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Background P2Y12 inhibitor medications are critical following percutaneous coronary intervention (PCI); however, adherence remains suboptimal. Our objective was to assess the effectiveness of a multifaceted intervention to improve P2Y12 inhibitor adherence following PCI. Methods and Results This was a modified stepped wedge trial of 52 eligible hospitals, of which 15 were randomly selected and agreed to participate (29 hospitals declined, and 8 eligible hospitals were not contacted). At each intervention hospital, patient recruitment occurred for 6 months and enrolled patients were followed up for 1 year after PCI. Three control groups were used: patients at intervention hospitals undergoing PCI (1) before the intervention period (preintervention); (2) after the intervention period (postintervention); or (3) at the 8 hospitals not contacted (concurrent controls). The intervention consisted of 4 components: (1) P2Y12 inhibitor delivered to patients’ bedside after PCI; (2) education on importance of P2Y12 inhibitors; (3) automated reminder telephone calls to refill medication; and (4) outreach to patients if they delayed refilling P2Y12 inhibitor. The primary outcomes were as follows: (1) proportion of patients with delays filling P2Y12 inhibitor at hospital discharge and (2) proportion of patients who were adherent in the year after PCI using pharmacy refill data. Primary analysis compared intervention with preintervention control patients. There were 1377 (intent‐to‐treat) potentially eligible patients, of whom 803 (per protocol) were approached at intervention sites versus 5910 preintervention, 2807 postintervention, and 4736 concurrent control patients. In the intent‐to‐treat analysis, intervention patients were less likely to delay filling P2Y12 at hospital discharge (−3.4%; 98.3% CI, −1.2% to −5.6%) and more likely to be adherent to P2Y12 (4.1%; 98.3% CI, 1.0%–7.1%) at 1 year, but had more clinical events (3.2%; 98.3% CI, 2.3%–4.1%) driven by repeated PCI compared with preintervention patients. In post hoc analysis looking at myocardial infarction, stroke, and death, intervention patients had lower event rates compared with preintervention patients (−1.7%; 98.3% CI, −2.3% to –1.1%). Conclusions A 4‐component intervention targeting P2Y12 inhibitor adherence was difficult to implement. The intervention produced mixed results. It improved P2Y12 adherence, but there was also an increase in repeat PCI. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01609842.

Background The significant morbidity associated with systolic heart failure makes it imperative to identify patients with a reversible cause. We thus sought to evaluate the proportion of patients who received an ischemic evaluation after a hospitalization for new‐onset systolic heart failure. Methods and Results Patients admitted with a new diagnosis of heart failure and a reduction in left ventricular ejection fraction (≤40%) were identified in the VA Healthcare System from January 2006 to August 2017. Among those who survived 90 days without a readmission, we evaluated the proportion of patients who underwent an ischemic evaluation. We identified 9625 patients who were admitted with a new diagnosis of systolic heart failure with a concomitant reduction in ejection fraction. A minority of patients (3859, 40%) underwent an ischemic evaluation, with significant variation across high‐performing (90th percentile) and low‐performing (10th percentile) sites (odds ratio, 3.79; 95% CI, 2.90–4.31). Patients who underwent an evaluation were more likely to be treated with angiotensin‐converting enzyme inhibitors (75% versus 64%, P

Background Quality of care incentives and reimbursements for cardiovascular testing differ between insurance providers. We hypothesized that there are differences in the use of guideline‐concordant testing between Medicaid versus commercial insurance patients

Background Secondary prevention after acute myocardial infarction (AMI) requires long‐term guideline‐directed medical therapy. However, the level of medication adherence, factors associated with poor adherence, and extent to which good adherence can reduce adverse events after AMI in China remain uncertain. Methods and Results In 2013 to 2014, 4001 AMI patients aged ≥18 years were discharged alive from 53 hospitals across China (mean age 60.5±11.7 years; 22.7% female). Good adherence was defined as taking medications (aspirin, β‐blockers, statins, clopidogrel, or angiotensin‐converting enzyme inhibitors/angiotensin‐receptor blockers) ≥90% of the time as prescribed. Cox models assessed the association between good adherence (a time‐varying covariate) and 1‐year cardiovascular events after AMI. The most common medications were aspirin (82.2%) and statins (80.5%). There were 243 patients who were not prescribed any medications during follow‐up; 1‐year event rates were higher for these patients (25.1%, 95% CI 19.7–30.6%) versus those taking ≥1 medications (6.6%, 95% CI 5.76–7.34%). The overall rate of good adherence was 52.9%. Good adherence was associated with lower risk of 1‐year events (adjusted hazard ratio 0.61, 95% CI 0.49–0.77). The most common reason for poor adherence was belief that one's condition had improved/no longer required medication. More comorbidities and lower education level were associated with poor adherence. Conclusions Good adherence reduced 1‐year cardiovascular event risk after AMI. About half of our cohort did not have good adherence. National efforts to improve AMI outcomes in China should focus on medication adherence and educating patients on the importance of cardiovascular medications for reducing risk of recurrent events. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT01624909.

