128 results on '"Sung, Sue Hee"'
Search Results
102. Hospital-Level Variation in Use of Cardiovascular Testing for Adults With Incident Heart Failure Findings From the Cardiovascular Research Network Heart Failure Study
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Farmer, Steven A., Lenzo, Justin, Magid, David J., Gurwitz, Jerry H., Smith, David H., Hsu, Grace, Sung, Sue Hee, and Go, Alan S.
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cardiovascular testing ,heart failure ,geographic variations - Abstract
ObjectivesThis study aimed to characterize the use of cardiovascular testing for patients with incident heart failure (HF) hospitalization who participated in the National Heart, Lung, and Blood Institute sponsored Cardiovascular Research Network (CVRN) Heart Failure study.BackgroundHF is a common cause of hospitalization, and testing and treatment patterns may differ substantially between providers. Testing choices have important implications for the cost and quality of care.MethodsCrude and adjusted cardiovascular testing rates were calculated for each participating hospital. Cox proportional hazards regression models were used to examine hospital testing rates after adjustment for hospital-level patient case mix.ResultsOf the 37,099 patients in the CVRN Heart Failure study, 5,878 patients were hospitalized with incident HF between 2005 and 2008. Of these, evidence of cardiovascular testing was available for 4,650 (79.1%) patients between 14 days before the incident HF admission and ending 6 months after the incident discharge. We compared crude and adjusted cardiovascular testing rates at the hospital level because the majority of testing occurred during the incident HF hospitalization. Of patients who underwent testing, 4,085 (87.9%) had an echocardiogram, 4,345 (93.4%) had a systolic function assessment, and 1,714 (36.9%) had a coronary artery disease assessment. Crude and adjusted testing rates varied markedly across the profiled hospitals, for individual testing modalities (e.g., echocardiography, stress echocardiography, nuclear stress testing, and left heart catheterization) and for specific clinical indications (e.g., systolic function assessment and coronary artery disease assessment).ConclusionsFor patients with newly diagnosed HF, we did not observe widespread overuse of cardiovascular testing in the 6 months following incident HF hospitalization relative to existing HF guidelines. Variations in testing were greatest for assessment of ischemia, in which testing guidelines are less certain.
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103. Abstract 10401: Human Immunodeficiency Virus Infection and Risks of Death and Heart Failure Hospitalization in Adults With Incident Heart Failure
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Avula, Harshith R, Ambrosy, Andrew P, Silverberg, Michael J, Reynolds, Kristi, Towner, William J, Hechter, Rulin C, Horberg, Michael, Vupputuri, Suma, Leong, Thomas K, Leyden, Wendy A, Harrison, Teresa N, Lee, Keane K, Sung, Sue Hee, and Go, Alan S
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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.
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- 2019
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104. Abstract 12926: Using Natural Language Processing to Accurately Identify Aortic Stenosis in a Large, Integrated Healthcare Delivery System
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Solomon, Matthew D, Tabada, Grace, Allen, Amanda, Sung, Sue Hee, and Go, Alan S
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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.
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- 2019
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105. Abstract 13609: Functional Iron Deficiency is Independently Associated With Increased Risk of Morbidity and Mortality in Older Adults With Heart Failure and Incident Anemia
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Ambrosy, Andrew P, Tabada, Grace, Gurwitz, Jerry, Artz, Andrew, Schrier, Stanley, Rao, Sunil V, Reynolds, Kristi, Smith, David H, Peterson, Pamela N, Sung, Sue Hee, Cohen, Harvey, and Go, Alan S
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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.
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- 2019
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106. Abstract 11432: The Influence of Race/Ethnicity on Burden of Atrial Fibrillation: The KP RHYTHM Study
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Yang, Jingrong, Reynolds, Kristi, Gupta, Nigel, Lenane, Judith C, Garcia, Elisha, Sung, Sue Hee, Harrison, Teresa N, Solomon, Matthew, and Go, Alan S
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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.
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- 2019
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107. Abstract 11497: Prevalence and Factors Associated With Falls and Initiation of Fall Prevention Programs in Adults With Atrial Fibrillation: The ATRIA2-CVRN Study
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An, Jaejin, Singer, Daniel E, Go, Alan S, Fang, Margaret C, Shah, Sachin J, Sung, Sue Hee, Harrison, Teresa N, Lo, Joan C, and Reynolds, Kristi
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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.
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- 2019
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108. Abstract 16034: Can Natural Language Processing Improve the Accuracy of Identifying Acute Heart Failure in Electronic Health Records?
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Parikh, Rishi V, Tan, Thida C, Sung, Sue Hee, Leong, Thomas K, Lee, Keane K, Avula, Harshith, and Go, Alan S
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- 2018
109. Abstract 12623: A New ASCVD Risk Estimator is More Accurate Than the ACC/AHA Pooled Cohort Equation in Four Diverse Community-Based Populations in the U.S. and Canada.
