30 results on '"Pandey, Ambarish"'
Search Results
2. Sex differences in long-term outcomes following acute heart failure hospitalization: Findings from the Get With The Guidelines-Heart Failure registry.
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Keshvani, Neil, Shah, Sonia, Ayodele, Iyanuoluwa, Chiswell, Karen, Alhanti, Brooke, Allen, Larry, Greene, Stephen, Yancy, Clyde, Alonso, Windy, Van Spall, Harriette, Heidenreich, Paul, Pandey, Ambarish, and Fonarow, Gregg
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Ejection fraction ,Heart failure ,Outcomes ,Sex differences ,Humans ,Male ,Female ,Aged ,United States ,Aged ,80 and over ,Heart Failure ,Prognosis ,Sex Characteristics ,Aftercare ,Stroke Volume ,Patient Discharge ,Medicare ,Hospitalization ,Registries - Abstract
AIMS: Sex differences in long-term outcomes following hospitalization for heart failure (HF) across ejection fraction (EF) subtypes are not well described. In this study, we evaluated the risk of mortality and rehospitalization among males and females across the spectrum of EF over 5 years of follow-up following an index HF hospitalization event. METHODS AND RESULTS: Patients hospitalized with HF between 1 January 2006 and 31 December 2014 from the American Heart Associations Get With The Guidelines-Heart Failure registry with available 5-year follow-up using Medicare Part A claims data were included. The association between sex and risk of mortality and readmission over a 5-year follow-up period for each HF subtype (HF with reduced EF [HFrEF, EF ≤40%], HF with mildly reduced EF [HFmrEF, EF 41-49%], and HF with preserved EF [HFpEF, EF >50%]) was assessed using adjusted Cox models. The effect modification by the HF subtype for the association between sex and outcomes was assessed by including multiplicative interaction terms in the models. A total of 155 670 patients (median age: 81 years, 53.4% female) were included. Over 5-year follow-up, males and females had comparably poor survival post-discharge; however, females (vs. males) had greater years of survival lost to HF compared with the median age- and sex-matched US population (HFpEF: 17.0 vs. 14.6 years; HFrEF: 17.3 vs. 15.1 years; HFmrEF: 17.7 vs. 14.6 years for age group 65-69 years). In adjusted analysis, females (vs. males) had a lower risk of 5-year mortality (adjusted hazard ratio [aHR] 0.89, 95% confidence interval [CI] 0.87-0.90, p
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- 2023
3. Patterns of Referral and Postdischarge Utilization of Cardiac Rehabilitation Among Patients Hospitalized With Heart Failure: An Analysis From the GWTG-HF Registry.
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Keshvani, Neil, Subramanian, Vinayak, Wrobel, Christopher, Solomon, Nicole, Alhanti, Brooke, Greene, Stephen, DeVore, Adam, Yancy, Clyde, Allen, Larry, Pandey, Ambarish, and Fonarow, Gregg
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Medicare ,cardiac rehabilitation ,health care quality ,access ,and evaluation ,heart failure ,Humans ,Aged ,Female ,United States ,Male ,Heart Failure ,Cardiac Rehabilitation ,Patient Discharge ,Aftercare ,Medicare ,Registries ,Referral and Consultation - Abstract
BACKGROUND: Coverage for cardiac rehabilitation (CR) for patients with heart failure with reduced ejection fraction was expanded in 2014, but contemporary referral and participation rates remain unknown. METHODS: Patients hospitalized for heart failure with reduced ejection fraction (≤35%) in the American Heart Association Get With The Guidelines-Heart Failure registry from 2010 to 2020 were included, and CR referral status was described as yes, no, or not captured. Temporal trends in CR referral were assessed in the overall cohort. Patient and hospital-level predictors of CR referral were assessed using multivariable-adjusted logistic regression models. Additionally, CR referral and proportional utilization of CR within 1-year of referral were evaluated among patients aged >65 years with available Medicare administrative claims data who were clinically stable for 6-weeks postdischarge. Finally, the association of CR referral with the risk of 1-year death and readmission was evaluated using multivariable-adjusted Cox models. RESULTS: Of 69,441 patients with heart failure with reduced ejection fraction who were eligible for CR (median age 67 years; 33% women; 30% Black), 17,076 (24.6%) were referred to CR, and referral rates increased from 8.1% in 2010 to 24.1% in 2020 (Ptrend
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- 2023
4. Historical Redlining, Socioeconomic Distress, and Risk of Heart Failure Among Medicare Beneficiaries.
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Mentias, Amgad, Mujahid, Mahasin, Sumarsono, Andrew, Nelson, Robert, Madron, Justin, Powell-Wiley, Tiffany, Essien, Utibe, Keshvani, Neil, Girotra, Saket, Morris, Alanna, Sims, Mario, Capers, Quinn, Yancy, Clyde, Desai, Milind, Menon, Venu, Rao, Shreya, and Pandey, Ambarish
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heart failure ,policies ,race factors ,socioeconomic disparities in health ,systemic racism ,Aged ,Humans ,Male ,Black People ,Comorbidity ,Heart Failure ,Medicare ,Socioeconomic Factors ,United States ,White People ,Financial Stress ,Neighborhood Characteristics ,Social Determinants of Health ,Black or African American - Abstract
BACKGROUND: The association of historical redlining policies, a marker of structural racism, with contemporary heart failure (HF) risk among White and Black individuals is not well established. METHODS: We aimed to evaluate the association of redlining with the risk of HF among White and Black Medicare beneficiaries. Zip code-level redlining was determined by the proportion of historically redlined areas using the Mapping Inequality Project within each zip code. The association between higher zip code redlining proportion (quartile 4 versus quartiles 1-3) and HF risk were assessed separately among White and Black Medicare beneficiaries using generalized linear mixed models adjusted for potential confounders, including measures of the zip code-level Social Deprivation Index. RESULTS: A total of 2 388 955 Medicare beneficiaries (Black n=801 452; White n=1 587 503; mean age, 71 years; men, 44.6%) were included. Among Black beneficiaries, living in zip codes with higher redlining proportion (quartile 4 versus quartiles 1-3) was associated with increased risk of HF after adjusting for age, sex, and comorbidities (risk ratio, 1.08 [95% CI, 1.04-1.12]; P
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- 2023
5. Achieving Equity in Hospital Performance Assessments Using Composite Race-Specific Measures of Risk-Standardized Readmission and Mortality Rates for Heart Failure.
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Mentias, Amgad, Peterson, Eric, Keshvani, Neil, Kumbhani, Dharam, Yancy, Clyde, Morris, Alanna, Allen, Larry, Girotra, Saket, Starling, Randall, Alvarez, Paulino, Desai, Milind, Cram, Peter, Pandey, Ambarish, and Fonarow, Gregg
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health policy ,healthcare disparities ,heart failure ,mortality ,patient readmission ,treatment outcome ,Humans ,Aged ,United States ,Patient Readmission ,Medicare ,Hospitalization ,Hospitals ,Heart Failure ,Hospital Mortality - Abstract
BACKGROUND: The contemporary measures of hospital performance for heart failure hospitalization and 30-day risk-standardized readmission rate (RSRR) and risk-standardized mortality rate (RSMR) are estimated using the same risk adjustment model and overall event rate for all patients. Thus, these measures are mainly driven by the care quality and outcomes for the majority racial and ethnic group, and may not adequately represent the hospital performance for patients of Black and other races. METHODS: Fee-for-service Medicare beneficiaries from January 2014 to December 2019 hospitalized with heart failure were identified. Hospital-level 30-day RSRR and RSMR were estimated using the traditional race-agnostic models and the race-specific approach. The composite race-specific performance metric was calculated as the average of the RSRR/RMSR measures derived separately for each race and ethnicity group. Correlation and concordance in hospital performance for all patients and patients of Black and other races were assessed using the composite race-specific and race-agnostic metrics. RESULTS: The study included 1 903 232 patients (75.7% White [n=1 439 958]; 14.5% Black [n=276 684]; and 9.8% other races [n=186 590]) with heart failure from 1860 hospitals. There was a modest correlation between hospital-level 30-day performance metrics for patients of White versus Black race (Pearson correlation coefficient: RSRR=0.42; RSMR=0.26). Compared with the race-agnostic RSRR and RSMR, composite race-specific metrics for all patients demonstrated stronger correlation with RSRR (correlation coefficient: 0.60 versus 0.74) and RSMR (correlation coefficient: 0.44 versus 0.51) for Black patients. Concordance in hospital performance for all patients and patients of Black race was also higher with race-specific (versus race-agnostic) metrics (RSRR=64% versus 53% concordantly high-performing; 61% versus 51% concordantly low-performing). Race-specific RSRR and RSMR metrics (versus race-agnostic) led to reclassification in performance ranking of 35.8% and 39.2% of hospitals, respectively, with better 30-day and 1-year outcomes for patients of all race groups at hospitals reclassified as high-performing. CONCLUSIONS: Among patients hospitalized with heart failure, race-specific 30-day RSMR and RSRR are more equitable in representing hospital performance for patients of Black and other races.
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- 2023
6. The need for increased pragmatism in cardiovascular clinical trials
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Usman, Muhammad Shariq, Van Spall, Harriette GC, Greene, Stephen J, Pandey, Ambarish, McGuire, Darren K, Ali, Ziad A, Mentz, Robert J, Fonarow, Gregg C, Spertus, John A, Anker, Stefan D, Butler, Javed, James, Stefan K, and Khan, Muhammad Shahzeb
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Biomedical and Clinical Sciences ,Clinical Sciences ,Comparative Effectiveness Research ,Cardiovascular ,Heart Disease ,Clinical Trials and Supportive Activities ,Prevention ,Clinical Research ,Good Health and Well Being ,Cardiovascular Diseases ,Humans ,Cardiovascular System & Hematology ,Cardiovascular medicine and haematology - Abstract
The majority of cardiovascular randomized controlled trials (RCTs) test interventions in selected patient populations under explicitly protocol-defined settings. Although these 'explanatory' trial designs optimize conditions to test the efficacy and safety of an intervention, they limit the generalizability of trial findings in broader clinical settings. The concept of 'pragmatism' in RCTs addresses this concern by providing counterbalance to the more idealized situation underpinning explanatory RCTs and optimizing effectiveness over efficacy. The central tenets of pragmatism in RCTs are to test interventions in routine clinical settings, with patients who are representative of broad clinical practice, and to reduce the burden on investigators and participants by minimizing the number of trial visits and the intensity of trial-based testing. Pragmatic evaluation of interventions is particularly important in cardiovascular diseases, where the risk of death among patients has remained fairly stable over the past few decades despite the development of new therapeutic interventions. Pragmatic RCTs can help to reveal the 'real-world' effectiveness of therapeutic interventions and elucidate barriers to their implementation. In this Review, we discuss the attributes of pragmatism in RCT design, conduct and interpretation as well as the general need for increased pragmatism in cardiovascular RCTs. We also summarize current challenges and potential solutions to the implementation of pragmatism in RCTs and highlight selected ongoing and completed cardiovascular RCTs with pragmatic trial designs.