Background Incidence of cardiovascular disease in young adults is unabated. Increased prevalence of self‐reported atherosclerotic risk factors may be driving this trend. The goal of this study was to examine whether the prevalence of atherosclerotic risk factors in young adults is increasing over time using both self‐report and standard clinical criteria. Methods and Results Data from young adults, aged 20 to 45 years, in the National Health and Nutrition Examination Survey from 1999/2000 to 2013/2014 were analyzed. Risk factor prevalence of hypertension, diabetes mellitus, and hyperlipidemia was measured using clinical criteria and self‐report. Smoking was based on self‐report only, and obesity was based clinically on body mass index and waist to height ratio. Prevalence by survey was adjusted for age, sex, and race/ethnicity. By clinical criteria, adjusted prevalence of any 3 risk factors (hypertension, diabetes mellitus, and hyperlipidemia) declined slightly from 21.8% to 18.9% (P for trend=0.05). However, by self‐report, the adjusted prevalence of any 3 risk factors increased from 17.8% to 26.5% (P

Background Cardioprotective medication adherence can mitigate the risk of recurrent cardiovascular events and mortality after acute myocardial infarction (AMI). We examined the associations of diabetes mellitus status and glycemic control with cardioprotective medication adherence after AMI. Methods and Results We performed a retrospective observational cohort study of 14 517 US veterans who were hospitalized for their first AMI between 2011 and 2014 and prescribed a beta‐blocker, 3‐hydroxy‐3‐methyl‐glutaryl‐CoA‐reductase inhibitor, and angiotensin‐converting enzyme inhibitor or angiotensin receptor blocker. The primary exposure was a diagnosis of type 2 diabetes mellitus; in diabetes mellitus patients, hemoglobin A1c (HbA1c) was a secondary exposure. The primary outcome was 1‐year adherence to all 3 medication classes, defined as proportion of days covered ≥0.8, assessed using adjusted risk differences and multivariable Poisson regression. Of 14 517 patients (mean age, 66.3 years; 98% male), 52% had diabetes mellitus; 9%, 31%, 24%, 15%, and 21% had HbA1c

BackgroundScientific statements have championed the measurement of clinical outcomes after cardiac stress testing to better define their value. Using contemporary national data, we sought to describe the characteristics of patients who experience outcomes after stress testing. Methods and ResultsUsing administrative claims from a large national private insurer, we conducted an observational cohort study of patients without cardiovascular disease aged 25 to 64 years who underwent stress testing from 2006 to 2011 and had at least 1 year of membership in the insurance company before and after testing. We used Kaplan–Meier time‐to‐event analyses to determine rates of acute myocardial infarction (AMI), elective coronary revascularization, and coronary angiography without revascularization in the year following testing. We used logistic regression to determine factors associated with outcomes, and stratified the cohort into quintiles based on likelihood of experiencing AMI and/or revascularization to describe the characteristics of patients at highest and lowest risk. Among 553 027 patients who underwent stress testing (mean age 50 years, 49% women, 73% white), 0.8% were hospitalized for AMI, 1.8% underwent elective coronary revascularization, and 2.5% underwent coronary angiography without revascularization within 1 year. Patients who were older, male, and white were more likely to undergo subsequent revascularization. Patients in the lowest likelihood quintile were young (mean age 40 years), frequently women (84.7%), had a low incidence of coexisting conditions (5.2% with diabetes mellitus), and had a 0.5% rate of AMI and/or revascularization. ConclusionsThe proportion of US patients younger than 65 who had AMI and/or coronary revascularization after stress testing was low. Assessing risk of subsequent outcomes may be useful in improving patient referrals for stress testing.

BackgroundAntianginal medications (AAMs) can be perceived to be less important after percutaneous coronary intervention (PCI) and may be de‐escalated after revascularization. We examined the frequency of AAM de‐escalation at discharge post‐PCI and its association with follow‐up health status. Methods and ResultsIn a 10‐center PCI registry, the Seattle Angina Questionnaire was assessed before and 6 months post‐PCI. AAM de‐escalation was defined as fewer AAMs at discharge versus admission or >25% absolute dose decrease. Of 2743 PCI patients (70% male), AAM were de‐escalated, escalated, and unchanged in 299 (11%), 714 (26%), and 1730 (63%) patients, respectively. Patients whose AAM were de‐escalated were more likely to report angina at 6 months, compared with unchanged or escalated AAM (34% versus 24% versus 21%; P