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Go, Alan S, Tabada, Grace, Reynolds, Kristi, Fortmann, Stephen P, Garg, Amit, Scott, Ronald D, Young, Joseph, Lo, Joan C, Solomon, Matthew D, Wei, Rong, Allison, Michael J, McArthur, Eric, Nash, Danielle M, Sung, Sue Hee, and Rana, Jamal S
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- 2018
110. Administrative codes inaccurately identify recurrent venous thromboembolism: The CVRN VTE study
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Baumgartner, Christine, Go, Alan S, Fan, Dongjie, Sung, Sue Hee, Witt, Daniel M, Schmelzer, John R, Williams, Marc S, Yale, Steven H, VanWormer, Jeffrey J, and Fang, Margaret C
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cardiovascular diseases ,equipment and supplies ,610 Medicine & health ,3. Good health - Abstract
BACKGROUND Studies using administrative data commonly rely on diagnosis codes to identify venous thromboembolism (VTE) events. Our objective was to assess the validity of using International Classification of Disease, 9th Revision (ICD-9) codes in identifying recurrent VTE. MATERIALS AND METHODS Among 5497 adults with confirmed incident VTE from four healthcare delivery systems in the Cardiovascular Research Network (CVRN), we identified all subsequent inpatient, emergency department (ED), and ambulatory clinical encounters associated with an ICD-9 code for VTE (combined with relevant radiology procedure codes for inpatient/ED VTE codes in the secondary discharge position or outpatient codes) during the follow-up period. Medical records were reviewed using standardized diagnostic criteria to assess for the presence of new, recurrent VTE. The positive predictive value (PPV) of codes was calculated as the number of valid events divided by total encounters. RESULTS We identified 2397 encounters that were considered potential recurrent VTE by ICD-9 codes. However, only 31.1% (95%CI: 29.3-33.0%) of encounters were verified by reviewers as true recurrent VTE. Hospital or ED encounters with VTE codes in the primary position were more likely to represent valid recurrent VTE (PPV 61.3%, 95%CI: 56.7-66.3%) than codes in secondary positions (PPV 35.4%, 95%CI: 31.9-39.3%), or outpatient codes (PPV 20.3%, 95%CI: 18.3-22.5%). PPV was low for all VTE types (29.9% for pulmonary embolism, 38.3% for lower and 37.7% for upper extremity deep venous thrombosis, and 14.1% for other VTE). CONCLUSIONS ICD-9 codes do not accurately identify new VTE events in patients with a prior history of VTE.
111. Abstract 301
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Smith, David H, Thorp, Micah L, Gurwitz, Jerry H, McManus, David D, Goldberg, Robert J, Allen, Larry A, Hsu, Grace, Sung, Sue Hee, Magid, David J, and Go, Alan S
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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.
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- 2013
112. Abstract 133
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Go, Alan S, Leong, Thomas K, Yang, Jingrong, Sung, Sue Hee, and Hlatky, Mark A
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- 2012
113. Health-related quality of life associated with warfarin and direct oral anticoagulants in venous thromboembolism.
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Fang, Margaret C., Go, Alan S., Prasad, Priya A., Zhou, Hui X., Parks, Anna L., Fan, Dongjie, Portugal, Cecilia, Sung, Sue Hee, and Reynolds, Kristi
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THROMBOEMBOLISM , *QUALITY of life , *ORAL medication , *WARFARIN , *INTEGRATED health care delivery - Abstract
Venous thromboembolism (VTE) is commonly treated with oral anticoagulants, including warfarin or direct oral anticoagulants (DOACs). Although DOACs are associated with favorable treatment satisfaction, few studies have assessed whether quality of life differs between DOAC and warfarin users. We invited adults enrolled in two California-based integrated health care delivery systems and with a history of VTE between January 1, 2015 and June 30, 2018 to complete a survey on their experience with anticoagulants. Health-related quality of life (QOL) was assessed using the RAND 36-item Short Form Health Survey (SF-36), which measures QOL in 2 general component scores (physical and mental). We used multivariable linear regression to compare mean QOL component scores between DOAC-users and warfarin-users, adjusting for patient and clinical characteristics. Overall, 2230 patients (43.1 % women and 31.8 % >75 years of age) taking anticoagulants answered at least 1 question on the SF-36, 975 taking DOACs and 1255 taking warfarin. After adjustment for patient-level factors, there were no significant differences in either physical component scores (39.2 v 38.3, p = 0.24) or mental component scores (48.5 v 49.0, p = 0.42) between DOAC and warfarin users. Health-related QOL did not significantly differ between DOAC and warfarin users with a history of VTE. • Health-related quality of life (QOL) is a key outcome measure in venous thromboembolism (VTE). • Little is known about differences in QOL for patients prescribed warfarin versus direct oral anticoagulants (DOACs). • We assessed QOL using RAND 36-item Short Form Health Survey (SF-36) in patients with VTE in Kaiser integrated healthcare system. • Among 2230 patients, there were no significant differences in physical or mental QOL scores between warfarin and DOAC users. [ABSTRACT FROM AUTHOR]
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- 2022
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114. Initial antiretroviral therapy regimen and risk of heart failure.
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Silverberg MJ, Pimentel N, Leyden WA, Leong TK, Reynolds K, Ambrosy AP, Towner WJ, Hechter RC, Horberg M, Vupputuri S, Harrison TN, Lea AN, Sung SH, Go AS, and Neugebauer R
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- Male, Humans, Female, Reverse Transcriptase Inhibitors adverse effects, Cohort Studies, Dideoxynucleosides adverse effects, Tenofovir adverse effects, HIV Infections complications, HIV Infections drug therapy, Anti-HIV Agents adverse effects, HIV Protease Inhibitors adverse effects, Heart Failure chemically induced, Heart Failure epidemiology, Heart Failure drug therapy, Cyclopropanes, Dideoxyadenosine analogs & derivatives
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Objectives: Heart failure risk is elevated in people with HIV (PWH). We investigated whether initial antiretroviral therapy (ART) regimens influenced heart failure risk., Design: Cohort study., Methods: PWH who initiated an ART regimen between 2000 and 2016 were identified from three integrated healthcare systems. We evaluated heart failure risk by protease inhibitor, nonnucleoside reverse transcriptase inhibitors (NNRTI), and integrase strand transfer inhibitor (INSTI)-based ART, and comparing two common nucleotide reverse transcriptase inhibitors: tenofovir disoproxil fumarate (tenofovir) and abacavir. Follow-up for each pairwise comparison varied (i.e. 7 years for protease inhibitor vs. NNRTI; 5 years for tenofovir vs. abacavir; 2 years for INSTIs vs. PIs or NNRTIs). Hazard ratios were from working logistic marginal structural models, fitted with inverse probability weighting to adjust for demographics, and traditional cardiovascular risk factors., Results: Thirteen thousand six hundred and thirty-four PWH were included (88% men, median 40 years of age; 34% non-Hispanic white, 24% non-Hispanic black, and 24% Hispanic). The hazard ratio (95% CI) were: 2.5 (1.5-4.3) for protease inhibitor vs. NNRTI-based ART (reference); 0.5 (0.2-1.8) for protease inhibitor vs. INSTI-based ART (reference); 0.1 (0.1-0.8) for NNRTI vs. INSTI-based ART (reference); and 1.7 (0.5-5.7) for tenofovir vs. abacavir (reference). In more complex models of cumulative incidence that accounted for possible nonproportional hazards over time, the only remaining finding was evidence of a higher risk of heart failure for protease inhibitor compared with NNRTI-based regimens (1.8 vs. 0.8%; P = 0.002)., Conclusion: PWH initiating protease inhibitors may be at higher risk of heart failure compared with those initiating NNRTIs. Future studies with longer follow-up with INSTI-based and other specific ART are warranted., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)
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- 2024
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115. Physician assessment of aortic stenosis severity, quantitative parameters, and long-term outcomes: Results from the KP-VALVE project.
