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IMPORTANCE: The risk of adverse events from ascending thoracic aorta aneurysm (TAA) is poorly understood but drives clinical decision-making. OBJECTIVE: To evaluate the association of TAA size with outcomes in nonsyndromic patients in a large non–referral-based health care delivery system. DESIGN, SETTING, AND PARTICIPANTS: The Kaiser Permanente Thoracic Aortic Aneurysm (KP-TAA) cohort study was a retrospective cohort study at Kaiser Permanente Northern California, a fully integrated health care delivery system insuring and providing care for more than 4.5 million persons. Nonsyndromic patients from a regional TAA safety net tracking system were included. Imaging data including maximum TAA size were merged with electronic health record (EHR) and comprehensive death data to obtain demographic characteristics, comorbidities, medications, laboratory values, vital signs, and subsequent outcomes. Unadjusted rates were calculated and the association of TAA size with outcomes was evaluated in multivariable competing risk models that categorized TAA size as a baseline and time-updated variable and accounted for potential confounders. Data were analyzed from January 2018 to August 2021. EXPOSURES: TAA size. MAIN OUTCOMES AND MEASURES: Aortic dissection (AD), all-cause death, and elective aortic surgery. RESULTS: Of 6372 patients with TAA identified between 2000 and 2016 (mean [SD] age, 68.6 [13.0] years; 2050 female individuals [32.2%] and 4322 male individuals [67.8%]), mean (SD) initial TAA size was 4.4 (0.5) cm (828 individuals [13.0% of cohort] had initial TAA size 5.0 cm or larger and 280 [4.4%] 5.5 cm or larger). Rates of AD were low across a mean (SD) 3.7 (2.5) years of follow-up (44 individuals [0.7% of cohort]; incidence 0.22 events per 100 person-years). Larger initial aortic size was associated with higher risk of AD and all-cause death in multivariable models, with an inflection point in risk at 6.0 cm. Estimated adjusted risks of AD within 5 years were 0.3% (95% CI, 0.3-0.7), 0.6% (95% CI, 0.4-1.3), 1.5% (95% CI, 1.2-3.9), 3.6% (95% CI, 1.8-12.8), and 10.5% (95% CI, 2.7-44.3) in patients with TAA size of 4.0 to 4.4 cm, 4.5 to 4.9 cm, 5.0 to 5.4 cm, 5.5 to 5.9 cm, and 6.0 cm or larger, respectively, in time-updated models. Rates of the composite outcome of AD and all-cause death were higher than for AD alone, but a similar inflection point for increased risk was observed at 6.0 cm. CONCLUSIONS AND RELEVANCE: In a large sociodemographically diverse cohort of patients with TAA, absolute risk of aortic dissection was low but increased with larger aortic sizes after adjustment for potential confounders and competing risks. Our data support current consensus guidelines recommending prophylactic surgery in nonsyndromic individuals with TAA at a 5.5-cm threshold.

To evaluate the risk of heart failure (HF) linked to human immunodeficiency virus (HIV) infection, how risk varies by demographic characteristics, and whether it is explained by atherosclerotic disease or risk factor treatment.

Atrial fibrillation (AF) is highly prevalent in CKD and is associated with worse cardiovascular and kidney outcomes. However, data are limited on use of AF pharmacotherapies and AF-related procedures by CKD status. This paper examined a large ?real-world? contemporary population with incident AF, and found that CKD severity was significantly associated with lower receipt of rate control agents, anticoagulation, and AF-related procedures. Additional data on efficacy and safety of AF therapies in CKD populations are needed to inform management strategies.

Limited data exist on the epidemiology, evaluation, and prognosis of otherwise unexplained anaemia of the elderly in heart failure (HF). Thus, we aimed to determine the incidence of anaemia, to characterize diagnostic testing patterns for potentially reversible causes of anaemia, and to evaluate the independent association between incident anaemia and long-term morbidity and mortality.