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- 2022
7. Heart failure quality of care and in‐hospital outcomes during the COVID‐19 pandemic: findings from the Get With The Guidelines‐Heart Failure registry
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Keshvani, Neil, Mehta, Anurag, Alger, Heather M, Rutan, Christine, Williams, Joseph, Zhang, Shuiaqi, Young, Rebecca, Alhanti, Brooke, Chiswell, Karen, Greene, Stephen J, DeVore, Adam D, Yancy, Clyde W, Fonarow, Gregg C, and Pandey, Ambarish
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Biomedical and Clinical Sciences ,Cardiovascular Medicine and Haematology ,Heart Disease ,Cardiovascular ,Clinical Research ,Patient Safety ,8.1 Organisation and delivery of services ,Health and social care services research ,Good Health and Well Being ,Aged ,COVID-19 ,Female ,Heart Failure ,Hospitalization ,Hospitals ,Humans ,Male ,Pandemics ,Quality of Health Care ,Registries ,United States ,Heart failure ,Quality of care ,Outcomes ,Cardiorespiratory Medicine and Haematology ,Cardiovascular System & Hematology ,Cardiovascular medicine and haematology - Abstract
AimsTo assess heart failure (HF) in-hospital quality of care and outcomes before and during the COVID-19 pandemic.Methods and resultsPatients hospitalized for HF with ejection fraction (EF)
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- 2022
8. Frailty, Guideline-Directed Medical Therapy, and Outcomes in HFrEF: From the GUIDE-IT Trial.
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Anker, Stefan, Felker, G, Januzzi, James, Butler, Javed, Pandey, Ambarish, Khan, Muhammad, Segar, Matthew, Usman, Muhammad, Singh, Sumitabh, Greene, Stephen, and Fonarow, Gregg
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frailty ,guideline-directed medical therapy ,heart failure with reduced ejection fraction ,mortality ,Angiotensin-Converting Enzyme Inhibitors ,Frailty ,Heart Failure ,Humans ,Mineralocorticoid Receptor Antagonists ,Stroke Volume - Abstract
OBJECTIVES: In this study, we sought to evaluate the association of frailty with the use of optimal guideline-directed medical therapy (GDMT) and outcomes in heart failure with reduced ejection fraction (HFrEF). BACKGROUND: The burden of frailty in HFrEF is high, and the patterns of GDMT use according to frailty status have not been studied previously. METHODS: A post hoc analysis of patients with HFrEF enrolled in the GUIDE-IT (Guiding Evidence-Based Therapy Using Biomarker Intensified Treatment in Heart Failure) trial was conducted. Frailty was assessed with the use of a frailty index (FI) using a 38-variable deficit model, and participants were categorized into 3 groups: class 1: nonfrail, FI 0.31). Multivariate-adjusted Cox models were used to study the association of frailty status with clinical outcomes. Use of optimal GDMT over time (beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and mineralocorticoid receptor antagonists) across frailty strata was assessed with the use of adjusted linear and logistic mixed-effect models. RESULTS: The study included 879 participants, of which 56.3% had high frailty burden (class 3 FI). A higher frailty burden was associated with a significantly higher risk of HF hospitalization or death in adjusted Cox models: high frailty vs nonfrail HR: 1.76, 95% CI: 1.20-2.58. On follow-up, participants with high frailty burden also had a significantly lower likelihood of achieving optimal GDMT: high frailty vs non-frail GDMT triple therapy use at study end: 17.7% vs 28.4%; P interaction, frailty class × time
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- 2022
9. Community-Level Economic Distress, Race, and Risk of Adverse Outcomes After Heart Failure Hospitalization Among Medicare Beneficiaries
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Mentias, Amgad, Desai, Milind Y, Vaughan-Sarrazin, Mary S, Rao, Shreya, Morris, Alanna A, Hall, Jennifer L, Menon, Venu, Hockenberry, Jason, Sims, Mario, Fonarow, Gregg C, Girotra, Saket, and Pandey, Ambarish
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Health Services and Systems ,Health Sciences ,Cardiovascular ,Clinical Research ,Heart Disease ,Patient Safety ,Behavioral and Social Science ,Mind and Body ,Good Health and Well Being ,Aged ,Aged ,80 and over ,Female ,Heart Failure ,Hospitalization ,Humans ,Long Term Adverse Effects ,Male ,Medicare ,Race Factors ,United States ,heart failure ,mortality ,racial disparity ,readmission ,Cardiorespiratory Medicine and Haematology ,Clinical Sciences ,Public Health and Health Services ,Cardiovascular System & Hematology ,Cardiovascular medicine and haematology ,Clinical sciences ,Sports science and exercise - Abstract
BackgroundSocioeconomic disadvantage is a strong determinant of adverse outcomes in patients with heart failure. However, the contribution of community-level economic distress to adverse outcomes in heart failure may differ across races and ethnicities.MethodsPatients of self-reported Black, White, and Hispanic race and ethnicity hospitalized with heart failure between 2014 and 2019 were identified from the Medicare MedPAR Part A 100% Files. We used patient-level residential ZIP code to quantify community-level economic distress on the basis of the Distressed Community Index (quintile 5: economically distressed versus quintiles 1-4: nondistressed). The association of continuous and categorical measures (distressed versus nondistressed) of Distressed Community Index with 30-day, 6-month, and 1-year risk-adjusted mortality, readmission burden, and home time were assessed separately by race and ethnicity groups.ResultsThe study included 1 611 586 White (13.2% economically distressed), 205 840 Black (50.6% economically distressed), and 89 199 Hispanic (27.3% economically distressed) patients. Among White patients, living in economically distressed (versus nondistressed) communities was significantly associated with a higher risk of adverse outcomes at 30-day and 1-year follow-up. Among Black and Hispanic patients, the risk of adverse outcomes associated with living in distressed versus nondistressed communities was not meaningfully different at 30 days and became more prominent by 1-year follow-up. Similarly, in the restricted cubic spline analysis, a stronger and more graded association was observed between Distressed Community Index score and risk of adverse outcomes in White patients (versus Black and Hispanic patients). Furthermore, the association between community-level economic distress and risk of adverse outcomes for Black patients differed in rural versus urban areas. Living in economically distressed communities was significantly associated with a higher risk of mortality and lower home time at 1-year follow-up in rural areas but not urban areas.ConclusionsThe association between community-level economic distress and risk of adverse outcomes differs across race and ethnic groups, with a stronger association noted in White patients at short- and long-term follow-up. Among Black patients, the association of community-level economic distress with a higher risk of adverse outcomes is less evident in the short term and is more robust and significant in the long-term follow-up and rural areas.
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- 2022
10. Incorporation of natriuretic peptides with clinical risk scores to predict heart failure among individuals with dysglycaemia.
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Segar, Matthew, Khan, Muhammad, Patel, Kershaw, Vaduganathan, Muthiah, Kannan, Vaishnavi, Willett, Duwayne, Peterson, Eric, Tang, W, Butler, Javed, Everett, Brendan, Wang, Thomas, McGuire, Darren, Pandey, Ambarish, and Fonarow, Gregg
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Biomarkers ,Diabetes ,Heart failure ,Pre-diabetes ,Risk prediction ,Risk stratification ,Adult ,Cohort Studies ,Glucose Metabolism Disorders ,Heart Failure ,Humans ,Natriuretic Peptides ,Risk Assessment ,Risk Factors - Abstract
AIMS: To evaluate the performance of the WATCH-DM risk score, a clinical risk score for heart failure (HF), in patients with dysglycaemia and in combination with natriuretic peptides (NPs). METHODS AND RESULTS: Adults with diabetes/pre-diabetes free of HF at baseline from four cohort studies (ARIC, CHS, FHS, and MESA) were included. The machine learning- [WATCH-DM(ml)] and integer-based [WATCH-DM(i)] scores were used to estimate the 5-year risk of incident HF. Discrimination was assessed by Harrells concordance index (C-index) and calibration by the Greenwood-Nam-DAgostino (GND) statistic. Improvement in model performance with the addition of NP levels was assessed by C-index and continuous net reclassification improvement (NRI). Of the 8938 participants included, 3554 (39.8%) had diabetes and 432 (4.8%) developed HF within 5 years. The WATCH-DM(ml) and WATCH-DM(i) scores demonstrated high discrimination for predicting HF risk among individuals with dysglycaemia (C-indices = 0.80 and 0.71, respectively), with no evidence of miscalibration (GND P ≥0.10). The C-index of elevated NP levels alone for predicting incident HF among individuals with dysglycaemia was significantly higher among participants with low/intermediate (
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- 2022
11. Exercise Intolerance in Older Adults With Heart Failure With Preserved Ejection Fraction JACC State-of-the-Art Review
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Pandey, Ambarish, Shah, Sanjiv J, Butler, Javed, Kellogg, Dean L, Lewis, Gregory D, Forman, Daniel E, Mentz, Robert J, Borlaug, Barry A, Simon, Marc A, Chirinos, Julio A, Fielding, Roger A, Volpi, Elena, Molina, Anthony JA, Haykowsky, Mark J, Sam, Flora, Goodpaster, Bret H, Bertoni, Alain G, Justice, Jamie N, White, James P, Ding, Jingzhone, Hummel, Scott L, LeBrasseur, Nathan K, Taffet, George E, Pipinos, Iraklis I, and Kitzman, Dalane
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Aging ,Heart Disease ,Cardiovascular ,Animals ,Exercise Tolerance ,Heart Failure ,Diastolic ,Humans ,exercise intolerance ,heart failure with preserved ejection fraction ,senescence ,skeletal muscle ,aging ,Cardiorespiratory Medicine and Haematology ,Public Health and Health Services ,Cardiovascular System & Hematology - Abstract
Exercise intolerance (EI) is the primary manifestation of chronic heart failure with preserved ejection fraction (HFpEF), the most common form of heart failure among older individuals. The recent recognition that HFpEF is likely a systemic, multiorgan disorder that shares characteristics with other common, difficult-to-treat, aging-related disorders suggests that novel insights may be gained from combining knowledge and concepts from aging and cardiovascular disease disciplines. This state-of-the-art review is based on the outcomes of a National Institute of Aging-sponsored working group meeting on aging and EI in HFpEF. We discuss aging-related and extracardiac contributors to EI in HFpEF and provide the rationale for a transdisciplinary, "gero-centric" approach to advance our understanding of EI in HFpEF and identify promising new therapeutic targets. We also provide a framework for prioritizing future research, including developing a uniform, comprehensive approach to phenotypic characterization of HFpEF, elucidating key geroscience targets for treatment, and conducting proof-of-concept trials to modify these targets.