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Solomon MD, Tabada G, Sung SH, Allen A, Mishell JM, Rassi AN, McNulty E, Philip F, Lange DC, Ambrosy AP, Zaroff JG, Krishnaswami A, Lee C, DeMaria A, Nishimura R, and Go AS
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- Humans, Aged, Aortic Valve diagnostic imaging, Aortic Valve surgery, Echocardiography, Catheters, Severity of Illness Index, Aortic Valve Stenosis diagnostic imaging, Aortic Valve Stenosis surgery
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Background: Contemporary outcomes for aortic stenosis (AS) and the association between physician-assessed AS severity and quantitative parameters is poorly understood. We aimed to evaluate AS natural history, compare outcomes for physicians' AS assessment vs. quantitative parameters, and identify AS parameters with the most explanatory power., Methods: We ascertained physician-assessed AS severity, echocardiographic parameters, and clinical data for 546,769 patients from 2008-2018, examined multivariable associations of physician-assessed AS severity and number of quantitative severe AS parameters with death, cardiovascular hospitalization, and aortic valve replacement, and estimated the relative contribution of different quantitative AS parameters on outcomes., Results: Among 49,604 AS patients (mean [SD] age 77 [11] years), 17.6% had moderate, 3.6% moderate-severe, and 9.4% severe AS. During median 3.7 [IQR 1.7-6.8] years, physician-assessed AS severity strongly correlated with outcomes, with moderate AS patients tracking closest to mild AS, and moderate-to-severe AS patients more comparable to severe AS. Although the number of quantitative severe AS parameters strongly predicted outcomes (adjusted HR [95% CI] for death 1.40 [1.34-1.46], 1.70 [1.56-1.85], and 1.78 [1.63-1.94] for 1, 2, and 3 parameters, respectively), aortic valve area <1.0 cm
2 was the most frequent severe AS parameter, explained the largest relative contribution (67%), and was common in patients classified as moderate (21%) or moderate-severe (56%) AS., Conclusions: Physician-assessed AS severity predicts outcomes, with cumulative effects for each severe AS parameter. Moderate AS includes a wide spectrum of patients, with discordant AVA <1.0 cm2 being both common and predictive. Better identification of non-classical severe AS phenotypes may improve outcomes., Competing Interests: Disclosures Dr Solomon reports relevant research support from Edwards Lifesciences (Irvine, CA). Dr Ambrosy reports relevant research support from Abbott Vascular (Santa Clara, CA) and Edwards Lifesciences (Irvine, CA). Dr Go reports research support from Abbott Vascular (Santa Clara, CA) and Edwards Lifesciences (Irvine, CA). All remaining authors have nothing to disclose. The authors are solely responsible for the design and conduct of this study, all study analyses, the drafting and editing of the paper and its final contents., (Copyright © 2023 Elsevier Inc. All rights reserved.)- Published
- 2023
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116. Outcomes of Adults with Severe Aortic Stenosis Undergoing Urgent or Emergent vs. Elective Transcatheter Aortic Valve Replacement Within an Integrated Health Care Delivery System.
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Slade JJ, Ambrosy AP, Leong TK, Sung SH, Garcia EA, Ku IA, Solomon MD, McNulty EJ, Rassi AN, Lange DC, Philip F, Go AS, and Mishell JM
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Background: 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., Methods: We identified all adults who received TAVR for primary aortic stenosis between 2013 and 2019 within an integrated health care delivery system in Northern California. Elective or urgent/emergent procedure status was based on standard Society of Thoracic Surgeons definitions. Data were obtained from electronic health records, the Society of Thoracic Surgeons-American College of Cardiology Transcatheter Valve Therapy Registry, and state/national reporting databases. Logistic regression and Cox proportional hazard models were performed., Results: Among 1564 eligible adults that underwent TAVR, 81 (5.2%) were classified as urgent/emergent. These patients were more likely to have heart failure (63.0% vs. 47.4%), reduced left ventricular ejection fraction (21.0% vs. 11.8%), or a prior aortic valve balloon valvuloplasty (13.6% vs. 5.0%) and experienced higher unadjusted rates of 30-day and 1-year morbidity and mortality. Urgent/emergent TAVR status was independently associated with non-improved quality of life at 30-days (hazard ratio, 4.87; p < 0.01) and acute kidney injury within 1-year post-TAVR (hazard ratio, 2.11; p = 0.01). There was not a significant difference in adjusted 1-year mortality with urgent/emergent TAVR., Conclusions: Urgent/emergent TAVR status was uncommon and associated with high-risk clinical features and higher unadjusted rates of short- and long-term morbidity and mortality. Procedure status may be useful to identify patients less likely to experience significant short term improvement in health-related quality of life post-TAVR., Competing Interests: Andrew P. Ambrosy is supported by a Mentored Patient-Oriented Research Career Development Award (K23HL150159) through the National Heart, Lung, and Blood Institute and has received research support through grants to his institution from Abbott, Amarin Pharma, Edwards Lifesciences, Esperion, Lexicon, and Novartis. Alan S. Go has received research support through grants to his institution from the National Heart, Lung and Blood Institute; National Institute of Diabetes, Digestive and Kidney Diseases; National Institute on Aging; Amarin Pharma, Inc.; Novartis; Janssen Research & Development; and CSL Behring. All other authors have no potential conflicts of interest to declare., (© 2023 The Authors.)