Transcatheter aortic valve replacement (TAVR) may be used to urgently or emergently treat severe aortic stenosis, but outcomes for this high-risk population have not been well-characterized. We sought to describe the incidence, clinical characteristics, and outcomes of patients undergoing urgent or emergent vs. elective TAVR.

IMPORTANCE: Atrial fibrillation is a potent risk factor for stroke, but whether the burden of atrial fibrillation in patients with paroxysmal atrial fibrillation independently influences the risk of thromboembolism remains controversial. OBJECTIVE: To determine if the burden of atrial fibrillation characterized using noninvasive, continuous ambulatory monitoring is associated with the risk of ischemic stroke or arterial thromboembolism in adults with paroxysmal atrial fibrillation. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study conducted from October 2011 and October 2016 at 2 large integrated health care delivery systems used an extended continuous cardiac monitoring system to identify adults who were found to have paroxysmal atrial fibrillation on 14-day continuous ambulatory electrocardiographic monitoring. EXPOSURES: The burden of atrial fibrillation was defined as the percentage of analyzable wear time in atrial fibrillation or flutter during the up to 14-day monitoring period. MAIN OUTCOMES AND MEASURES: Ischemic stroke and other arterial thromboembolic events occurring while patients were not taking anticoagulation were identified through November 2016 using electronic medical records and were validated by manual review. We evaluated the association of the burden of atrial fibrillation with thromboembolism while not taking anticoagulation after adjusting for the Anticoagulation and Risk Factors in Atrial Fibrillation (ATRIA) or CHA2DS2-VASc stroke risk scores. RESULTS: Among 1965 adults with paroxysmal atrial fibrillation, the mean (SD) age was 69 (11.8) years, 880 (45%) were women, 496 (25%) were persons of color, the median ATRIA stroke risk score was 4 (interquartile range [IQR], 2-7), and the median CHA2DS2-VASc score was 3 (IQR, 1-4). The median burden of atrial fibrillation was 4.4% (IQR ,1.1%-17.23%). Patients with a higher burden of atrial fibrillation were less likely to be women or of Hispanic ethnicity, but had more prior cardioversion attempts compared with those who had a lower burden. After adjusting for either ATRIA or CHA2DS2-VASc stroke risk scores, the highest tertile of atrial fibrillation burden (≥11.4%) was associated with a more than 3-fold higher adjusted rate of thromboembolism while not taking anticoagulants (adjusted hazard ratios, 3.13 [95% CI, 1.50-6.56] and 3.16 [95% CI, 1.51-6.62], respectively) compared with the combined lower 2 tertiles of atrial fibrillation burden. Results were consistent across demographic and clinical subgroups. CONCLUSIONS AND RELEVANCE: A greater burden of atrial fibrillation is associated with a higher risk of ischemic stroke independent of known stroke risk factors in adults with paroxysmal atrial fibrillation.