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- 2021
12. Association of Medicaid Expansion with Rates of Utilization of Cardiovascular Therapies Among Medicaid Beneficiaries Between 2011 and 2018
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Sumarsono, Andrew, Lalani, Hussain, Segar, Matthew W, Rao, Shreya, Vaduganathan, Muthiah, Wadhera, Rishi K, Das, Sandeep R, Navar, Ann Marie, Fonarow, Gregg C, and Pandey, Ambarish
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Public Health ,Health Sciences ,Prevention ,Clinical Research ,Health Services ,Brain Disorders ,Cardiovascular ,Good Health and Well Being ,Drug Utilization ,Humans ,Medicaid ,Medically Uninsured ,Patient Protection and Affordable Care Act ,Prescription Drugs ,United States ,anticoagulant ,drug prescription ,drug utilization ,medicaid ,risk factor ,Cardiorespiratory Medicine and Haematology ,Public Health and Health Services ,Cardiovascular System & Hematology ,Cardiovascular medicine and haematology ,Public health - Abstract
BackgroundThe Affordable Care Act expanded Medicaid eligibility allowing low-income individuals greater access to health care. However, the uptake of state Medicaid expansion has been variable. It remains unclear how the Medicaid expansion was associated with the temporal trends in use of evidence-based cardiovascular drugs.MethodsWe used the publicly available Medicaid Drug Utilization and Current Population Survey to extract filled prescription rates per 1000 Medicaid beneficiaries of statins, antihypertensives, P2Y12 inhibitors, and direct oral anticoagulants. We defined expander states as those who expanded Medicaid on or before January 1, 2014, and nonexpander states as those who had not expanded by December 31, 2018. Difference-in-differences (DID) analyses were performed to compare the association of the Medicaid expansion with per-capita cardiovascular drug prescription rates in expander versus nonexpander states.ResultsBetween 2011 and 2018, the total number of prescriptions among all Medicaid beneficiaries increased, with gains of 89.7% in statins (11.0 to 20.8 million), 76% in antihypertensives (35.3 to 62.2 million), and 37% in P2Y12 inhibitors (1.7 to 2.3 million). Medicaid expansion was associated with significantly greater increases in quarterly prescriptions (per 1000 Medicaid beneficiaries) of statins (DID estimate [95% CI]: 22.5 [16.5-28.6], P75% of the expander states had increases in prescription rates of both statins and antihypertensives. In contrast, 44% of nonexpander states saw declines in statins and antihypertensives. The Medicaid expansion was not associated with higher direct oral anticoagulants prescription rates (DID estimate [95% CI] 0.9 [-0.3 to 2.1], P=0.142).ConclusionsThe 2014 Medicaid expansion was associated with a significant increase in per-capita utilization of cardiovascular prescription drugs among Medicaid beneficiaries. These gains in utilization may contribute to long-term cardiovascular benefits to lower-income and previously underinsured populations.
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- 2021
13. Effect of Progression of Valvular Calcification on Left Ventricular Structure and Frequency of Incident Heart Failure (from the Multiethnic Study of Atherosclerosis)
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Fashanu, Oluwaseun E, Upadhrasta, Sireesha, Zhao, Di, Budoff, Matthew J, Pandey, Ambarish, Lima, Joao AC, and Michos, Erin D
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Biomedical and Clinical Sciences ,Cardiovascular Medicine and Haematology ,Cardiovascular ,Heart Disease ,Aging ,Prevention ,Atherosclerosis ,Biomedical Imaging ,2.1 Biological and endogenous factors ,Aged ,Aortic Valve ,Calcinosis ,Cardiac-Gated Imaging Techniques ,Disease Progression ,Female ,Heart Failure ,Heart Valve Diseases ,Heart Ventricles ,Humans ,Incidence ,Male ,Middle Aged ,Mitral Valve ,Proportional Hazards Models ,Stroke Volume ,Tomography ,X-Ray Computed ,Cardiorespiratory Medicine and Haematology ,Cardiovascular System & Hematology ,Cardiovascular medicine and haematology - Abstract
Heart failure (HF) is a leading cause of morbidity. Strategies for preventing HF are paramount. Prevalent extracoronary calcification is associated with HF risk but less is known about progression of mitral annular (MAC) and aortic valve calcification (AVC) and HF risk. Progression of valvular calcification (VC) [interval change of >0 units/yr] was assessed by 2 cardiac computed tomography scans over a median of 2.4 years. We used Cox regression to determine the risk of adjudicated HF and linear mixed effects models to determine 10-year change in left ventricular (LV) parameters measured by cardiac magnetic resonance imaging associated with VC progression. We studied 5,591 MESA participants free of baseline cardiovascular disease. Mean ± SD age was 62 ± 10 years; 53% women; 83% had no VC progression, 15% progressed at 1 site (AVC or MAC) and 3% at both sites. There were 251 incident HF over 15 years. After adjusting for cardiovascular risk factors, the hazard ratios (95% confidence interval) of HF associated with VC progression at 1 and 2 sites were 1.62 (1.21 to 2.17) and 1.88 (1.14 to 3.09), respectively, compared with no progression (p-for-trend
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- 2020
14. Medicaid Expansion and Utilization of Antihyperglycemic Therapies
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Sumarsono, Andrew, Buckley, Leo F, Machado, Sara R, Wadhera, Rishi K, Warraich, Haider J, Desai, Rishi J, Everett, Brendan M, McGuire, Darren K, Fonarow, Gregg C, Butler, Javed, Pandey, Ambarish, and Vaduganathan, Muthiah
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Reproductive Medicine ,Biomedical and Clinical Sciences ,Health Services ,Clinical Research ,Good Health and Well Being ,Adult ,Diabetes Mellitus ,Type 2 ,Drug Utilization ,Female ,Glucagon-Like Peptide-1 Receptor ,Humans ,Male ,Medicaid ,Patient Protection and Affordable Care Act ,Poverty ,Sodium-Glucose Transporter 2 Inhibitors ,United States ,Medical and Health Sciences ,Endocrinology & Metabolism ,Biomedical and clinical sciences ,Health sciences - Abstract
ObjectiveCertain antihyperglycemic therapies modify cardiovascular and kidney outcomes among patients with type 2 diabetes, but early uptake in practice appears restricted to particular demographics. We examine the association of Medicaid expansion with use of and expenditures related to antihyperglycemic therapies among Medicaid beneficiaries.Research design and methodsWe employed a difference-in-difference design to analyze the association of Medicaid expansion on prescription of noninsulin antihyperglycemic therapies. We used 2012-2017 national and state Medicaid data to compare prescription claims and costs between states that did (n = 25) and did not expand (n = 26) Medicaid by January 2014.ResultsFollowing Medicaid expansion in 2014, average noninsulin antihyperglycemic therapies per state/1,000 enrollees increased by 4.2%/quarter in expansion states and 1.6%/quarter in nonexpansion states. For sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1RA), quarterly growth rates per 1,000 enrollees were 125.3% and 20.7% for expansion states and 87.6% and 16.0% for nonexpansion states, respectively. Expansion states had faster utilization of SGLT2i and GLP-1RA than nonexpansion states. Difference-in-difference estimates for change in volume of prescriptions after Medicaid expansion between expansion versus nonexpansion states was 1.68 (95% CI 1.09-2.26; P < 0.001) for all noninsulin therapies, 0.125 (-0.003 to 0.25; P = 0.056) for SGLT2i, and 0.12 (0.055-0.18; P < 0.001) for GLP-1RA.ConclusionsUse of noninsulin antihyperglycemic therapies, including SGLT2i and GLP-1RA, increased among low-income adults in both Medicaid expansion and nonexpansion states, with a significantly greater increase in overall use and in GLP-1RA use in expansion states. Future evaluation of the population-level health impact of expanded access to these therapies is needed.