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- 2023
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117. Predicting short-term outcomes after transcatheter aortic valve replacement for aortic stenosis.
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Savitz ST, Leong T, Sung SH, Kitzman DW, McNulty E, Mishell J, Rassi A, Ambrosy AP, and Go AS
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- Humans, United States, Quality of Life, Treatment Outcome, Risk Factors, Registries, Aortic Valve surgery, Transcatheter Aortic Valve Replacement methods, Aortic Valve Stenosis surgery, Aortic Valve Stenosis epidemiology, Heart Failure etiology
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Background: The approved use of transcatheter aortic valve replacement (TAVR) for aortic stenosis has expanded substantially over time. However, gaps remain with respect to accurately delineating risk for poor clinical and patient-centered outcomes. Our objective was to develop prediction models for 30-day clinical and patient-centered outcomes after TAVR within a large, diverse community-based population., Methods: We identified all adults who underwent TAVR between 2013-2019 at Kaiser Permanente Northern California, an integrated healthcare delivery system, and were monitored for the following 30-day outcomes: all-cause death, improvement in quality of life, all-cause hospitalizations, all-cause emergency department (ED) visits, heart failure (HF)-related hospitalizations, and HF-related ED visits. We developed prediction models using gradient boosting machines using linked demographic, clinical and other data from the Society for Thoracic Surgeons (STS)/American College of Cardiology (ACC) TVT Registry and electronic health records. We evaluated model performance using area under the curve (AUC) for model discrimination and associated calibration plots. We also evaluated the association of individual predictors with outcomes using logistic regression for quality of life and Cox proportional hazards regression for all other outcomes., Results: We identified 1,565 eligible patients who received TAVR. The risks of adverse 30-day post-TAVR outcomes ranged from 1.3% (HF hospitalizations) to 15.3% (all-cause ED visits). In models with the highest discrimination, discrimination was only moderate for death (AUC 0.60) and quality of life (AUC 0.62), but better for HF-related ED visits (AUC 0.76). Calibration also varied for different outcomes. Importantly, STS risk score only independently predicted death and all-cause hospitalization but no other outcomes. Older age also only independently predicted HF-related ED visits, and race/ethnicity was not significantly associated with any outcomes., Conclusions: Despite using a combination of detailed STS/ACC TVT Registry and electronic health record data, predicting short-term clinical and patient-centered outcomes after TAVR remains challenging. More work is needed to identify more accurate predictors for post-TAVR outcomes to support personalized clinical decision making and monitoring strategies., Competing Interests: Disclosures Dr. Ambrosy is supported by a Mentored Patient-Oriented Research Career Development Award (K23HL150159) through the National Heart, Lung, and Blood Institute, has received relevant research support through grants to his institution from Amarin Pharma, Inc., Abbott, and Novartis, and modest reimbursement for travel from Novartis. Dr. Go has received research funding through his institution from the National Heart, Lung and Blood Institute; National Institute on Aging; National Institute of Diabetes, Digestive and Kidney Diseases; Novartis; Janssen Research & Development; and Bristol Meyers-Squibb., (Copyright © 2022 Elsevier Inc. All rights reserved.)
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- 2023
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118. Association of Kidney Function With Risk of Adverse Effects of Therapies for Atrial Fibrillation.
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Bansal N, Zelnick LR, An J, Harrison TN, Lee MS, Singer DE, Sung SH, Fan D, and Go AS
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Introduction: Atrial fibrillation (AF) is common in chronic kidney disease (CKD) and is treated with rate control medications, antiarrhythmic medications, as well as anticoagulation and procedures, each of which have associated risks. We aimed to evaluate the association of CKD status with the risks of adverse effects after initiation of AF therapies., Methods: This was a cohort study of community-based adults who newly initiated rate control medications, antiarrhythmic medications, warfarin, direct oral anticoagulants (DOACs) or received AF procedures in the 1 year after diagnosis of AF. Baseline estimated glomerular filtration rate (eGFR) was calculated using outpatient serum creatinine measures. Adverse effects within 1 year related to each AF therapy or within 1 month of an AF procedure were ascertained from vital sign databases, electrocardiograms (ECGs), and administrative codes. Fine-Gray hazard models were used to study the association of eGFR categories with risk of adverse effects for each AF therapy., Results: Among 115,564 patients with incident AF, lower eGFR (vs. eGFR ≥60 ml/min per 1.73 m
2 ) was significantly associated with higher adjusted risk of adverse effects after initiation of rate control therapies (most commonly hypotension and bradycardia) as follows: eGFR 45-59 (hazard ratio [HR] 1.14, 95% confidence interval [CI] 1.07-1.22), 30-44 (HR 1.15, 95% CI 1.06-1.25), and 15-29 (HR 1.29, 95% CI: 1.12-1.47) ml/min per 1.73 m2 . Lower eGFR was associated with higher adjusted risk of adverse effects (most commonly prolonged QRS and QTc intervals) after initiation of an antiarrhythmic medication (vs. eGFR >60 ml/min per 1.73 m2 ) as follows: eGFR 45-59 (HR 1.12, 95% CI 1.01-1.23) and eGFR<15 (HR 1.43, 95% CI 1.01-2.01) ml/min per 1.73 m2 ., Conclusion: There was a graded association between lower eGFR and risk of major bleeding with warfarin use, with the greatest risk among those with eGFR <15 ml/min per 1.73 m2 (HR of 2.93, 95% CI 1.99-4.30). There was no association of eGFR with major bleeding in patients receiving DOACs. Rates of adverse effects within 1 month of an AF procedure were low among patients with ( n = 18) and without ( n = 41) CKD and was underpowered for further analyses. In conclusion, lower eGFR was associated with significantly higher risks of adverse effects after initiation of commonly used therapies to treat AF. These data may help inform the complex therapeutic decisions in patients with CKD and AF., (© 2022 Published by Elsevier Inc. on behalf of the International Society of Nephrology.)- Published
- 2022
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119. Thromboembolism after treatment with 4-factor prothrombin complex concentrate or plasma for warfarin-related bleeding.
