (p < 0.0001). After adjustment for baseline characteristics, in-hospital mortality remained higher for patients with nonsystem delays.ConclusionsNonsystem reasons for delay in D2BT in ST-segment elevation myocardial infarction patients presenting for primary percutaneous coronary intervention are common and associated with high in-hospital mortality.

Background Extrapulmonary tuberculosis is likely a marker of underlying immune compromise. Our objective was to determine race and sex differences in extrapulmonary tuberculosis risk in order to identify the optimal population in which to assess for host factors associated with extrapulmonary tuberculosis. Methods We performed an observational study of all tuberculosis cases reported to the Tennessee Department of Health, January 1, 2000 to December 31, 2006. We compared the incidence of extrapulmonary tuberculosis by race and sex. We also examined risk factors associated with extrapulmonary disease among all persons with tuberculosis. Results Extrapulmonary tuberculosis incidence per 100,000 population was 5.93 in black men, 3.21 in black women, 1.01 in non-black men, and 0.58 in non-black women. Among those with tuberculosis, black women were most likely to have extrapulmonary disease (38.6%), followed by black men (28.1%), non-black women (24.6%) and non-black men (21.1%). In multivariate logistic regression among persons with tuberculosis, black women (OR 1.82 (95% CI 1.24-2.65), p = 0.002), black men (OR 1.54 (95% CI 1.13-2.09, p = 0.006), foreign birth (OR 1.55 (95% CI 1.12-2.14), p = 0.009), and HIV infection (OR 1.45 (95% CI 0.99-2.11), p = 0.06) were associated with extrapulmonary tuberculosis. Conclusions Black men and black women had the highest incidence of extrapulmonary tuberculosis, and high odds of extrapulmonary disease among persons with tuberculosis. These data suggest that factors in addition to tuberculosis exposure contribute to extrapulmonary tuberculosis risk in blacks.