IMPORTANCE: Chronic kidney disease (CKD) is common in adults with heart failure and is associated with an increased risk of sudden cardiac death. Randomized trials of participants without CKD have demonstrated that implantable cardioverter defibrillators (ICDs) decrease the risk of arrhythmic death in selected patients with reduced left ventricular ejection fraction (LVEF) heart failure. However, whether ICDs improve clinical outcomes in patients with CKD is not well elucidated. OBJECTIVE: To examine the association of primary prevention ICDs with risk of death and hospitalization in a community-based population of potentially ICD-eligible patients who had heart failure with reduced LVEF and CKD. DESIGN, SETTINGS, AND PARTICIPANTS: This noninterventional cohort study included adults with heart failure and an LVEF of 40% or less and measures of serum creatinine levels available from January 1, 2005, through December 31, 2012, who were enrolled in 4 Kaiser Permanente health care delivery systems. Chronic kidney disease was defined as an estimated glomerular filtration rate of less than 60 mL/min/1.73 m2. Patients who received and did not receive an ICD were matched (1:3) on CKD status, age, and high-dimensional propensity score to receive an ICD. Follow-up was completed on December 31, 2013. Data were analyzed from 2015 to 2017. EXPOSURES: Placement of an ICD. MAIN OUTCOMES AND MEASURES: All-cause death, hospitalizations due to heart failure, and any-cause hospitalizations. RESULTS: A total of 5877 matched eligible adults with CKD (1556 with an ICD and 4321 without an ICD) were identified (4049 men [68.9%] and 1828 women [31.1%]; mean [SD] age, 72.9 [8.2] years). In models adjusted for demographics, comorbidity, and cardiovascular medication use, no difference was found in all-cause mortality between patients with CKD in the ICD vs non-ICD groups (adjusted hazard ratio, 0.96; 95% CI, 0.87-1.06). However, ICD placement was associated with increased risk of subsequent hospitalization due to heart failure (adjusted relative risk, 1.49; 95% CI, 1.33-1.60) and any-cause hospitalization (adjusted relative risk, 1.25; 95% CI, 1.20-1.30) among patients with CKD. CONCLUSIONS AND RELEVANCE: In a large, contemporary, noninterventional study of community-based patients with heart failure and CKD, ICD placement was not significantly associated with improved survival but was associated with increased risk for subsequent hospitalization due to heart failure and all-cause hospitalization. The potential risks and benefits of ICDs should be carefully considered in patients with heart failure and CKD.

ObjectivePatients with chronic kidney disease (CKD) have higher risk of sudden cardiac death; however, they may not receive implantable cardioverter defibrillators (ICDs), in part due to higher risk of complications. We evaluated whether CKD is associated with greater risk of device-delivered shocks/antitachycardia pacing (ATP) therapies among patients receiving a primary prevention ICD.MethodsWe studied participants in the observational Cardiovascular Research Network Longitudinal Study of Implantable Cardioverter Defibrillators. CKD was defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2. Outcomes included all delivered shocks/ATPs therapies and type of shock/ATP therapies (inappropriate or appropriate, determined by physician adjudication) within the 3 years. We evaluated the associations between CKD and time to first device therapy, burden of device therapy, and inappropriate versus appropriate device therapy, adjusting for demographics, comorbidity, laboratory values and medication use.ResultsAmong 2161 participants, 1066 (49.3%) had CKD (eGFR 44±11 mL/min/1.73 m2) at ICD implantation. During mean of 2.26±0.89 years, 9.8% and 18.5% of participants had at least one inappropriate and appropriate shock/ATP therapies, respectively. CKD was not associated with time to first shock/ATP therapies (adjusted HR 0.87, 95% CI 0.73 to 1.05), overall burden of shock/ATP therapies (adjusted relative rate 0.93, 95% CI 0.74 to 1.17) or inappropriate versus appropriate shock/ATP therapies (adjusted relative risk 0.88, 95% CI 0.68 to 1.14) compared with not having CKD.ConclusionsIn adults receiving a primary prevention ICD, mild-to-moderate CKD was not associated with the timing, burden or appropriateness of subsequent device therapy. Potential concern for inappropriate ICD-delivered therapies should not preclude ICDs among eligible patients with CKD.

The eligibility and potential benefit of transcatheter edge-to-edge repair (TEER) in addition to guideline-directed medical therapy to treat moderate-severe or severe secondary mitral regurgitation (MR) has not been reported in a contemporary heart failure (HF) population. In this study 50,841 adults with HF identified between 2013-2018 were screened for TEER eligibility based on the Food and Drug Administration (FDA) labeling. After applying the FDA eligibility criteria, 2,461 of these patients (4.8%) qualified for TEER (FDA+). These patients had higher natriuretic peptide levels and were more likely to have had a prior 1-year HF hospitalization. The estimated number needed to treat to prevent or postpone all-cause hospitalization was 4.4, 8.8 for HF hospitalization, and 5.3 for all-cause death at 24 months. The low prevalence of FDA eligibility for TEER treatment was primarily due to absence of moderate-severe or severe MR. Additional research is necessary to validate the scope of eligibility and comparative effectiveness of TEER.