BackgroundLittle is known about facility‐level variation in the use of revascularization procedures for the management of stable obstructive coronary artery disease. Furthermore, it is unknown if variation in the use of coronary revascularization is associated with use of other cardiovascular procedures. Methods and ResultsWe evaluated all elective coronary angiograms performed in the Veterans Affairs system between September 1, 2007, and December 31, 2011, using the Clinical Assessment and Reporting Tool and identified patients with obstructive coronary artery disease. Patients were considered managed with revascularization if they received percutaneous coronary intervention (PCI) or coronary artery bypass grafting within 30 days of diagnosis. We calculated risk‐adjusted facility‐level rates of overall revascularization, PCI, and coronary artery bypass grafting. In addition, we determined the association between facility‐level rates of revascularization and post‐PCI stress testing. Among 15 650 patients at 51 Veterans Affairs sites who met inclusion criteria, the median rate of revascularization was 59.6% (interquartile range, 55.7%–66.7%). Across all facilities, risk‐adjusted rates of overall revascularization varied from 41.5% to 88.1%, rate of PCI varied from 23.2% to 80.6%, and rate of coronary artery bypass graftingvariedfrom 7.5% to 36.5%. Of 6179 patients who underwent elective PCI, the median rate of stress testing in the 2 years after PCI was 33.7% (interquartile range, 30.7%–47.1%). There was no evidence of correlation between facility‐level rate of revascularization and follow‐up stress testing. ConclusionsWithin the Veterans Affairs system, we observed large facility‐level variation in rates of revascularization for obstructive coronary artery disease, with variation driven primarily by PCI. There was no association between facility‐level use of revascularization and follow‐up stress testing, suggesting use rates are specific to a particular procedure and not a marker of overall facility‐level use.

Background Thirty‐day readmission after percutaneous coronary intervention (PCI) is common, costly, and linked to poor patient outcomes. Accordingly, facility‐level 30‐day readmission rates have been considered as a potential quality measure. However, it is unknown whether facility‐level 30‐day readmission rates are associated with facility‐level mortality. We sought to determine the effect of 30‐day readmissions after PCI on mortality at both the patient and facility level in the Veterans Administration hospital system. Methods and Results We included all patients who underwent PCI in the Veterans Administration hospital system nationally from October 2007 through August 2012, comparing all‐cause mortality rates between patients with and without 30‐day readmissions following PCI. Patients were then aggregated at the hospital level to evaluate the correlation between hospital‐level readmission rates with hospital‐level 1‐year mortality rates. Among 41 069 patients undergoing PCI at 62 sites, 12.2% were readmitted within 30 days of discharge. Patients with 30‐day readmission had higher risk‐adjusted mortality (hazard ratio 1.53, 95% CI 1.44–1.63, P

BackgroundAngina is common both before and after myocardial infarction (MI). Whether the change in angina status within the first 30 days after MI is associated with subsequent readmission and angina persistence is unknown. Methods and ResultsWe studied 2915 MI patients enrolled at 24 hospitals in the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients’ Health Status (TRIUMPH) registry. Angina before and 30 days after MI was assessed with the Seattle Angina Questionnaire. Patients were divided into angina‐free pre‐ and post‐MI (−/−), resolved angina (+/−), new angina (−/+), and persistent angina (+/+) groups. Multivariable proportional hazards and hierarchical modified Poisson models were performed to assess the association of each group with all‐cause readmission, readmission for MI or unplanned revascularization, and angina persistence at 1 year. Overall, 1293 patients (44%) had angina before their MI and 849 (29%) reported angina within 30 days of discharge. Patients with post‐MI angina were more likely to be younger, nonwhite, and uninsured. Compared with patients who were angina‐free pre‐ and post‐MI, 1‐year all‐cause readmission risks were significantly higher for patients with persistent angina (hazard ratio [HR], 1.35; 95% CI 1.06–1.71) or new angina (HR, 1.40; 95% CI, 1.08–1.82). At 1 year, angina was present in 22% of patients and was more likely if angina was persistent (HR, 3.55; 95% CI, 3.05–4.13) or new (HR, 3.38; 95% CI, 2.59–4.42) at 30 days compared with patients who were angina‐free pre‐ and post‐MI. ConclusionsPost‐MI angina, whether new or persistent, is associated with higher likelihood of readmission. Prioritizing post‐MI angina management is a potential means of improving 1‐year outcomes.