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- 2020
15. Association of Long-term Change and Variability in Glycemia With Risk of Incident Heart Failure Among Patients With Type 2 Diabetes: A Secondary Analysis of the ACCORD Trial
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Segar, Matthew W, Patel, Kershaw V, Vaduganathan, Muthiah, Caughey, Melissa C, Butler, Javed, Fonarow, Gregg C, Grodin, Justin L, McGuire, Darren K, and Pandey, Ambarish
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Heart Disease ,Prevention ,Diabetes ,Clinical Research ,Cardiovascular ,Metabolic and endocrine ,Aged ,Blood Glucose ,Diabetes Mellitus ,Type 2 ,Diabetic Angiopathies ,Female ,Follow-Up Studies ,Glycated Hemoglobin ,Glycemic Control ,Heart Failure ,Humans ,Incidence ,Male ,Middle Aged ,Retrospective Studies ,Risk Factors ,Time Factors - Abstract
ObjectiveTo evaluate the associations between long-term change and variability in glycemia with risk of heart failure (HF) among patients with type 2 diabetes mellitus (T2DM).Research design and methodsAmong participants with T2DM enrolled in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, variability in HbA1c was assessed from stabilization of HbA1c following enrollment (8 months) to 3 years of follow-up as follows: average successive variability (ASV) (average absolute difference between successive values), coefficient of variation (SD/mean), and SD. Participants with HF at baseline or within 3 years of enrollment were excluded. Adjusted Cox models were used to evaluate the association of percent change (from baseline to 3 years of follow-up) and variability in HbA1c over the first 3 years of enrollment and subsequent risk of HF.ResultsThe study included 8,576 patients. Over a median follow-up of 6.4 years from the end of variability measurements at year 3, 388 patients had an incident HF hospitalization. Substantial changes in HbA1c were significantly associated with higher risk of HF (hazard ratio [HR] for ≥10% decrease 1.32 [95% CI 1.08-1.75] and for ≥10% increase 1.55 [1.19-2.04]; reference
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- 2020
16. Predictive Value of Coronary Artery Calcium Score Categories for Coronary Events Versus Strokes: Impact of Sex and Race
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Mehta, Anurag, Pandey, Ambarish, Ayers, Colby R, Khera, Amit, Sperling, Laurence S, Szklo, Moyses, Gottesman, Rebecca F, Budoff, Mathew J, Blaha, Michael J, Blumenthal, Roger S, Nasir, Khurram, and Joshi, Parag H
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Biomedical and Clinical Sciences ,Cardiovascular Medicine and Haematology ,Clinical Sciences ,Cardiovascular ,Aging ,Brain Disorders ,Heart Disease - Coronary Heart Disease ,Clinical Research ,Patient Safety ,Stroke ,Atherosclerosis ,Prevention ,Heart Disease ,Good Health and Well Being ,Adult ,Aged ,Aged ,80 and over ,Comorbidity ,Coronary Artery Disease ,Coronary Disease ,Female ,Heart Disease Risk Factors ,Humans ,Incidence ,Male ,Middle Aged ,Predictive Value of Tests ,Race Factors ,Risk Assessment ,Severity of Illness Index ,Sex Factors ,Time Factors ,United States ,Vascular Calcification ,atherosclerosis ,calcium ,cardiovascular disease ,coronary artery disease ,risk ,stroke ,Cardiovascular System & Hematology ,Cardiovascular medicine and haematology ,Clinical sciences - Abstract
BackgroundCoronary artery calcium (CAC) predicts atherosclerotic cardiovascular disease (ASCVD) events, inclusive of coronary heart disease (CHD) and stroke, and is a decision-making aid for primary prevention. The predictive value of CAC categories for CHD and stroke separately and across sex and race groups of an asymptomatic population is unclear.MethodsWhite, Black, and Hispanic participants of MESA (Multi-Ethnic Study of Atherosclerosis) and DHS (Dallas Heart Study) underwent CAC measurement at enrollment and were followed for incident ASCVD events. Ten-year CHD-to-stroke incidence ratios across CAC score categories 0, 1 to 99, and ≥100 were assessed. Associations of CAC with incident CHD and stroke events were evaluated using multivariable-adjusted Cox models and multiplicative interactions of CAC with sex/race were tested.ResultsAmong 7042 participants (mean age, 57 years, 54% women, 36% Black, 23% Hispanic, 49% CAC=0, 19% CAC ≥100), 574 incident ASCVD events (333 CHD and 241 stroke) were observed over 12.3-year follow-up. Ten-year CHD-to-stroke incidence ratio increased significantly across CAC categories in men, women, Whites, Blacks, and Hispanics (all P
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- 2020
17. Longitudinal trajectories of hospital performance across targeted cardiovascular conditions in the USA.
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Vaduganathan, Muthiah, McCarthy, Cian P, Ayers, Colby, Bhatt, Deepak L, Kumbhani, Dharam J, de Lemos, James A, Fonarow, Gregg C, and Pandey, Ambarish
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Clinical Research ,Cardiovascular ,Heart Disease - Coronary Heart Disease ,Heart Disease ,Health Services ,Good Health and Well Being ,Cardiovascular Diseases ,Follow-Up Studies ,Hospital Mortality ,Hospitals ,Humans ,Patient Readmission ,Retrospective Studies ,United States ,Heart failure ,Hospital performance ,Myocardial infarction ,Quality - Abstract
AimsThirty-day risk standardized readmission and mortality rates (RSRR, RSMR) are key determinants for hospital performance for cardiovascular conditions such as acute myocardial infarction (AMI) and heart failure (HF). We evaluated whether individual hospitals in the USA perform similarly for HF and AMI over time based on readmission and mortality metrics.Methods and resultsA total of 1950 hospitals in the USA with continuous participation in the Centers for Medicare and Medicaid Services (CMS) public reporting programme between 2010 and 2016 were identified. Latent mixture modelling was used to define performance trajectory groups. Overall, there were consistent declines in the RSMR (16.1-14.0%) and RSRR (20.3-16.6%) for AMI from 2010 to 2016. For HF, RSRR declined over time (25.1-21.7%), while there was a modest increase in RSMR (11.3-12.0%); parallel findings were observed across performance trajectory groups. The proportion of best performing centres for HF care that were also best performers for AMI care based on the 30-day RSMR and 30-day RSRR metric was 54% and 35%, respectively. Furthermore, the discordance rate between the best and worst performers for both conditions was low (
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- 2020
18. Machine Learning to Predict the Risk of Incident Heart Failure Hospitalization Among Patients With Diabetes: The WATCH-DM Risk Score
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Segar, Matthew W, Vaduganathan, Muthiah, Patel, Kershaw V, McGuire, Darren K, Butler, Javed, Fonarow, Gregg C, Basit, Mujeeb, Kannan, Vaishnavi, Grodin, Justin L, Everett, Brendan, Willett, Duwayne, Berry, Jarett, and Pandey, Ambarish
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Heart Disease ,Patient Safety ,Nutrition ,Prevention ,Cardiovascular ,Clinical Research ,Diabetes ,Metabolic and endocrine ,Aged ,Clinical Trials as Topic ,Cohort Studies ,Diabetes Mellitus ,Type 2 ,Female ,Follow-Up Studies ,Heart Failure ,Hospitalization ,Humans ,Incidence ,Machine Learning ,Male ,Middle Aged ,Outpatients ,Predictive Value of Tests ,Reproducibility of Results ,Risk Assessment ,Risk Factors ,Time Factors - Abstract
ObjectiveTo develop and validate a novel, machine learning-derived model to predict the risk of heart failure (HF) among patients with type 2 diabetes mellitus (T2DM).Research design and methodsUsing data from 8,756 patients free at baseline of HF, with
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- 2019
19. Identifying a low‐flow phenotype in heart failure with preserved ejection fraction: a secondary analysis of the RELAX trial
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Patel, Kershaw V, Mauricio, Rina, Grodin, Justin L, Ayers, Colby, Fonarow, Gregg C, Berry, Jarett D, and Pandey, Ambarish
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Biomedical and Clinical Sciences ,Cardiovascular Medicine and Haematology ,Cardiovascular ,Heart Disease ,Clinical Research ,Clinical Trials and Supportive Activities ,Aged ,Exercise Tolerance ,Female ,Heart Failure ,Humans ,Male ,Middle Aged ,Natriuretic Peptide ,Brain ,Peptide Fragments ,Phenotype ,Stroke Volume ,Heart failure with preserved ejection fraction ,Stroke volume ,Fitness ,Biomarkers ,Cardiorespiratory Medicine and Haematology ,Cardiovascular medicine and haematology - Abstract
AimsThe relationship between resting stroke volume (SV) and prognostic markers in heart failure with preserved ejection fraction (HFpEF) is not well established. We evaluated the association of SV index (SVI) at rest with exercise capacity and N-terminal pro-B-type natriuretic peptide (NT-proBNP) in stable patients with HFpEF.Methods and resultsParticipants enrolled in the Phosphodiesterase-5 Inhibition to Improve Clinical Status and Exercise Capacity in Diastolic Heart Failure (RELAX) trial with available data on SVI by the Doppler method were included in this analysis (n = 185). A low-flow state defined by resting SVI
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- 2019
20. Thirty-Day Readmissions After Hospitalization for Hypertensive Emergency
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Kumar, Nilay, Simek, Shawn, Garg, Neetika, Vaduganathan, Muthiah, Kaiksow, Farah, Stein, James H, Fonarow, Gregg C, Pandey, Ambarish, and Bhatt, Deepak L
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Biomedical and Clinical Sciences ,Clinical Sciences ,Cardiovascular ,Health Services ,Clinical Research ,Heart Disease ,Prevention ,Hypertension ,Good Health and Well Being ,Aged ,Databases ,Factual ,Emergencies ,Emergency Treatment ,Female ,Hospitalization ,Humans ,Incidence ,Male ,Middle Aged ,Patient Readmission ,Prognosis ,Risk Factors ,United States ,blood pressure ,emergency ,heart failure ,hypertension ,stroke ,Cardiorespiratory Medicine and Haematology ,Public Health and Health Services ,Cardiovascular System & Hematology ,Cardiovascular medicine and haematology ,Clinical sciences - Abstract
Hypertensive emergency is a clinical entity with potentially serious health implications and high healthcare utilization. There is a lack of nationally representative data on incidence, causes, and predictors of 30-day readmission after hospitalization for hypertensive emergency. We used the 2013 to 2014 Nationwide Readmissions Database to identify index hospitalizations for hypertensive emergency. Primary outcome was all-cause unplanned 30-day readmission. Multivariable hierarchical logistic regression was used to identify independent predictors of readmission. There were 166 531 index hospitalizations for hypertensive emergency representative of 355 627 (SE, 9401) hospitalizations nationwide in 2013 to 2014. Mean age was 66.0 (SE, 0.14) years, and 53.7% were women. The overall incidence of unplanned 30-day readmissions was 17.8%. The most common causes of readmission were heart failure (14.2%), hypertension with complications (10.2%), sepsis (5.9%), acute kidney injury (5.1%), and cerebrovascular accident (5.1%). Noncardiovascular causes accounted for 57.9% of readmissions. We found age
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- 2019
21. Sex and Race Differences in Lifetime Risk of Heart Failure With Preserved Ejection Fraction and Heart Failure With Reduced Ejection Fraction
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Pandey, Ambarish, Omar, Wally, Ayers, Colby, LaMonte, Michael, Klein, Liviu, Allen, Norrina B, Kuller, Lewis H, Greenland, Philip, Eaton, Charles B, Gottdiener, John S, Lloyd-Jones, Donald M, and Berry, Jarett D
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Cardiovascular ,Heart Disease ,Prevention ,Clinical Research ,Heart Disease - Coronary Heart Disease ,Aging ,Patient Safety ,Good Health and Well Being ,African Americans ,Age Factors ,Aged ,Aged ,80 and over ,Female ,Heart Failure ,Hispanic or Latino ,Humans ,Incidence ,Male ,Middle Aged ,Myocardial Infarction ,Prognosis ,Prospective Studies ,Racial Groups ,Risk Assessment ,Risk Factors ,Sex Factors ,Stroke Volume ,Time Factors ,United States ,Ventricular Function ,Left ,Whites ,heart failure ,risk ,White People ,Black or African American ,Cardiorespiratory Medicine and Haematology ,Clinical Sciences ,Public Health and Health Services ,Cardiovascular System & Hematology - Abstract
BackgroundLifetime risk of heart failure has been estimated to range from 20% to 46% in diverse sex and race groups. However, lifetime risk estimates for the 2 HF phenotypes, HF with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF), are not known.MethodsParticipant-level data from 2 large prospective cohort studies, the CHS (Cardiovascular Health Study) and MESA (Multiethnic Study of Atherosclerosis), were pooled, excluding individuals with prevalent HF at baseline. Remaining lifetime risk estimates for HFpEF (EF ≥45%) and HFrEF (EF 45 years of age (22.2% blacks, 44.8% men) who were followed up for median duration of 11.6 years with 2178 overall incident HF events with 561 HFrEF events and 726 HFpEF events. At the index age of 45 years, the lifetime risk for any HF through 90 years of age was higher in men than women (27.4% versus 23.8%). Among HF subtypes, the lifetime risk for HFrEF was higher in men than women (10.6% versus 5.8%). In contrast, the lifetime risk for HFpEF was similar in men and women. In race-stratified analyses, lifetime risk for overall HF was higher in nonblacks than blacks (25.9% versus 22.4%). Among HF subtypes, the lifetime risk for HFpEF was higher in nonblacks than blacks (11.2% versus 7.7%), whereas that for HFrEF was similar across the 2 groups. Among participants with antecedent myocardial infarction before HF diagnosis, the remaining lifetime risks for HFpEF and HFrEF were up to 2.5-fold and 4-fold higher, respectively, compared with those without antecedent myocardial infarction.ConclusionsLifetime risks for HFpEF and HFrEF vary by sex, race, and history of antecedent myocardial infarction. These insights into the distribution of HF risk and its subtypes could inform the development of targeted strategies to improve population-level HF prevention and control.