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Go AS, Leong TK, Sung SH, Wei R, Harrison TN, Gupta N, Baker N, Goldstein B, Ataher Q, Solomon MD, and Reynolds K
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- Aged, Aged, 80 and over, Anticoagulants adverse effects, Blood Coagulation Factors, Factor IX, Female, Hemorrhage chemically induced, Humans, International Normalized Ratio, Male, Retrospective Studies, Vitamin K, Venous Thromboembolism chemically induced, Venous Thromboembolism drug therapy, Warfarin adverse effects
- Abstract
Limited data exist in large, representative populations about whether the risk of thromboembolic events varies after receiving four-factor human prothrombin complex concentrate (4F-PCC) versus treatment with human plasma for urgent reversal of oral vitamin K antagonist therapy. We conducted a multicenter observational study to compare the 45-day risk of thromboembolic events in adults with warfarin-associated major bleeding after treatment with 4F-PCC (Kcentra®) or plasma. Hospitalized patients in two large integrated healthcare delivery systems who received 4F-PCC or plasma for reversal of warfarin due to major bleeding from January 1, 2008 to March 31, 2020 were identified and were matched 1:1 on potential confounders and a high-dimensional propensity score. Arterial and venous thromboembolic events were identified up to 45 days after receiving 4F-PCC or plasma from electronic health records and adjudicated by physician review. Among 1119 patients receiving 4F-PCC and a matched historical cohort of 1119 patients receiving plasma without a recent history of thromboembolism, mean (SD) age was 76.7 (10.5) years, 45.6% were women, and 9.4% Black, 14.6% Asian/Pacific Islander, and 15.7% Hispanic. The 45-day risk of thromboembolic events was 3.4% in those receiving 4F-PCC and 4.1% in those receiving plasma (P = 0.26; adjusted hazard ratio 0.76; 95% confidence interval 0.49-1.16). The adjusted risk of all-cause death at 45 days post-treatment was lower in those receiving 4F-PCC compared with plasma. Among a large, ethnically diverse cohort of adults treated for reversal of warfarin-associated bleeding, receipt of 4F-PCC was not associated with an excess risk of thromboembolic events at 45 days compared with plasma therapy., (© 2022. The Author(s).)
- Published
- 2022
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120. Analysis of Worsening Heart Failure Events in an Integrated Health Care System.
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Ambrosy AP, Parikh RV, Sung SH, Tan TC, Narayanan A, Masson R, Lam PQ, Kheder K, Iwahashi A, Hardwick AB, Fitzpatrick JK, Avula HR, Selby VN, Ku IA, Shen X, Sanghera N, Cristino J, and Go AS
- Subjects
- Adult, Aged, Aged, 80 and over, Diuretics, Emergency Service, Hospital, Female, Hospitalization, Humans, Male, Middle Aged, Stroke Volume, Ventricular Function, Left, Delivery of Health Care, Integrated, Heart Failure diagnosis, Heart Failure epidemiology, Heart Failure therapy
- Abstract
Background: There is growing interest to disentangle worsening heart failure (WHF) from location of care and move away from hospitalization as a surrogate for acuity., Objectives: The purpose of this study was to describe the incidence of WHF events across the care continuum from ambulatory encounters to hospitalizations., Methods: We studied calendar year cohorts of adults with diagnosed heart failure (HF) from 2010-2019 within a large, integrated health care delivery system. Electronic health record (EHR) data were accessed for outpatient encounters, emergency department (ED) visits/observation stays, and hospitalizations. WHF was defined as ≥1 symptom, ≥2 objective findings including ≥1 sign, and ≥1 change in HF-related therapy. Symptoms and signs were ascertained using natural language processing., Results: We identified 103,138 eligible individuals with mean age 73.6 ± 13.7 years, 47.5% women, and mean left ventricular ejection fraction of 51.4% ± 13.7%. There were 1,136,750 unique encounters including 743,039 (65.4%) outpatient encounters, 224,670 (19.8%) ED visits/observation stays, and 169,041 (14.9%) hospitalizations. A total of 126,008 WHF episodes were identified, including 34,758 (27.6%) outpatient encounters, 28,301 (22.5%) ED visits/observation stays, and 62,949 (50.0%) hospitalizations. The annual incidence (events per 100 person-years) of WHF increased from 25 to 33 during the study period primarily caused by outpatient encounters (7 to 10) and ED visits/observation stays (4 to 7). The 30-day rate of hospitalizations for WHF ranged from 8.2% for outpatient encounters to 12.4% for hospitalizations., Conclusions: ED visits/observation stays and outpatient encounters account for approximately one-half of WHF events, are driving the underlying growth in HF morbidity, and portend a poor short-term prognosis., Competing Interests: Funding Support and Author Disclosures The UTILIZE-WHF study received funding from Novartis AG and the Kaiser Permanente Northern California Community Benefit Program. The funder approved the study in advance but had no formal role in design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Dr Ambrosy is supported by a Mentored Patient-Oriented Research Career Development Award (K23HL150159) through the National Heart, Lung, and Blood Institute; has received relevant research support through grants to his institution from Amarin Pharma, Abbott, and Novartis; and has modest reimbursement for travel from Novartis. Drs Shen, Sanghera, and Cristino are employees of Novartis AG. Dr Go has received relevant research support through grants to his institution from the National Heart, Lung, and Blood Institute; National Institute of Diabetes, Digestive and Kidney Diseases; National Institute on Aging; Amarin Pharma Inc; Novartis; Janssen Research and Development; and CSL Behring. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)
- Published
- 2022
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121. Multimorbidity Burden and Incident Heart Failure Among People With and Without HIV: The HIV-HEART Study.