Background:Prior risk models in patients with heart failure (HF) have focused on hospitalizations for worsening HF (WHF) and have not evaluated for differences in predictors by left ventricular ejection fraction (LVEF). We used natural language processing (NLP) and machine learning methods with access to longitudinal electronic health record (EHR) data to develop risk prediction models for WHF events across practice settings and by LVEF category.Methods:We identified all adults with HF and known LVEF on January 1stof each year from 2011-2019 in an integrated health care system. WHF events within 1 year were defined as any hospitalization, emergency department, or outpatient encounter with ≥1 symptom, ≥2 objective findings including ≥1 sign, and ≥1 change in HF-related therapy. Signs and symptoms were ascertained using rule-based NLP. We conducted boosted decision tree-based ensemble models for any WHF event within each LVEF category: HF with reduced EF (HFrEF; LVEF ≤40%), HF with mildly reduced EF (HFmrEF; LVEF 41-49%), and HF with preserved EF (HFpEF; LVEF ≥50%). We evaluated model discrimination using area under the curve (AUC) and model calibration using Brier scores.Results:Among 359,298 patients from 2011-2019, 65,838 (18%) had HFrEF, 52,491 (15%) had HFmrEF, and 240,969 (67%) had HFpEF. Mean age was 75±12, 47% were women, and 37% were minorities including 10% Black, 11% Asian/Pacific Islander, and 12% of Hispanic ethnicity. WHF events occurred in 22% of patients with HFrEF, 17% with HFmrEF, and 16% with HFpEF. The models displayed an AUC of 0.75 and Brier score of 0.15 for HFrEF and an AUC of 0.77 and Brier scores of 0.12 for both HFmrEF and HFpEF. Clinical predictors were similar across LVEF categories (Table).Conclusions:Longitudinal EHR data can be leveraged using NLP and machine learning for accurate risk estimation that reliably identifies clinical predictors across a range of LVEF. These findings may provide novel insight into the natural history of HF.

Patients with risk factors for or established atherosclerotic cardiovascular disease (ASCVD) remain at high risk for subsequent ischemic events despite statin therapy. Triglyceride (TG) levels may contribute to residual ASCVD risk, and the performance of global risk assessment calculators across a broad range of TG levels is unknown.

Clinical guidelines recommend digoxin for patients with symptomatic systolic heart failure (HF) receiving optimal medical therapy, but this recommendation is based on limited, older trial data. We evaluated the effectiveness and safety of digoxin in a contemporary cohort of patients with incident systolic HF.

Although heart failure (HF) is a syndrome with important differences in response to therapy by left ventricular ejection fraction (LVEF), existing risk stratification models typically group all HF patients together. The relative importance of common predictor variables for important clinical outcomes across strata of LVEF is relatively unknown.

There is scant evidence on the effect that chronic kidney disease (CKD) confers on clinically meaningful outcomes among patients with heart failure with preserved left ventricular ejection fraction (HF-PEF).

Implantable cardioverter-defibrillators (ICDs) are increasingly used for primary prevention after randomized, controlled trials demonstrating that they reduce the risk of death in patients with left ventricular systolic dysfunction. The extent to which the clinical characteristics and long-term outcomes of unselected, community-based patients with left ventricular systolic dysfunction undergoing primary prevention ICD implantation in a real-world setting compare with those enrolled in the randomized, controlled trials is not well characterized. This study is being conducted to address these questions.

Systematic case identification is critical to improving population health, but widely used diagnosis code-based approaches for conditions like valvular heart disease are inaccurate and lack specificity.

Limited existing data suggest that the novel COVID-19 may increase risk of VTE, but information from large, ethnically diverse populations with appropriate control participants is lacking.