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- 2018
22. Relationship Between Physical Activity, Body Mass Index, and Risk of Heart Failure
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Pandey, Ambarish, LaMonte, Michael, Klein, Liviu, Ayers, Colby, Psaty, Bruce M, Eaton, Charles B, Allen, Norrina B, de Lemos, James A, Carnethon, Mercedes, Greenland, Philip, and Berry, Jarett D
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Biomedical and Clinical Sciences ,Clinical Sciences ,Clinical Research ,Heart Disease ,Cardiovascular ,Prevention ,Aging ,Aged ,Body Mass Index ,Cohort Studies ,Exercise ,Female ,Heart Failure ,Humans ,Male ,Middle Aged ,Proportional Hazards Models ,Risk Factors ,Stroke Volume ,body mass index ,dose-response relationship ,heart failure ,physical activity ,dose–response relationship ,Cardiorespiratory Medicine and Haematology ,Public Health and Health Services ,Cardiovascular System & Hematology ,Cardiovascular medicine and haematology - Abstract
BackgroundLower leisure-time physical activity (LTPA) and higher body mass index (BMI) are independently associated with risk of heart failure (HF). However, it is unclear if this relationship is consistent for both heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF).ObjectivesThis study sought to quantify dose-response associations between LTPA, BMI, and the risk of different HF subtypes.MethodsIndividual-level data from 3 cohort studies (WHI [Women's Health Initiative], MESA [Multi-Ethnic Study of Atherosclerosis], and CHS [Cardiovascular Health Study]) were pooled and participants were stratified into guideline-recommended categories of LTPA and BMI. Associations between LTPA, BMI, and risk of overall HF, HFpEF (ejection fraction ≥45%), and HFrEF (ejection fraction 1,000 MET-min/week) were associated with an 19% lower risk of HFpEF (hazard ratio: 0.81; 95% confidence interval: 0.68 to 0.97). The dose-response relationship for BMI with HFpEF risk was also more consistent than with HFrEF risk, such that increasing BMI above the normal range (≥25 kg/m2) was associated with a greater increase in risk of HFpEF than HFrEF.ConclusionsOur study findings show strong, dose-dependent associations between LTPA levels, BMI, and risk of overall HF. Among HF subtypes, higher LTPA levels and lower BMI were more consistently associated with lower risk of HFpEF compared with HFrEF.
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- 2017
23. Variation in Hospital Use and Outcomes Associated With Pulmonary Artery Catheterization in Heart Failure in the United States
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Khera, Rohan, Pandey, Ambarish, Kumar, Nilay, Singh, Rajeev, Bano, Shah, Golwala, Harsh, Kumbhani, Dharam J, Girotra, Saket, and Fonarow, Gregg C
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Clinical Research ,Cardiovascular ,Heart Disease ,Good Health and Well Being ,Aged ,Arrhythmias ,Cardiac ,Case-Control Studies ,Catheterization ,Swan-Ganz ,Cerebrovascular Disorders ,Coronary Artery Disease ,Databases ,Factual ,Disease Management ,Female ,Heart Arrest ,Heart Failure ,Hospital Mortality ,Hospitals ,Humans ,Length of Stay ,Logistic Models ,Male ,Middle Aged ,Myocardial Infarction ,Odds Ratio ,Practice Patterns ,Physicians' ,Propensity Score ,Shock ,Cardiogenic ,United States ,catheterization ,heart failure ,hospitalization ,International Classification of Diseases ,pulmonary artery ,Biochemistry and Cell Biology ,Cardiorespiratory Medicine and Haematology ,Medical Physiology ,Cardiovascular System & Hematology - Abstract
There has been an increase in the use of pulmonary artery (PA) catheters in heart failure (HF) in the United States in recent years. However, patterns of hospital use and trends in patient outcomes are not known. In the National Inpatient Sample 2001 to 2012, using International Classification of Diseases-Ninth Revision codes, we identified 11 888 525 adult (≥18 years) HF hospitalizations nationally, of which an estimated 75 209 (SE 0.6%) received a PA catheter. In 2001, the number of hospitals with ≥1 PA catheterization was 1753, decreasing to 1183 in 2011. The mean PA catheter use per hospital trended from 4.9 per year in 2001 (limits 1-133) to 3.8 per year in 2007 (limits 1-46), but increased to 5.5 per year in 2011 (limits 1-70). During 2001 to 2006, PA catheterization declined across hospitals; however, in 2007 to 2012, there was a disproportionate increase at hospitals with large bedsize, teaching programs, and advanced HF capabilities. The overall in-hospital mortality with PA catheter use was higher than without PA catheter use (13.1% versus 3.4%; P
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- 2016
24. Effect of Mineralocorticoid Receptor Antagonists on Cardiac Structure and Function in Patients With Diastolic Dysfunction and Heart Failure With Preserved Ejection Fraction: A Meta-Analysis and Systematic Review.
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Pandey, Ambarish, Garg, Sushil, Matulevicius, Susan, Shah, Amil, Garg, Jalaj, Drazner, Mark, Berry, Jarett, Marwick, Thomas, Marso, Steven, de Lemos, James, Kumbhani, Dharam, and Amin, Alpesh
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diastolic dysfunction ,heart failure with preserved ejection fraction ,mineralocorticoid receptor antagonist ,Chi-Square Distribution ,Diastole ,Fibrosis ,Heart Failure ,Humans ,Mineralocorticoid Receptor Antagonists ,Randomized Controlled Trials as Topic ,Recovery of Function ,Stroke Volume ,Treatment Outcome ,Ventricular Dysfunction ,Left ,Ventricular Function ,Left ,Ventricular Remodeling - Abstract
BACKGROUND: There has been an increasing interest in use of mineralocorticoid receptor antagonists (MRAs) in patients with heart failure with preserved ejection fraction (HFPEF). However, a comprehensive evaluation of MRA effects on left ventricular (LV) structure and function in these patients is lacking. In this meta-analysis, we evaluated the effects of MRAs on LV structure and function among patients with diastolic dysfunction or HFPEF. METHODS & RESULTS: Randomized, controlled clinical trials evaluating the efficacy of MRAs in patients with diastolic dysfunction or HFPEF were included. The primary outcome was change in E/e, a specific measure of diastolic function. Secondary outcomes included changes in other measures of diastolic function, LV structure, surrogate markers for myocardial fibrosis (carboxy-terminal peptide of procollagen type I [PICP] and amino-terminal peptide of pro-collagen type-II [PIIINP]), blood pressure, and exercise tolerance. In the pooled analysis, MRA use was associated with significant reduction in E/e (weighted mean difference [WMD] [95% confidence interval {CI}]: -1.68 [-2.03 to -1.33]; P
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- 2015
25. Comparison of Morisky Medication Adherence Scale with therapeutic drug monitoring in apparent treatment–resistant hypertension
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Pandey, Ambarish, Raza, Fayez, Velasco, Alejandro, Brinker, Stephanie, Ayers, Colby, Das, Sandeep R, Morisky, Donald E, Halm, Ethan A, and Vongpatanasin, Wanpen
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Pharmacology and Pharmaceutical Sciences ,Biomedical and Clinical Sciences ,Clinical Research ,Hypertension ,Cardiovascular ,6.1 Pharmaceuticals ,5.1 Pharmaceuticals ,Evaluation of treatments and therapeutic interventions ,Development of treatments and therapeutic interventions ,Age Factors ,Antihypertensive Agents ,Area Under Curve ,Cohort Studies ,Confidence Intervals ,Drug Monitoring ,Drug Resistance ,Female ,Follow-Up Studies ,Humans ,Male ,Medication Adherence ,Middle Aged ,Retrospective Studies ,Risk Assessment ,Sensitivity and Specificity ,Sex Factors ,Surveys and Questionnaires ,Blood pressure control ,self reported adherence ,serum drug levels ,Cardiorespiratory Medicine and Haematology ,Cardiovascular System & Hematology ,Cardiovascular medicine and haematology - Abstract
The Morisky Medication Adherence Scale (MMAS-8) is a questionnaire developed for screening of non-adherence in patients with several chronic conditions, including uncomplicated hypertension. However, its accuracy in predicting non-adherence in patients with apparent treatment-resistant hypertension (a-TRH) is not known. Accordingly, we performed a retrospective study in 47 patients with a-TRH who had completed the eight-item MMAS during the initial clinic visit. Non-adherence was defined as presence of undetected serum levels of at least one prescribed antihypertensive drug by therapeutic drug monitoring. We found that 26% of patients were considered to have low adherence score (
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- 2015
26. Therapeutic Anticoagulation with Heparin in Noncritically Ill Patients with Covid-19