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Mefford MT, Silverberg MJ, Leong TK, Hechter RC, Towner WJ, Go AS, Horberg M, Hu H, Harrison TN, Sung SH, and Reynolds K
- Abstract
Objective: To examine the association between multimorbidity burden and incident heart failure (HF) among people with HIV (PWH) and people without HIV (PWoH)., Patients and Methods: The HIV-HEART study is a retrospective cohort study that included adult PWH and PWoH aged 21 years or older at Kaiser Permanente between 2000 and 2016. Multimorbidity burden was defined by the baseline prevalence of 22 chronic conditions and was categorized as 0-1, 2-3, and 4 or more comorbidities on the basis of distribution of the overall population. People with HIV and PWoH were followed for a first HF event, all-cause death, or up to the end of follow-up on December 31, 2016. Using Cox proportional hazard regression, hazard ratios and 95% CIs were calculated to examine the association between multimorbidity burden and incident HF among PWH and PWoH, separately., Results: The prevalences of 0-1, 2-3, and 4 or more comorbidities were 83.3%, 13.0%, and 3.7% in PWH (n=38,868), and 82.2%, 14.3%, and 3.5% in PWoH (n=386,586), respectively. After multivariable adjustment, compared with people with 0-1 comorbidities, the hazard ratios of incident HF associated with 2-3 and 4 or more comorbidities were 1.33 (95% CI, 1.04-1.71) and 2.41 (95% CI, 1.78-3.25) in PWH and 2.10 (95% CI, 1.92-2.29) and 4.09 (95% CI, 3.64-4.61) in PWoH, respectively., Conclusion: Multimorbidity was associated with a higher risk of incident HF among PWH and PWoH, with more prominent associations in PWoH and certain patient subgroups. The identification of specific multimorbidity patterns that contribute to higher HF risk in PWH may lead to future preventative strategies., (© 2022 The Authors.)
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- 2022
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122. Human Immunodeficiency Virus Infection and Variation in Heart Failure Risk by Age, Sex, and Ethnicity: The HIV HEART Study.
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Go AS, Reynolds K, Avula HR, Towner WJ, Hechter RC, Horberg MA, Vupputuri S, Leong TK, Leyden WA, Harrison TN, Lee KK, Sung SH, and Silverberg MJ
- Subjects
- Adult, Ethnicity, Female, Humans, Male, Middle Aged, Retrospective Studies, Risk Factors, HIV Infections complications, HIV Infections drug therapy, HIV Infections epidemiology, Heart Failure complications, Heart Failure etiology
- Abstract
Objectives: 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., Patients and Methods: We performed a retrospective cohort study of persons with HIV (PWHs) from January 1, 2000, through December 31, 2016, frequency-matched 1:10 to persons without HIV on year of entry, age, sex, race/ethnicity, and treating facility. We evaluated the risk of incident HF associated with HIV infection, overall and by left ventricular systolic function, and whether HF risk varied by demographic characteristics., Results: Among 38,868 PWHs and 386,586 matched persons without HIV, mean ± SD age was 41.4±10.8 years, with 12.3% female, 21.1% Black, 20.5% Hispanic, and 3.9% Asian/Pacific Islander. During median follow-up of 3.8 years (interquartile range, 1.4-9.0 years), the rate (per 100 person-years) of incident HF was 0.23 in PWHs vs 0.15 in those without HIV (P<.001). The PWHs had a higher adjusted HF rate (adjusted hazard ratio [aHR], 1.73; 95% confidence interval [CI], 1.57 to 1.91), which was only modestly attenuated after accounting for interim acute coronary syndrome events. Results were similar by systolic function category. The adjusted risk of HF in PWHs was more prominent for those 40 years and younger (aHR, 2.45; 95% CI, 1.92 to 3.03), women (aHR, 2.48; 95% CI, 1.90 to 3.26), and Asian/Pacific Islanders (aHR, 2.46; 95% CI, 1.27 to 4.74)., Conclusion: HIV infection increases the risk of HF, which varied by demographic characteristics and was not primarily mediated through atherosclerotic disease pathways or differential use of cardiopreventive medications., (Copyright © 2021 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)
- Published
- 2022
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123. Human immunodeficiency virus infection and risks of morbidity and death in adults with incident heart failure.
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Avula HR, Ambrosy AP, Silverberg MJ, Reynolds K, Towner WJ, Hechter RC, Horberg M, Vupputuri S, Leong TK, Leyden WA, Harrison TN, Lee KK, Sung SH, and Go AS
- Abstract
Aims: Human immunodeficiency virus (HIV) increases the risk of heart failure (HF), but whether it influences subsequent morbidity and mortality remains unclear., Methods and Results: We investigated the risks of hospitalization for HF, HF-related emergency department (ED) visits, and all-cause death in an observational cohort of incident HF patients with and without HIV using data from three large US integrated healthcare delivery systems. We estimated incidence rates and adjusted hazard ratios (aHRs) by HIV status at the time of HF diagnosis for subsequent outcomes. We identified 448 persons living with HIV (PLWH) and 3429 without HIV who developed HF from a frequency-matched source cohort of 38 868 PLWH and 386 586 without HIV. Mean age was 59.5 ± 11.3 years with 9.8% women and 31.8% Black, 13.1% Hispanic, and 2.2% Asian/Pacific Islander. Compared with persons without HIV, PLWH had similar adjusted rates of HF hospitalization [aHR 1.01, 95% confidence interval (CI): 0.81-1.26] and of HF-related ED visits [aHR 1.22 (95% CI: 0.99-1.50)], but higher adjusted rates of all-cause death [aHR 1.31 (95% CI: 1.08-1.58)]. Adjusted rates of HF-related morbidity and all-cause death were directionally consistent across a wide range of CD4 counts but most pronounced in the subset with a baseline CD4 count <200 or 200-499 cells/μL., Conclusion: In a large, diverse cohort of adults with incident HF receiving care within integrated healthcare delivery systems, PLWH were at an independently higher risk of all-cause death but not HF hospitalizations or HF-related ED visits. Future studies investigating modifiable HIV-specific risk factors may facilitate more personalized care to optimize outcomes for PLWH and HF., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.)
- Published
- 2021
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124. Anticoagulant treatment satisfaction with warfarin and direct oral anticoagulants for venous thromboembolism.
