Search

IMPORTANCE: The long-term benefits of off-pump (“beating heart”) vs on-pump coronary artery bypass grafting (CABG) remain controversial. OBJECTIVE: To evaluate the 10-year outcomes and costs of off-pump vs on-pump CABG in the Department of Veterans Affairs (VA) Randomized On/Off Bypass (ROOBY) trial. DESIGN, SETTING, AND PARTICIPANTS: From February 27, 2002, to May 7, 2007, 2203 veterans in the ROOBY trial were randomly assigned to off-pump or on-pump CABG procedures at 18 participating VA medical centers. Per protocol, the veterans were observed for 10 years; the 10-year, post-CABG clinical outcomes and costs were assessed via centralized abstraction of electronic medical records combined with merges to VA and non-VA databases. With the use of an intention-to-treat approach, analyses were performed from May 7, 2017, to December 9, 2021. INTERVENTIONS: On-pump and off-pump CABG procedures. MAIN OUTCOMES AND MEASURES: The 10-year coprimary end points included all-cause death and a composite end point identifying patients who had died or had undergone subsequent revascularization (ie, percutaneous coronary intervention [PCI] or repeated CABG); these 2 end points were measured dichotomously and as time-to-event variables (ie, time to death and time to composite end points). Secondary 10-year end points included PCIs, repeated CABG procedures, changes in cardiac symptoms, and 2018-adjusted VA estimated costs. Changes from baseline to 10 years in post-CABG, clinically relevant cardiac symptoms were evaluated for New York Heart Association functional class, Canadian Cardiovascular Society angina class, and atrial fibrillation. Outcome differences were adjudicated by an end points committee. Given that pre-CABG risks were balanced, the protocol-driven primary and secondary hypotheses directly compared 10-year treatment-related effects. RESULTS: A total of 1104 patients (1097 men [99.4%]; mean [SD] age, 63.0 [8.5] years) were enrolled in the off-pump group, and 1099 patients (1092 men [99.5%]; mean [SD] age, 62.5 [8.5] years) were enrolled in the on-pump group. The 10-year death rates were 34.2% (n = 378) for the off-pump group and 31.1% (n = 342) for the on-pump group (relative risk, 1.05; 95% CI, 0.99-1.11; P = .12). The median time to composite end point for the off-pump group (4.6 years; IQR, 1.4-7.5 years) was approximately 4.3 months shorter than that for the on-pump group (5.0 years; IQR, 1.8-7.9 years; P = .03). No significant 10-year treatment-related differences were documented for any other primary or secondary end points. After the removal of conversions, sensitivity analyses reconfirmed these findings. CONCLUSIONS AND RELEVANCE: No off-pump CABG advantages were found for 10-year death or revascularization end points; the time to composite end point was lower in the off-pump group than in the on-pump group. For veterans, in the absence of on-pump contraindications, a case cannot be made for supplanting the traditional on-pump CABG technique with an off-pump approach. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01924442

This subanalysis of the Randomized On-Off Bypass (ROOBY) trial examined transit time flow measurement (TTFM) use and its impact on graft patency and long-term clinical outcomes after coronary artery bypass graft surgery.Use of TTFM for ROOBY centers and surgeons was assessed. Comparative patient outcomes based on TTFM use included 1-year graft patency and 1-year and 5-year major adverse cardiac events: all-cause mortality, nonfatal myocardial infarction, and revascularization (percutaneous coronary intervention or repeat coronary artery bypass graft surgery).Transit time flow measurement was used in 1067 patients (TTFM group) and not used in 501 patients (non-TTFM group); of the TTFM group, median percentage TTFM use was 79% (interquartile range, 41% to 98%) among 18 Veterans Affairs Medical Centers, and 74% (interquartile range, 13% to 98%) among 48 surgeons. Patients were comparable in age (63 ± 8.5 years TTFM vs 62 ± 8 years non-TTFM, P = .30) and estimated 30-day mortality risk (1.8 ± 1.7 TTFM vs 1.9 non-TTFM, P = .53). One-year FitzGibbon A patency was 83% (1600 of 1988 grafts) for TTFM assessed grafts and 78% (629 of 803) for non-TTFM assessed grafts (P.01). Fewer TTFM patients had an occluded graft (29%, vs 38% non-TTFM; P = .01). Comparing TTFM patients with non-TTFM patients, 5-year major adverse cardiac event rates were 30% vs 25% (P = .06). Individual component rates were 14% vs 11% for death (P = .06), 12% vs 8.8% for myocardial infarction (P = .07), and 13% vs 12% for revascularization (P = .62).The association of TTFM use with graft patency and clinical outcome is uncertain. Future randomized studies that account for patient risk factors and practice variation would help address this knowledge gap.