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Lawler, Patrick R, Golighe, Ewan C, Berge, Jeffrey S, Neal, Matthew D, McVerry, Bryan J, Nicolau, Jose C, Gong, Michelle N, Carrier, Marc, Rosenson, Robert S, Reynolds, Harmony R, Turgeon, Alexis F, Escobedo, Jorge, Huang, David T, Bradbury, Charlotte A, Houston, Brett L, Kornblith, Lucy Z, Kumar, Anand, Kah, Susan RN, Cushman, Mary, McQuilten, Zoe, Slutsky, Arthur S, Kim, Keri S, Gordon, Anthony C, Kirwan, Bridget-Anne, Brooks, Maria M, Higgins, Alisa M, Lewis, Roger J, Lorenzi, Elizabeth, Berry, Scott M, Berry, Lindsay R, Angus, Derek C, McArthur, Colin J, Webb, Steven A, Farkouh, Michael E, Hochman, Judith S, Zarychanski, Ryan, Aday, Aaron W, Al-Beidh, Farah, Annane, Djillali, Arabi, Yaseen M, Aryal, Diptesh, Kreuziger, Lisa Baumann, Beane, Abi, Bhimani, Zahra, Bihari, Shailesh, Billett, Henny H, Bond, Lindsay, Bonten, Marc, Brunkhorst, Frank, Buxton, Meredith, Buzgau, Adrian, Castellucci, Lana A, Chekuri, Sweta, Chen, Jen-Ting, Cheng, Allen C, Chkhikvadzw, Tamta, Coiffard, Benjamin, Costantini, Todd W, de Brouwer, Sophie, Derde, Lennie PG, Detry, Michelle A, Duggal, Abhijit, Dzavik, Vladimir, Effron, Mark B, Estcourt, Lise J, Everett, Brendan M, Fergusson, Dean A, Fitzgerald, Mark, Fowler, Robert A, Galanaud, Jean P, Galen, Benjamin T, Gandotra, Sheetal, Garcia-Madrona, Sebastian, Girard, Timothy D, Godoy, Lucas C, Goodman, Andrew L, Goossens, Herman, Green, Cameron, Greenstein, Yonatan Y, Gross, Peter L, Hamburg, Naomi M, Haniffa, Rashan, Hanna, George, Hanna, Nicholas, Hegde, Sheila M, Hendrickson, Carolyn M, Hite, R Duncan, Hindenburg, Alexander A, Hope, Aluko A, Horowitz, James M, Horvat, Christopher M, Hudock, Kristin, Hunt, Beverley J, Husain, Mansoor, Hyzy, Robert C, Iyer, Vivek N, Jacobson, Jeffrey R, Jayakumar, Devachandran, Keller, Norma M, Khan, Akram, Kim, Yuri, Kindzelski, Andrei L, Kin, Andrew J, Knudson, M Margaret, Kornblith, Aaron E, Krishnan, Vidya, Kutcher, Matthew E, Laffan, Michael A, Lamontagne, Francois, Le Gal, Gregoire, Leeper, Christine M, Leifer, Eric S, Lim, George, Lima, Felipe Gallego, Linstrum, Kelsey, Litton, Edward, Lopez-Sendon, Jose, Moreno, Jose L Lopez-Sendon, Lother, Sylvain A, Malhotra, Saurabh, Marcos, Miguel, Marinez, Andrea Saud, Marshall, John C, Marten, Nicole, Matthay, Michael A, McAuley, Daniel F, McDonald, Emily G, McGlothlin, Anna, McGuinness, Shay P, Middeldorp, Saskia, Montgomery, Stephanie K, Moore, Steven C, Guerreor, Raquel Morillo, Mouncey, Paul R, Murthy, Srinivas, Nair, Girish B, Nair, Rahul, Nichol, Alistair D, Nunez-Garcia, Brenda, Pandey, Ambarish, Park, Pauline K, Parke, Rachael L, Parker, Jane C, Parnia, Sam, Paul, Jonathan D, Gonzalez, Yessica S Perez, Pompilio, Mauricio, Prekker, Matthew E, Quigley, John G, Rost, Natalia S, Rowan, Kathryn, Santos, Fernanda O, Santos, Marlene, Santos, Mayler Olombrada, Satterwhite, Lewis, Saunders, Christina T, Schutgens, Roger EG, Seymour, Christopher W, Siegal, Deborah M, Jr, Silva Delcio G, Shankar-Hari, Manu, Sheehan, John P, Singhal, Aneesh B, Solvaso, Dayna, Stanworth, Simon J, Tritschler, Tobias, Turner, Anne M, Van Bentum-Puijk, Wilma, van de Veerdonk, Frank L, van Diepen, Sean, Vazquez-Grande, Gloria, Wahid, Lana, Wareham, Vanessa, Wells, Bryan J, Widmer, R Jay, Wilson, Jennifer G, Yuriditsky, Eugene, Zampieri, Fernando G, Investigators, ATTACC, Investigators, ACTIV-4a, Investigators, REMAP-CAP, Investigators, ATTACC, Investigators, ACTIV-4a, Investigators, REMAP-CAP, Université de Versailles Saint-Quentin-en-Yvelines (UVSQ), 215522, AR7-162822, CS-2016-16-011, RP-2015-06-18, National Institutes of Health, NIH: 1OT2HL156812-01, OTA-20-011, UL1TR001445, National Heart, Lung, and Blood Institute, NHLBI, Breast Cancer Research Foundation, BCRF, National Center for Advancing Translational Sciences, NCATS, New York University, NYU, Medical Center, University of Pittsburgh, CancerCare Manitoba Foundation, CCMF, University of Manitoba, UM, Health Research Board, HRB: CTN 2014-012, Canadian Institutes of Health Research, CIHR, National Institute for Health Research, NIHR, European Commission, EC: 602525, FP7-HEALTH-2013-INNOVATION, National Health and Medical Research Council, NHMRC: APP1101719, APP1116530, Health Research Council of New Zealand, HRC: 158584, 16/631, 447335, Canada Research Chairs, Eisai, Ministère des Affaires Sociales et de la Santé: PHRC-20-0147, Horizon 2020: 101003589, NIHR Imperial Biomedical Research Centre, BRC, Minderoo Foundation, The ATTACC platform was supported by grants from the Canadian Institutes of Health Research, LifeArc Foundation, Thistledown Foundation, Research Manitoba, Ontario Ministry of Health, Peter Munk Cardiac Centre, CancerCare Manitoba Foundation, and Victoria General Hospital Foundation. The ACTIV-4a platform was sponsored by the National Heart, Lung, and Blood Institute, National Institutes of Health (NIH) (grant numbers, OTA-20-011 and 1OT2HL156812-01). The pilot program (PROTECT) was funded in part by a grant (UL1TR001445) from the New York University Clinical and Translational Science Award program, supported by the National Center for Advancing Translational Sciences of the NIH. The REMAP-CAP platform was supported by the European Union through FP7-HEALTH-2013-INNOVATION: the Platform for European Preparedness Against (Re-)emerging Epidemics (PREPARE) consortium (602525) and the Horizon 2020 research and innovation program: the Rapid European Covid-19 Emergency Research response (RECOVER) consortium (101003589), by the Australian National Health and Medical Research Council (APP1101719 and APP1116530), the Health Research Council of New Zealand (16/631), the Canadian Institutes of Health Research (Strategy for Patient-Oriented Research Innovative Clinical Trials Program Grant [158584] and Covid-19 Rapid Research Operating Grant [447335]), the U.K. National Institute for Health Research (NIHR) and the NIHR Imperial Biomedical Research Centre, the Health Research Board of Ireland (CTN 2014-012), the Learning While Doing Program at the University of Pittsburgh Medical Center, the Breast Cancer Research Foundation, the French Ministry of Health (PHRC-20-0147), the Minderoo Foundation, Am-gen, Eisai, the Global Coalition for Adaptive Research, and the Wellcome Trust Innovations Project (215522). Dr. Goligher is the recipient of an Early Career Investigator award from the Canadian Institutes of Health Research (grant AR7-162822). Dr. Gordon is supported by an NIHR Research Professorship (RP-2015-06-18), Dr. Shankar-Hari by an NIHR Clinician Scientist Fellowship (CS-2016-16-011), and Dr. Turgeon by a Canada Research Chair (Tier 2). Dr. Zarychanski is the recipient of the Lyonel G. Israels Research Chair in Hematology (University of Manitoba)., Listed are data that were included in the analysis involving patients with moderate severity of coronavirus disease 2019 (Covid-19). The denominators of patients in the anticoagulation group and the thrombophylaxis group are un-equal owing to response-adaptive randomization. The baseline characteristics of the patients according to d-dimer level are provided in Table S2 in the Supplementary Appendix. To convert the values for creatinine to micromoles per liter, multiply by 88.4. ULN denotes upper limit of the normal range. † Race or ethnic group was reported by the patients. ‡ The body-mass index is the weight in kilograms divided by the square of the height in meters. § Severe cardiovascular disease was defined as a baseline history of heart failure, myocardial infarction, coronary artery disease, peripheral arterial disease, or cerebrovascular disease (stroke or transient ischemic attack) in the ATTACC (Antithrombotic Therapy to Ameliorate Complications of Covid-19) and ACTIV-4a (A Multicenter, Adaptive, Ran-domized Controlled Platform Trial of the Safety and Efficacy of Antithrombotic Strategies in Hospitalized Adults with COVID-19) platforms and as a baseline history of New York Heart Association class IV symptoms in the REMAP-CAP platform (Randomized, Embedded, Multifactorial Adaptive Platform Trial for Community-Acquired Pneumonia). ¶ Chronic respiratory disease was defined as a baseline history of asthma, chronic obstructive pulmonary disease, bron-chiectasis, interstitial lung disease, primary lung cancer, pulmonary hypertension, active tuberculosis, or the receipt of home oxygen therapy. ‖ Not listed are 74 patients who were coenrolled in the REMAP-CAP Antiplatelet Domain (39 in the anticoagulation group and 35 in the thromboprophylaxis group). ** In REMAP-CAP, levels of oxygen support (including no support) below the level of high-flow nasal cannula were not reported. †† The relative proportion of patients who were randomly assigned in each platform was imbalanced owing to imple-mentation of response-adaptive randomization in ATTACC on December 15, 2020. ‡‡ A total of 215 patients who were enrolled in the ATTACC platform were funded by the ACTIV4a platform by the National Heart, Lung, and Blood Institute. §§ Other participating countries were Mexico, Nepal, Australia, the Netherlands, and Spain., ATTACC Investigators, ACTIV-4a Investigators, REMAP-CAP Investigators, Vascular Medicine, ACS - Pulmonary hypertension & thrombosis, Lawler, Patrick R [0000-0001-5155-5071], Neal, Matthew D [0000-0001-8931-6236], McVerry, Bryan J [0000-0002-1175-4874], Carrier, Marc [0000-0001-8296-2972], Escobedo, Jorge [0000-0003-1942-7402], Huang, David T [0000-0001-7649-1633], Bradbury, Charlotte A [0000-0001-5248-8165], Houston, Brett L [0000-0002-8776-4083], Kornblith, Lucy Z [0000-0002-1861-9691], Kim, Keri S [0000-0002-8480-4801], Gordon, Anthony C [0000-0002-0419-547X], Higgins, Alisa M [0000-0001-8295-7559], Aday, Aaron W [0000-0001-6243-3432], Aryal, Diptesh [0000-0002-1431-8293], Baumann Kreuziger, Lisa [0000-0002-1171-0548], Beane, Abi [0000-0001-7046-1580], Coiffard, Benjamin [0000-0002-8896-5346], Derde, Lennie PG [0000-0002-3577-5629], Detry, Michelle A [0000-0002-2794-1439], Estcourt, Lise J [0000-0003-4309-9162], Everett, Brendan M [0000-0002-6331-5224], Galen, Benjamin T [0000-0001-8172-258X], Girard, Timothy D [0000-0002-9833-4871], Godoy, Lucas C [0000-0001-6171-1269], Greenstein, Yonatan Y [0000-0002-5718-4408], Haniffa, Rashan [0000-0002-8288-449X], Hanna, George [0000-0001-8737-3843], Hegde, Sheila M [0000-0001-8157-8899], Hendrickson, Carolyn M [0000-0003-4662-2385], Hite, R Duncan [0000-0002-2625-8750], Hindenburg, Alexander A [0000-0002-1232-2168], Horvat, Christopher M [0000-0002-1593-2252], Jacobson, Jeffrey R [0000-0001-8929-994X], Kim, Yuri [0000-0001-5978-5779], King, Andrew J [0000-0002-9809-0563], Kutcher, Matthew E [0000-0003-4566-5359], Lima, Felipe Gallego [0000-0003-1204-5743], Lopez-Sendon Moreno, Jose L [0000-0001-9414-3990], Marcos, Miguel [0000-0003-1269-4487], McGlothlin, Anna [0000-0002-9079-6166], Mouncey, Paul R [0000-0002-8510-8517], Nunez-Garcia, Brenda [0000-0002-0355-4557], Parnia, Sam [0000-0002-6158-4404], Quigley, John G [0000-0003-3116-4545], Saunders, Christina T [0000-0003-4325-9568], Shankar-Hari, Manu [0000-0002-5338-2538], Sheehan, John P [0000-0002-4328-2613], Tritschler, Tobias [0000-0002-8775-0511], Yuriditsky, Eugene [0000-0003-2263-9297], Zampieri, Fernando G [0000-0001-9315-6386], Angus, Derek C [0000-0002-7026-5181], Apollo - University of Cambridge Repository, NIHR, and National Institute for Health Research