BackgroundPremature clopidogrel discontinuation after drug‐eluting stent placement is associated with adverse outcomes. Little is known about patient and hospital factors associated with premature discontinuation or whether less variation in premature discontinuation exists in integrated health care systems such as the Veterans Affairs (VA). Methods and ResultsWe evaluated the frequency of premature clopidogrel discontinuation, defined as a gap between clopidogrel refills of ≥90 days during the first 6 months of treatment, among 12 707 patients who received drug‐eluting stents in VA hospitals between 2008 and 2010. We evaluated the association between premature discontinuation and all‐cause mortality and/or acute myocardial infarction, variation in the proportion of premature discontinuation among hospitals, the patient and hospital characteristics associated with premature discontinuation, and the extent to which unexplained hospital characteristics contribute to premature discontinuation. Of the patients, 963 (7.6%) discontinued clopidogrel prematurely. Premature discontinuation was associated with acute myocardial infarction and all‐cause mortality (hazard ratio 1.65, 95% CI 1.37–1.99, P

BackgroundThe association between chronic kidney disease (CKD) and health status outcomes after acute myocardial infarction (AMI) is unknown. Methods and ResultsPatients were enrolled between 2005 and 2008 in the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH) registry, a prospective multicenter observational study of AMI outcomes. The Seattle Angina Questionnaire and Short Form‐12 were collected at baseline and at 1, 6, and 12 months following AMI. CKD was defined by an estimated glomerular filtration rate

BackgroundStigma against the obese is well described in health care and may contribute to disparities in medical decision‐making. It is unknown whether similar disparity exists for obese patients in cardiovascular care. We evaluated the association between body mass index (BMI) and prescription of guideline‐recommended medications in patients undergoing elective percutaneous coronary intervention. Methods and ResultsUsing data from the Veterans Affairs Clinical Assessment, Reporting, and Tracking System Program, we identified patients undergoing elective percutaneous coronary intervention from 2007 to 2012, stratifying them by category of BMI. We described rates of prescription for class I guideline recommended medications for each BMI category (normal, overweight, and obese). Multivariable logistic regression assessed the association between BMI category and medication prescription. Seventeen thousand thirty‐seven patients were identified, with 35.3% having overweight BMI, and 50.8% obese BMI. Obese patients were more likely than normal BMI patients to be prescribed β‐blockers (OR 1.34), statins (OR 1.39), or ACE/ARB (odds ratio [OR] 1.52; all significant) when indicated. Overweight patients were more likely than normal BMI patients to be prescribed statins (OR 1.29) and angiotensin‐converting enzymes/angiotensin II receptor blockers (OR 1.41) when indicated. There was no association between BMI category and prescription of anticoagulants. ConclusionsOver 85% of patients undergoing elective percutaneous coronary intervention in the Veterans Affairs are overweight or obese. Rates of guideline‐indicated medication prescription were

Background Among patients diagnosed with high blood pressure (BP), initial dual therapy has been recommended for patients with high pretreatment systolic BP (≥160 mm Hg) since 2003, and first‐line β‐blocker use without a compelling condition has fallen out of favor in US guidelines. Methods and Results This serial cross‐sectional study of national Veterans Health Administration data included adult Veterans with incident hypertension initiating antihypertensive medication between January 1, 2000, and December 31, 2019. We assessed annual trends in initial regimens dispensed (index date: first antihypertensive dispense date) by number of classes and unique class combinations used overall and by pretreatment systolic BP (

Background Effective transitions from the procedural to outpatient setting are essential to ensure high‐quality cardiovascular care across health care systems, particularly among patients undergoing invasive cardiac procedures. We evaluated the association of postprocedural follow‐up visits and antiplatelet prescriptions with clinical outcomes among patients undergoing percutaneous coronary intervention for stable angina at community or Veterans Affairs (VA) hospitals. Methods and Results Patients who actively received care within the VA Healthcare System and underwent percutaneous coronary intervention for stable angina at a community or VA hospital between October 1, 2015, and September 30, 2019, were identified. We compared mortality for patients receiving community or VA care, and among subgroups of community‐treated patients by the presence of a postprocedural follow‐up visit within 30 days or prescription for antiplatelet (P2Y12) medication within 120 days of the procedure. Among 12 837 patients who survived the first 30 days, 5133 were treated at community hospitals, and 7704 were treated in the VA. Prescriptions for antiplatelet therapy were less common for those treated in the community (85%) compared with the VA at 1 year (95%; hazard ratio [HR], 0.46; 95% CI, 0.44–47). Compared with VA‐treated patients, the hazards for death were similar for patients treated in the community with a follow‐up visit (HR, 1.17; 95% CI, 0.97–1.40) or with a fill for an antiplatelet therapy (HR, 1.08; 95% CI, 0.90–1.30). However, patients treated in the community without a follow‐up visit had an 86% (HR, 1.86; 95% CI, 1.40–2.48) increased hazard of death, and those without antiplatelet prescription fill had a 144% increased hazard of death (HR, 2.44; 95% CI, 1.85–3.21) compared with all VA‐treated patients. Conclusions Patients treated at community facilities have a decreased chance of receiving antiplatelet prescriptions after percutaneous coronary intervention with a concordant increased hazard of mortality, emphasizing the importance of transitions of care across health care systems when assessing cardiovascular quality.