Introduction:Heart failure (HF)-related hospitalizations are a growing public health burden. We evaluated two published risk calculators for predicting 30-day readmission after HF hospitalizations: 1) using the original coefficients, 2) updating the coefficients 3) developing a new model with additional variables and updated coefficients.Hypothesis:Recalibrating model coefficients and adding variables would improve the performance of existing 30-day readmission risk calculators.Methods:We identified 45,059 adults hospitalized for HF between 2012-2017 within Kaiser Permanente Northern California, an integrated healthcare delivery system. We used split sampling for development and validation testing. The risk calculators tested included: LACE+ Index and Yale CORE. We used logistic regression on our population to derive the recalibrated coefficients. For the model with additional variables, we included all variables used in the original models plus additional variables, including cardiovascular medication use and socioeconomic status. We used gradient boosting with k-fold cross validation to avoid overfitting. We assessed model performance using area under the curve (AUC) and calibration plots.Results:Discrimination (AUC) was poor using original models: LACE+ [0.56 (0.54-0.58)] and Yale CORE [0.55 (0.54-0.57)]. Recalibrating coefficients resulted in small improvements for LACE+ [0.58 (0.57, 0.60)] and Yale CORE [0.58 (0.57, 0.60)]. Adding variables resulted in a modest improvement for the gradient boosting model [0.61 (0.59, 0.62)]. Calibration plots (Figure 1) showed good calibration except for the Yale CORE model with the original coefficients.Conclusions:Recalibrating coefficients and incorporating prior medication and socioeconomic status led to modest, significant improvements in discrimination while maintaining good calibration. However, overall performance improvements are needed to increase the utility of these published risk calculators to predict readmission.

Introduction:People living with HIV (PLWH) are at increased risk of incident heart failure (HF), but whether HIV status independently influences HF-related morbidity and mortality is unclear.Methods:In a 1:10 matched population of adults aged >21 years with (N=38,868) and without (N=386,586) HIV cared for in 3 large U.S. integrated healthcare systems, we identified all cases of incident HF from 2010-2016 using electronic heath records and followed these cases through December 2016 for all-cause death and HF hospitalization. Multivariable Cox regression was used to study the association between HIV status and HF-related outcomes.Results:Among 4,088 incident HF cases (483 PLWH; 3605 without HIV), PLWH vs. without HIV had significantly higher crude rates (per 100 person-years) of death (12.3 [95% CI: 10.8-14.0] vs. 8.6 [8.1-9.0], respectively, p<0.001) and HF hospitalizations (14.9 [13.3-16.8] vs. 13.4 [12.8-13.9], respectively, p=0.037). Of note, crude mortality was highest in PLWH with low (<200 cells/?L) CD4 counts (17.1 [13.4-21.8]). After adjustment for potential confounders, PLWH had a higher risk of death of borderline significance (adjusted Hazard Ratio [aHR] 1.25 [0.97-1.61]) but no excess risk of HF hospitalizations (aHR 1.00 [0.76-1.32]) (Figure). Compared to adults without HIV, PLWH with low CD4 counts had a significantly higher risk of death (aHR 1.65 [1.14-2.40]) but not HF hospitalization (aHR 1.07 [0.70-1.60]), while risks of death and HF hospitalization did not significantly differ for PLWH with 200-499 or >500 CD4 cells/?L.Conclusions:In a large U.S.-based cohort of incident HF, PLWH were at an increased risk of death that appeared modified by higher CD4 counts, but were not at increased risk of HF hospitalizations. Further research should identify additional modifiable factors contributing to excess mortality that help develop more accurate risk prediction models to better personalize care for PLWH and HF.