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Male ,covid-19, anticoagulation ,[SDV]Life Sciences [q-bio] ,lnfectious Diseases and Global Health Radboud Institute for Molecular Life Sciences [Radboudumc 4] ,030204 cardiovascular system & hematology ,heparin ,law.invention ,0302 clinical medicine ,Randomized controlled trial ,law ,Hemorrhage/chemically induced ,030212 general & internal medicine ,Hospital Mortality ,Heparin/administration & dosage ,anticoagulation ,11 Medical and Health Sciences ,Anticoagulants/administration & dosage ,Thrombosis/prevention & control ,low molecular weight heparin ,General Medicine ,Heparin ,Middle Aged ,Thrombosis ,Patient Discharge ,3. Good health ,Coagulation ,Original Article ,Female ,ATTACC Investigators ,medicine.symptom ,Covid-19 ,Life Sciences & Biomedicine ,medicine.drug ,Adult ,medicine.medical_specialty ,medicine.drug_class ,adaptive platform trial ,Low molecular weight heparin ,Inflammation ,Hemorrhage ,COVID-19/drug therapy ,03 medical and health sciences ,Medicine, General & Internal ,General & Internal Medicine ,medicine ,Humans ,Intensive care medicine ,Survival analysis ,Aged ,Science & Technology ,business.industry ,SARS-CoV-2 ,Anticoagulants ,COVID-19 ,Odds ratio ,Heparin, Low-Molecular-Weight ,medicine.disease ,Survival Analysis ,COVID-19 Drug Treatment ,lnfectious Diseases and Global Health Radboud Institute for Health Sciences [Radboudumc 4] ,Heparin, Low-Molecular-Weight/therapeutic use ,ACTIV-4a Investigators ,Human medicine ,REMAP-CAP Investigators ,business - Abstract
BACKGROUNDThrombosis and inflammation may contribute to the risk of death and complications among patients with coronavirus disease 2019 (Covid-19). We hypothesized that therapeutic-dose anticoagulation may improve outcomes in noncritically ill patients who are hospitalized with Covid-19.METHODSIn this open-label, adaptive, multiplatform, controlled trial, we randomly assigned patients who were hospitalized with Covid-19 and who were not critically ill (which was defined as an absence of critical care–level organ support at enrollment) to receive pragmatically defined regimens of either therapeutic-dose anticoagulation with heparin or usual-care pharmacologic thromboprophylaxis. The primary outcome was organ support–free days, evaluated on an ordinal scale that combined in-hospital death (assigned a value of −1) and the number of days free of cardiovascular or respiratory organ support up to day 21 among patients who survived to hospital discharge. This outcome was evaluated with the use of a Bayesian statistical model for all patients and according to the baseline d-dimer level.RESULTSThe trial was stopped when prespecified criteria for the superiority of therapeutic-dose anticoagulation were met. Among 2219 patients in the final analysis, the probability that therapeutic-dose anticoagulation increased organ support–free days as compared with usual-care thromboprophylaxis was 98.6% (adjusted odds ratio, 1.27; 95% credible interval, 1.03 to 1.58). The adjusted absolute between-group difference in survival until hospital discharge without organ support favoring therapeutic-dose anticoagulation was 4.0 percentage points (95% credible interval, 0.5 to 7.2). The final probability of the superiority of therapeutic-dose anticoagulation over usual-care thromboprophylaxis was 97.3% in the high d-dimer cohort, 92.9% in the low d-dimer cohort, and 97.3% in the unknown d-dimer cohort. Major bleeding occurred in 1.9% of the patients receiving therapeutic-dose anticoagulation and in 0.9% of those receiving thromboprophylaxis.CONCLUSIONSIn noncritically ill patients with Covid-19, an initial strategy of therapeutic-dose anticoagulation with heparin increased the probability of survival to hospital discharge with reduced use of cardiovascular or respiratory organ support as compared with usual-care thromboprophylaxis. (ATTACC, ACTIV-4a, and REMAP-CAP ClinicalTrials.gov numbers, NCT04372589. opens in new tab, NCT04505774. opens in new tab, NCT02735707. opens in new tab, and NCT04359277. opens in new tab.)
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- 2021
27. Predictive Value of Coronary Artery Calcium Score Categories for Coronary Events Versus Strokes: Impact of Sex and Race: MESA and DHS
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Mehta, Anurag, Pandey, Ambarish, Ayers, Colby R, Khera, Amit, Sperling, Laurence S, Szklo, Moyses S, Gottesman, Rebecca F, Budoff, Mathew J, Blaha, Michael J, Blumenthal, Roger S, Nasir, Khurram, and Joshi, Parag H
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Adult ,Male ,Aging ,Time Factors ,Clinical Sciences ,Coronary Disease ,Comorbidity ,Cardiovascular ,Severity of Illness Index ,Risk Assessment ,Sex Factors ,Predictive Value of Tests ,Clinical Research ,cardiovascular disease ,80 and over ,Humans ,cardiovascular diseases ,Vascular Calcification ,Heart Disease - Coronary Heart Disease ,Aged ,risk ,calcium ,Incidence ,Prevention ,nutritional and metabolic diseases ,Middle Aged ,stroke ,United States ,Race Factors ,Brain Disorders ,Heart Disease ,Cardiovascular System & Hematology ,Heart Disease Risk Factors ,cardiovascular system ,population characteristics ,Female ,Patient Safety ,atherosclerosis ,coronary artery disease - Abstract
BackgroundCoronary artery calcium (CAC) predicts atherosclerotic cardiovascular disease (ASCVD) events, inclusive of coronary heart disease (CHD) and stroke, and is a decision-making aid for primary prevention. The predictive value of CAC categories for CHD and stroke separately and across sex and race groups of an asymptomatic population is unclear.MethodsWhite, Black, and Hispanic participants of MESA (Multi-Ethnic Study of Atherosclerosis) and DHS (Dallas Heart Study) underwent CAC measurement at enrollment and were followed for incident ASCVD events. Ten-year CHD-to-stroke incidence ratios across CAC score categories 0, 1 to 99, and ≥100 were assessed. Associations of CAC with incident CHD and stroke events were evaluated using multivariable-adjusted Cox models and multiplicative interactions of CAC with sex/race were tested.ResultsAmong 7042 participants (mean age, 57 years, 54% women, 36% Black, 23% Hispanic, 49% CAC=0, 19% CAC ≥100), 574 incident ASCVD events (333 CHD and 241 stroke) were observed over 12.3-year follow-up. Ten-year CHD-to-stroke incidence ratio increased significantly across CAC categories in men, women, Whites, Blacks, and Hispanics (all P
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- 2020
28. Frailty Is Intertwined With Heart Failure: Mechanisms, Prevalence, Prognosis, Assessment, and Management
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Pandey, Ambarish, Kitzman, Dalane, and Reeves, Gordon
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Heart Failure ,Frailty ,Prevalence ,Humans ,Prognosis ,Article ,Aged - Abstract
Frailty, a syndrome characterized by an exaggerated decline in function and reserve of multiple physiological systems, is common in older patients with heart failure (HF) and is associated with worse clinical and patient-reported outcomes. Although several detailed assessment tools have been developed and validated in the geriatric population, they are cumbersome, not validated in patients with HF, and not commonly used in routine management of patients with HF. More recently, there has been an increasing interest in developing simple frailty screening tools that could efficiently and quickly identify frail patients with HF in routine clinical settings. As the burden and recognition of frailty in older patients with HF increase, a more comprehensive approach to management is needed that targets deficits across multiple domains, including physical function and medical, cognitive, and social domains. Such a multidomain approach is critical to address the unique, multidimensional challenges to the care of these high-risk patients and to improve their functional status, quality of life, and long-term clinical outcomes. This review discusses the burden of frailty, the conceptual underpinnings of frailty in older patients with HF, and potential strategies for the assessment, screening, and management of frailty in this vulnerable patient population.