- Author
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Fang MC, Go AS, Prasad PA, Hsu JW, Fan D, Portugal C, Sung SH, and Reynolds K
- Subjects
- Administration, Oral, Aged, Anticoagulants administration & dosage, Female, Humans, Male, Personal Satisfaction, Retrospective Studies, Warfarin therapeutic use, Venous Thromboembolism chemically induced, Venous Thromboembolism drug therapy
- Abstract
Treatment options for patients with venous thromboembolism (VTE) include warfarin and direct oral anticoagulants (DOACs). Although DOACs are easier to administer than warfarin and do not require routine laboratory monitoring, few studies have directly assessed whether patients are more satisfied with DOACs. We surveyed adults from two large integrated health systems taking DOACs or warfarin for incident VTE occurring between January 1, 2015 and June 30, 2018. Treatment satisfaction was assessed using the validated Anti-Clot Treatment Scale (ACTS), divided into the ACTS Burdens and ACTS Benefits scores; higher scores indicate greater satisfaction. Mean treatment satisfaction was compared using multivariable linear regression, adjusting for patient demographic and clinical characteristics. The effect size of the difference in means was calculated using a Cohen's d (0.20 is considered a small effect and ≥ 0.80 is considered large). We surveyed 2217 patients, 969 taking DOACs and 1248 taking warfarin at the time of survey. Thirty-one point five percent of the cohort was aged ≥ 75 years and 43.1% were women. DOAC users were on average more satisfied with anticoagulant treatment, with higher adjusted mean ACTS Burdens (50.18 v. 48.01, p < 0.0001) and ACTS Benefits scores (10.21 v. 9.84, p = 0.046) for DOACs vs. warfarin, respectively. The magnitude of the difference was small (Cohen's d of 0.29 for ACTS Burdens and 0.12 for ACTS Benefits). Patients taking DOACs for venous thromboembolism were on average more satisfied with anticoagulant treatment than were warfarin users, although the magnitude of the difference was small., (© 2021. The Author(s).)
- Published
- 2021
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125. Treatment and Outcomes of Acute Pulmonary Embolism and Deep Venous Thrombosis: The CVRN VTE Study.
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Fang MC, Fan D, Sung SH, Witt DM, Schmelzer JR, Williams MS, Yale SH, Baumgartner C, and Go AS
- Subjects
- Acute Disease, Adult, Aged, Cohort Studies, Databases, Factual, Female, Humans, Male, Middle Aged, Multivariate Analysis, Prognosis, Proportional Hazards Models, Pulmonary Embolism diagnostic imaging, Retrospective Studies, Risk Assessment, Severity of Illness Index, Survival Analysis, Treatment Outcome, Venous Thrombosis diagnostic imaging, Anticoagulants therapeutic use, Pulmonary Embolism drug therapy, Pulmonary Embolism mortality, Venous Thrombosis drug therapy, Venous Thrombosis mortality
- Abstract
Background: Few studies describe both inpatient and outpatient treatment and outcomes of patients with acute venous thromboembolism in the United States., Methods: A multi-institutional cohort of patients diagnosed with confirmed pulmonary embolism or deep venous thrombosis during the years 2004 through 2010 was established from 4 large, US-based integrated health care delivery systems. Computerized databases were accessed and medical records reviewed to collect information on patient demographics, clinical risk factors, initial antithrombotic treatment, and vital status. Multivariable Cox regression models were used to estimate the risk of death at 90 days., Results: The cohort comprised 5497 adults with acute venous thromboembolism. Pulmonary embolism was predominantly managed in the hospital setting (95.0%), while 54.5% of patients with lower extremity thrombosis were treated as outpatients. Anticoagulant treatment differed according to thromboembolism type: 2688 patients (92.8%) with pulmonary embolism and 1625 patients (86.9%) with lower extremity thrombosis were discharged on anticoagulants, compared with 286 patients (80.1%) with upper extremity thrombosis and 69 (54.8%) patients with other thrombosis. While 4.5% of patients died during the index episode, 15.4% died within 90 days. Pulmonary embolism was associated with a higher 90-day death risk than lower extremity thrombosis (adjusted hazard ratio 1.23; 95% confidence interval, 1.04-1.47), as was not being discharged on anticoagulants (adjusted hazard ratio 5.56; 95% confidence interval, 4.76-6.67)., Conclusions: In this multicenter, community-based study of patients with acute venous thromboembolism, anticoagulant treatment and outcomes varied by thromboembolism type. Although case fatality during the acute episode was relatively low, 15.4% of people with thromboembolism died within 90 days of the index diagnosis., (Copyright © 2019 Elsevier Inc. All rights reserved.)
- Published
- 2019
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126. Incident anaemia in older adults with heart failure: rate, aetiology, and association with outcomes.
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Ambrosy AP, Gurwitz JH, Tabada GH, Artz A, Schrier S, Rao SV, Barnhart HX, Reynolds K, Smith DH, Peterson PN, Sung SH, Cohen HJ, and Go AS
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- Aged, Aged, 80 and over, Cohort Studies, Female, Humans, Incidence, Male, Anemia epidemiology, Anemia etiology, Heart Failure complications
- Abstract
Aims: 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., Methods and Results: Within the Cardiovascular Research Network (CVRN), we identified adults age ≥65 years with diagnosed HF between 2005 and 2012 and no anaemia at entry. Incident anaemia was defined using World Health Organization (WHO) haemoglobin thresholds (<13.0 g/dL in men; <12.0 g/dL in women). All-cause death and hospitalizations for HF and any cause were identified from electronic health records. Among 38 826 older HF patients, 22 163 (57.1%) developed incident anaemia over a median (interquartile range) follow-up of 2.9 (1.2-5.6) years. The crude rate [95% confidence interval (CI)] per 100 person-years of incident anaemia was 26.4 (95% CI 26.0-26.7) and was higher for preserved ejection fraction (EF) [29.2 (95% CI 28.6-29.8)] compared with borderline EF [26.5 (95% CI 25.4-27.7)] or reduced EF [26.6 (95% CI 25.8-27.4)]. Iron indices, vitamin B12 level, and thyroid testing were performed in 20.9%, 14.9%, and 40.2% of patients, respectively. Reduced iron stores, vitamin B12 deficiency, and/or hypothyroidism were present in 29.7%, 3.2%, and 18.6% of tested patients, respectively. In multivariable analyses, incident anaemia was associated with excess mortality [hazard ratio (HR) 2.14, 95% CI 2.07-2.22] as well as hospitalization for HF (HR 1.80, 95% CI 1.72-1.88) and any cause (HR 1.77, 95% CI 1.72-1.83)., Conclusion: Among older adults with HF, incident anaemia is common and independently associated with substantially increased risks of morbidity and mortality. Additional research is necessary to clarify the value of routine evaluation and treatment of potentially reversible causes of anaemia., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)
- Published
- 2019
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127. Anxiety, Depression, and Adverse Clinical Outcomes in Patients With Atrial Fibrillation Starting Warfarin: Cardiovascular Research Network WAVE Study.