Introduction:Administrative claims data are often used for population management and quality reporting, but diagnosis codes for conditions such as valvular heart disease can be inaccurate and vary across health systems. Echocardiography (echo) data contain detailed clinical information but are generally unstructured and not feasible to extract manually in large scale.Methods:We developed and validated natural language processing (NLP) algorithms to identify aortic stenosis (AS) from echo reports in Kaiser Permanente Northern California (KPNC) and compared AS identification using NLP vs. administrative codes. Using NLP software (Linguamatics i2e), we initially developed algorithms to identify AS from a development set of >100 echo reports manually confirmed with AS, with iterative refinement using additional development sets (>100 echo reports each) until the NLP algorithm achieved positive and negative predictive values (PPV and NPV) of >95%. We then applied the NLP algorithm to all 2008-2018 echo reports (transthoracic, transesophageal or stress) in KPNC adults and compared results to ICD-9/10 diagnostic code-based definitions from 14 days before to 6 months after the echo date.Results:The NLP algorithm was developed and refined among >500 echo reports to achieve >95% PPV and NPV. Application of NLP to 957,505 echo reports (N=522,653 patients with mean age 63.3 years, 51% women, 8.5% black, 13.5% Asian/Pacific Islander, 12.9% Hispanic and median [interquartile range] 1 [1 to 2] echoes per person) yielded 104,090 echoes (10.9%) with AS (N=53,791 patients). Among echoes identified by NLP as positive for AS, 36,070 (34.7%) had diagnosis codes for AS between 14 days prior and 6 months after echo. Among echo?s without AS via NLP, 12,626 (1.5%) had diagnosis codes for AS between 14 days before to 6 months after the echo.Conclusions:An NLP algorithm applied to a large echo database was more accurate than using diagnosis codes for identifying AS and can facilitate more effective individual and population management than relying on administrative data alone. Future NLP development to characterize AS severity will further advance personalized and population-based care strategies for surveillance and treatment.

Introduction:Iron deficiency is common but infrequently tested for among older adults with heart failure (HF) and anemia. A low transferrin saturation (TSAT) and/or a reduced ferritin are suggestive of iron deficiency, but plasma concentrations of these proteins may be altered in response to inflammation and confound their interpretation in the setting of HF.Methods:We identified a multicenter cohort of adults age ?65 years with HF and incident anemia (hemoglobin <13 g/dL [men] or <12 g/dL [women]) between 2005-2012. Participants were required to have ferritin (ng/mL) and TSAT (%) evaluated within 90 days. Outcomes were ascertained from electronic health records.Results:Among 4,103 older adults with HF, incident anemia, and iron studies, 47% had TSAT <20% and median (IQR) ferritin was 126 (52.5, 256.0) ng/mL. Crude rates of HF hospitalization (Figure A) and all-cause death (Figure B) were higher for participants with a TSAT <20% vs. TSAT ?20% at any ferritin level. After adjustment for demographics, medical history, kidney function, proteinuria and medications, patients with TSAT <20% vs. TSAT ?20% were at increased risk of HF hospitalization for a corresponding ferritin <100 ng/mL (adjusted HR [aHR] 1.42, 95% CI 1.18-1.71) or 100-300 ng/mL (aHR 1.31, 95%CI:1.08-1.59). TSAT <20% (vs. >20%) was independently associated with an increased risk of death from any cause irrespective of baseline ferritin (<100 ng/mL: aHR 1.46, 95%CI:1.24-1.70; 100-300 ng/mL: aHR 1.21, 95%CI:1.03-1.42; >300 ng/mL: aHR 1.38, 95%CI:1.10-1.74).Conclusions:Among older adults with HF and incident anemia who had iron studies, ~50% had a TSAT <20%, which independently correlated with higher rates of morbidity and mortality across a wide range of ferritin levels. Additional research is required to clarify the role of routine evaluation and treatment of functional iron deficiency (impaired mobilization) based on an isolated low TSAT.