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- 2019
29. Association of cardiorespiratory fitness with left ventricular remodeling and diastolic function: the Cooper Center Longitudinal Study
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Brinker, Stephanie K, Pandey, Ambarish, Ayers, Colby R, Barlow, Carolyn E, DeFina, Laura F, Willis, Benjamin L, Radford, Nina B, Farzaneh-Far, Ramin, de Lemos, James A, Drazner, Mark H, and Berry, Jarett D
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Male ,Heart Failure, Diastolic ,Ventricular Remodeling ,Cardiac Volume ,Myocardium ,Stroke Volume ,Organ Size ,Middle Aged ,Article ,Ventricular Dysfunction, Left ,Cross-Sectional Studies ,Echocardiography ,Physical Fitness ,Exercise Test ,Humans ,Female ,Heart Atria ,Longitudinal Studies - Abstract
This study sought to compare the cross-sectional associations between fitness and echocardiographic measures of cardiac structure and function.Cardiorespiratory fitness is inversely associated with heart failure risk. However, the mechanism through which fitness lowers heart failure risk is not fully understood.We included 1,678 men and 1,247 women from the Cooper Center Longitudinal Study who received an echocardiogram from 1999 to 2011. Fitness was estimated by Balke protocol (in metabolic equivalents) and also categorized into age-specific quartiles, with quartile 1 representing low fitness. Cross-sectional associations between fitness (in metabolic equivalents) and relative wall thickness, left ventricular end-diastolic diameter indexed to body surface area, left atrial volume indexed to body surface area, left ventricular systolic function, and E/e' ratio were determined using multivariable linear regression analysis.Higher levels of mid-life fitness (metabolic equivalents) were associated with larger indexed left atrial volume (men: beta = 0.769, p0.0001; women: beta = 0.879, p value ≤0.0001) and indexed left ventricular end-diastolic diameter (men: beta = 0.231, p0.001; women: beta = 0.264, p0.0001). Similarly, a higher level of fitness was associated with a smaller relative wall thickness (men: beta = -0.002, p = 0.04; women: beta = -0.005, p0.0001) and E/e' ratio (men: beta = -0.11, p = 0.003; women: beta = -0.13, p = 0.01). However, there was no association between low fitness and left ventricular systolic function (p = NS).Low fitness is associated with a higher prevalence of concentric remodeling and diastolic dysfunction, suggesting that exercise may lower heart failure risk through its effect on favorable cardiac remodeling and improved diastolic function.
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- 2013
30. Therapeutic Anticoagulation with Heparin in Noncritically Ill Patients with Covid-19
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ATTACC Investigators, ACTIV-4a Investigators, REMAP-CAP Investigators, Lawler, Patrick R, Goligher, Ewan C, Berger, Jeffrey S, Neal, Matthew D, McVerry, Bryan J, Nicolau, Jose C, Gong, Michelle N, Carrier, Marc, Rosenson, Robert S, Reynolds, Harmony R, Turgeon, Alexis F, Escobedo, Jorge, Huang, David T, Bradbury, Charlotte A, Houston, Brett L, Kornblith, Lucy Z, Kumar, Anand, Kahn, Susan R, Cushman, Mary, McQuilten, Zoe, Slutsky, Arthur S, Kim, Keri S, Gordon, Anthony C, Kirwan, Bridget-Anne, Brooks, Maria M, Higgins, Alisa M, Lewis, Roger J, Lorenzi, Elizabeth, Berry, Scott M, Berry, Lindsay R, Aday, Aaron W, Al-Beidh, Farah, Annane, Djillali, Arabi, Yaseen M, Aryal, Diptesh, Baumann Kreuziger, Lisa, Beane, Abi, Bhimani, Zahra, Bihari, Shailesh, Billett, Henny H, Bond, Lindsay, Bonten, Marc, Brunkhorst, Frank, Buxton, Meredith, Buzgau, Adrian, Castellucci, Lana A, Chekuri, Sweta, Chen, Jen-Ting, Cheng, Allen C, Chkhikvadze, Tamta, Coiffard, Benjamin, Costantini, Todd W, De Brouwer, Sophie, Derde, Lennie PG, Detry, Michelle A, Duggal, Abhijit, Džavík, Vladimír, Effron, Mark B, Estcourt, Lise J, Everett, Brendan M, Fergusson, Dean A, Fitzgerald, Mark, Fowler, Robert A, Galanaud, Jean P, Galen, Benjamin T, Gandotra, Sheetal, García-Madrona, Sebastian, Girard, Timothy D, Godoy, Lucas C, Goodman, Andrew L, Goossens, Herman, Green, Cameron, Greenstein, Yonatan Y, Gross, Peter L, Hamburg, Naomi M, Haniffa, Rashan, Hanna, George, Hanna, Nicholas, Hegde, Sheila M, Hendrickson, Carolyn M, Hite, R Duncan, Hindenburg, Alexander A, Hope, Aluko A, Horowitz, James M, Horvat, Christopher M, Hudock, Kristin, Hunt, Beverley J, Husain, Mansoor, Hyzy, Robert C, Iyer, Vivek N, Jacobson, Jeffrey R, Jayakumar, Devachandran, Keller, Norma M, Khan, Akram, Kim, Yuri, Kindzelski, Andrei L, King, Andrew J, Knudson, M Margaret, Kornblith, Aaron E, Krishnan, Vidya, Kutcher, Matthew E, Laffan, Michael A, Lamontagne, Francois, Le Gal, Grégoire, Leeper, Christine M, Leifer, Eric S, Lim, George, Lima, Felipe Gallego, Linstrum, Kelsey, Litton, Edward, Lopez-Sendon, Jose, Lopez-Sendon Moreno, Jose L, Lother, Sylvain A, Malhotra, Saurabh, Marcos, Miguel, Saud Marinez, Andréa, Marshall, John C, Marten, Nicole, Matthay, Michael A, McAuley, Daniel F, McDonald, Emily G, McGlothlin, Anna, McGuinness, Shay P, Middeldorp, Saskia, Montgomery, Stephanie K, Moore, Steven C, Morillo Guerrero, Raquel, Mouncey, Paul R, Murthy, Srinivas, Nair, Girish B, Nair, Rahul, Nichol, Alistair D, Nunez-Garcia, Brenda, Pandey, Ambarish, Park, Pauline K, Parke, Rachael L, Parker, Jane C, Parnia, Sam, Paul, Jonathan D, Pérez González, Yessica S, Pompilio, Mauricio, Prekker, Matthew E, Quigley, John G, Rost, Natalia S, Rowan, Kathryn, Santos, Fernanda O, Santos, Marlene, Olombrada Santos, Mayler, Satterwhite, Lewis, Saunders, Christina T, Schutgens, Roger EG, Seymour, Christopher W, Siegal, Deborah M, Silva, Delcio G, Shankar-Hari, Manu, Sheehan, John P, Singhal, Aneesh B, Solvason, Dayna, Stanworth, Simon J, Tritschler, Tobias, Turner, Anne M, Van Bentum-Puijk, Wilma, Van De Veerdonk, Frank L, Van Diepen, Sean, Vazquez-Grande, Gloria, Wahid, Lana, Wareham, Vanessa, Wells, Bryan J, Widmer, R Jay, Wilson, Jennifer G, Yuriditsky, Eugene, Zampieri, Fernando G, Angus, Derek C, McArthur, Colin J, Webb, Steven A, Farkouh, Michael E, Hochman, Judith S, and Zarychanski, Ryan
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Adult ,Male ,Heparin ,Anticoagulants ,COVID-19 ,Hemorrhage ,Thrombosis ,Heparin, Low-Molecular-Weight ,Middle Aged ,Survival Analysis ,3. Good health ,COVID-19 Drug Treatment ,Humans ,Female ,Hospital Mortality ,Aged - Abstract
BACKGROUND: Thrombosis and inflammation may contribute to the risk of death and complications among patients with coronavirus disease 2019 (Covid-19). We hypothesized that therapeutic-dose anticoagulation may improve outcomes in noncritically ill patients who are hospitalized with Covid-19. METHODS: In this open-label, adaptive, multiplatform, controlled trial, we randomly assigned patients who were hospitalized with Covid-19 and who were not critically ill (which was defined as an absence of critical care-level organ support at enrollment) to receive pragmatically defined regimens of either therapeutic-dose anticoagulation with heparin or usual-care pharmacologic thromboprophylaxis. The primary outcome was organ support-free days, evaluated on an ordinal scale that combined in-hospital death (assigned a value of -1) and the number of days free of cardiovascular or respiratory organ support up to day 21 among patients who survived to hospital discharge. This outcome was evaluated with the use of a Bayesian statistical model for all patients and according to the baseline d-dimer level. RESULTS: The trial was stopped when prespecified criteria for the superiority of therapeutic-dose anticoagulation were met. Among 2219 patients in the final analysis, the probability that therapeutic-dose anticoagulation increased organ support-free days as compared with usual-care thromboprophylaxis was 98.6% (adjusted odds ratio, 1.27; 95% credible interval, 1.03 to 1.58). The adjusted absolute between-group difference in survival until hospital discharge without organ support favoring therapeutic-dose anticoagulation was 4.0 percentage points (95% credible interval, 0.5 to 7.2). The final probability of the superiority of therapeutic-dose anticoagulation over usual-care thromboprophylaxis was 97.3% in the high d-dimer cohort, 92.9% in the low d-dimer cohort, and 97.3% in the unknown d-dimer cohort. Major bleeding occurred in 1.9% of the patients receiving therapeutic-dose anticoagulation and in 0.9% of those receiving thromboprophylaxis. CONCLUSIONS: In noncritically ill patients with Covid-19, an initial strategy of therapeutic-dose anticoagulation with heparin increased the probability of survival to hospital discharge with reduced use of cardiovascular or respiratory organ support as compared with usual-care thromboprophylaxis. (ATTACC, ACTIV-4a, and REMAP-CAP ClinicalTrials.gov numbers, NCT04372589, NCT04505774, NCT04359277, and NCT02735707.).
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