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Baumgartner C, Fan D, Fang MC, Singer DE, Witt DM, Schmelzer JR, Williams MS, Gurwitz JH, Sung SH, and Go AS
- Subjects
- Aged, Anticoagulants therapeutic use, Anxiety etiology, Atrial Fibrillation complications, Depression epidemiology, Female, Follow-Up Studies, Humans, Incidence, Male, Prognosis, Retrospective Studies, Risk Factors, United States epidemiology, Anxiety epidemiology, Atrial Fibrillation drug therapy, Depression etiology, Risk Assessment methods, Thromboembolism prevention & control, Warfarin therapeutic use
- Abstract
Background: Anxiety and depression are associated with worse outcomes in several cardiovascular conditions, but it is unclear whether they affect outcomes in atrial fibrillation (AF). In a large diverse population of adults with AF, we evaluated the association of diagnosed anxiety and/or depression with stroke and bleeding outcomes., Methods and Results: The Cardiovascular Research Network WAVE (Community-Based Control and Persistence of Warfarin Therapy and Associated Rates and Predictors of Adverse Clinical Events in Atrial Fibrillation and Venous Thromboembolism) Study included adults with AF newly starting warfarin between 2004 and 2007 within 5 health delivery systems in the United States. Diagnosed anxiety and depression and other patient characteristics were identified from electronic health records. We identified stroke and bleeding outcomes from hospitalization databases using validated International Classification of Diseases, Ninth Revision ( ICD-9 ), codes. We used multivariable Cox regression to assess the relation between anxiety and/or depression with outcomes after adjustment for stroke and bleeding risk factors. In 25 570 adults with AF initiating warfarin, 490 had an ischemic stroke or intracranial hemorrhage (1.52 events per 100 person-years). In multivariable analyses, diagnosed anxiety was associated with a higher adjusted rate of combined ischemic stroke and intracranial hemorrhage (hazard ratio, 1.52; 95% confidence interval, 1.01-2.28). Results were not materially changed after additional adjustment for patient-level percentage of time in therapeutic anticoagulation range on warfarin (hazard ratio, 1.56; 95% confidence interval, 1.03-2.36). In contrast, neither isolated depression nor combined depression and anxiety were significantly associated with outcomes., Conclusions: Diagnosed anxiety was independently associated with increased risk of combined ischemic stroke and intracranial hemorrhage in adults with AF initiating warfarin that was not explained by differences in risk factors or achieved anticoagulation quality., (© 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)
- Published
- 2018
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128. Atrial fibrillation and outcomes in heart failure with preserved versus reduced left ventricular ejection fraction.
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McManus DD, Hsu G, Sung SH, Saczynski JS, Smith DH, Magid DJ, Gurwitz JH, Goldberg RJ, and Go AS
- Subjects
- Aged, Aged, 80 and over, Atrial Fibrillation diagnosis, Atrial Fibrillation mortality, Atrial Fibrillation physiopathology, Atrial Fibrillation therapy, Brain Ischemia epidemiology, Chi-Square Distribution, Female, Heart Failure diagnosis, Heart Failure mortality, Heart Failure physiopathology, Heart Failure therapy, Hospitalization, Humans, Incidence, Male, Middle Aged, Multivariate Analysis, Prognosis, Proportional Hazards Models, Risk Assessment, Risk Factors, Stroke epidemiology, Time Factors, United States epidemiology, Atrial Fibrillation epidemiology, Heart Failure epidemiology, Stroke Volume, Ventricular Function, Left
- Abstract
Background: Atrial fibrillation (AF) and heart failure (HF) are 2 of the most common cardiovascular conditions nationally and AF frequently complicates HF. We examined how AF has impacts on adverse outcomes in HF-PEF versus HF-REF within a large, contemporary cohort., Methods and Results: We identified all adults diagnosed with HF-PEF or HF-REF based on hospital discharge and ambulatory visit diagnoses and relevant imaging results for 2005-2008 from 4 health plans in the Cardiovascular Research Network. Data on demographic features, diagnoses, procedures, outpatient pharmacy use, and laboratory results were ascertained from health plan databases. Hospitalizations for HF, stroke, and any reason were identified from hospital discharge and billing claims databases. Deaths were ascertained from health plan and state death files. Among 23 644 patients with HF, 11 429 (48.3%) had documented AF (9081 preexisting, 2348 incident). Compared with patients who did not have AF, patients with AF had higher adjusted rates of ischemic stroke (hazard ratio [HR] 2.47 for incident AF; HR 1.57 for preexisting AF), hospitalization for HF (HR 2.00 for incident AF; HR 1.22 for preexisting AF), all-cause hospitalization (HR 1.45 for incident AF; HR 1.15 for preexisting AF), and death (incident AF HR 1.67; preexisting AF HR 1.13). The associations of AF with these outcomes were similar for HF-PEF and HF-REF, with the exception of ischemic stroke., Conclusions: AF is a potent risk factor for adverse outcomes in patients with HF-PEF or HF-REF. Effective interventions are needed to improve the prognosis of these high-risk patients.
- Published
- 2013
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