Introduction:Conflicting studies exist about whether the risk of developing atrial fibrillation (AF) varies by race, with even less known about whether race/ethnicity is associated with differential burden of AF (i.e., amount of time in AF).Methods:The Kaiser Permanente (KP) RHYTHM Study included all adult members of the KP Northern and Southern California integrated healthcare delivery systems who were prescribed 14-day continuous ambulatory ECG monitoring using the ZIO?XT Patch (iRhythm, Inc.) between October 2011-October 2016 and who were found to have any AF detected during monitoring. Self-reported race/ethnicity, other demographic characteristics and stroke risk factors were obtained from electronic medical records. We examined the multivariable association of race/ethnicity with log-transformed AF burden (ie, % of analyzable wear time spent in AF).Results:In 1069 eligible adults with any detected AF on continuous ambulatory ECG monitoring, mean age was 69.1 years, 45% were women, 4.2% black, 13.2% Asian/Pacific Islander, 10.5% Hispanic, and 2.2% other race. Median wear time (>13.3 days) did not vary by race/ethnicity. Overall, median AF burden was 4% (IQR:1-13%), with variation by race/ethnicity: white (3.6% [0.9-11.7%]), black (1.4% [0.2-6.5%], P=0.02), Asian/Pacific Islander (5.7% [1.4-19.2%], P=0.03) and Hispanic (2.5% [0.5-10.3%], P=0.18). After adjustment for age, gender, heart failure, hypertension, diabetes, eGFR, proteinuria, and prior stroke/TIA, compared with whites, black race was associated with a 54% lower burden of AF (adjusted relative estimate -54%, 95%CI:-77% to -19%), while Asian/Pacific Islander race was associated with a higher burden of AF that was of borderline significance (adjusted relative estimate 45%, 95%CI:-1% to 111%). Hispanic ethnicity was not associated with AF burden (adjusted relative estimate -26%, 95%CI:-51% to 13%).Conclusions:Among adults found to have AF on 14-day continuous, beat-to-beat ambulatory ECG monitoring, black race was independently associated with a >50% relatively lower burden of AF, while Asian/Pacific Islander race may be linked to a higher AF burden. These results support further investigation into potential pathways that may explain racial variation in AF burden.

Assessing fall risk is important for anticoagulation decision-making in adults with atrial fibrillation (AF). We investigated the prevalence of patient self-reported falls, and identified factors associated with falls and initiation of fall prevention programs in AF. The ATRIA2-CVRN study included adults with incident AF between 1/1/2006 - 6/30/2009 from Kaiser Permanente Northern and Southern California. We conducted surveys via mail and telephone to ascertain self-reported health and functional behaviors, including history of falls (fallen to the ground more than once in the past year), severe falls (falls requiring medical care), and initiation of fall prevention programs (physical therapy or exercise program) after a fall. Electronic health records provided clinical features. Associations between patient characteristics and falls and initiation of fall prevention programs were examined using multivariable logistic regression. Among 12,949 AF patients who completed the questionnaire (response rate = 55%; mean age 71y, 43% women), 56% were on anticoagulant therapy. Overall, 15% and 6% reported falls and serious falls, respectively (28% and 12% for ages ?85y). Older age, physical inactivity, disordered sleep pattern, unstable warfarin, and higher predicted risks of stroke and bleeds were associated with falls (Table). A minority of patients who experienced falls reported interactions with health care professionals about how to avoid falling (36%), behavior changes after the fall (30%), or initiation of fall prevention programs (22%). Experiencing severe falls, prior intracranial hemorrhage, and older age were significant factors for initiation of fall prevention programs.Falls were prevalent in older AF patients. Older adults who experienced severe falls were more likely to initiate fall prevention programs. Future research should consider the identified factors to develop effective fall assessment tools and fall prevention programs in AF.

Background:Patients with chronic kidney disease (CKD) often have heart failure with reduced left ventricular ejection fraction (HF-REF), and previous work has shown that the co-occurrence of those conditions confers a higher rate of poor outcomes than either condition alone. But few studies have examined whether CKD confers a clinically meaningful difference in outcomes among heart failure patients with preserved left ventricular ejection fraction (HF-PEF). Compared to previous work, our study uses more granular renal function estimates and a large, contemporary cohort.