Background: Poor preoperative health-related quality of life (HRQoL) has been associated with reduced short-term survival after coronary artery bypass graft surgery (CABG); however, it’s impact on long-term mortality is unknown. This study’s objective was to determine if baseline HRQoL status predicts five-year post-CABG mortality. Methods: This pre-specified, Randomized On/Off Bypass Follow-up Study (ROOBY-FS) sub-analysis compared baseline patient characteristics and HRQoL scores, obtained from the Seattle Angina Questionnaire (SAQ) and Veterans Rand Short Form 36 (VR-36), between five-year post-CABG survivors and non-survivors. Standardized sub-scores were calculated for each questionnaire. Multivariable logistic regression assessed whether HRQoL survey sub-components independently predicted five-year mortality (p < 0.05). Results: Of the 2,203 ROOBY-FS enrollees, 2,104 (95.5%) completed baseline surveys. Significant differences between five-years post-CABG deaths (n = 286) and survivors (n = 1818) included age, history of chronic obstructive pulmonary disease, stroke, peripheral vascular disease, renal dysfunction, diabetes, lower left ventricular ejection fraction, atrial fibrillation, depression, non-white race/ethnicity, lower education status, and off-pump CABG. Adjusting for these factors, baseline VR-36 Physical Component Summary score (PCS) [p = 0.01], VR-36 Mental Component Summary score (MCS) (p < 0.001) and SAQ Physical Limitation score (SAQ-PL) (p = 0.003) were all associated with five-year all-cause mortality. Conclusions: Pre-CABG HRQoL scores may provide clinically relevant prognostic information beyond traditional risk models and prove useful for patient-provider shared decision making and enhancing pre-CABG informed consent.

Poor preoperative health-related quality of life (HRQoL) has been associated with reduced short-term survival after coronary artery bypass graft (CABG) surgery; however, its impact on long-term mortality is unknown. This study's objective was to determine if baseline HRQoL status predicts 5-year post-CABG mortality.This prespecified, randomized on/off bypass follow-up study (ROOBY-FS) subanalysis compared baseline patient characteristics and HRQoL scores, obtained from the Seattle Angina Questionnaire (SAQ) and Veterans RAND Short Form-36 (VR-36), between 5-year post-CABG survivors and nonsurvivors. Standardized subscores were calculated for each questionnaire. Multivariable logistic regression assessed whether HRQoL survey subcomponents independently predicted 5-year mortality (p ≤ .05).Of the 2203 ROOBY-FS enrollees, 2104 (95.5%) completed baseline surveys. Significant differences between 5-year post-CABG deaths (n = 286) and survivors (n = 1818) included age, history of chronic obstructive pulmonary disease, stroke, peripheral vascular disease, renal dysfunction, diabetes, lower left ventricular ejection fraction, atrial fibrillation, depression, non-White race/ethnicity, lower education status, and off-pump CABG. Adjusting for these factors, baseline VR-36 physical component summary score (p = .01), VR-36 mental component summary score (p .001), and SAQ physical limitation score (p = .003) were all associated with 5-year all-cause mortality.Pre-CABG HRQoL scores may provide clinically relevant prognostic information beyond traditional risk models and prove useful for patient-provider shared decision-making and enhancing pre-CABG informed consent.

Background It remains unclear whether cardiovascular risk factors and access to healthcare for veterans with cardiovascular disease (CVD) vary among US regions. This study sought to determine the extent of regional variations in cardiovascular risk factors and access to medical care in a cohort of veterans with CVD in the USA. Methods The 2016 Centers for Disease Control Behavioral Risk Factor Surveillance Survey was utilized to identify a cohort of veteran patients with CVD. Participants were classified based on four US regions: (1) Northeast, (2) Midwest, (3) South, and (4) West. We compared demographic data, medical history, and access to care for veterans of each US region. The outcomes of interest included financial barriers to medical care and annual medical checkup. Results Among the 13 835 veterans, 18.3% were from the Northeast, while 23.5, 37.1, and 21.1% were from the Midwest, South, and West, respectively. Veterans of each region differed significantly with respect to demographic characteristics, prior medical history, and access to care. Rates of financial barriers to medical care were similar across the four regions (7.3 vs. 7.1 vs. 8.0 vs. 6.9%, P = 0.203). Veterans from the West had the lowest rates of medical checkup within the past year (91.7 vs. 89.5 vs. 91.4 vs. 86.6%). On multivariate analysis, the Midwest [odds ratio (OR) 0.69; 95% CI, 0.53-0.89] and West (OR 0.53; 95% CI 0.41-0.68) regions were independently associated with lower rates of medical checkup within the past year compared to the Northeast. Conclusions In this observational study involving US veterans with CVD, cardiovascular risk factors and frequency of annual medical checkup differed amongst each US region. Further large-scale studies examining the prevalence of impaired access to care and quality of care in US veterans with CVD are warranted.

Compared with randomized controlled trials (RCTs) in medical specialties, RCTs in cardiac surgery face specific issues. Individual and collective equipoise, rapid evolution of the surgical techniques, as well as difficulties in obtaining funding, and limited education in clinical epidemiology in the surgical community are among the most important challenges in the design phase of the trial. Use of complex interventions and learning curve effect, differences in individual operators' expertise, difficulties in blinding, and slow recruitment make the successful completion of cardiac surgery RCTs particularly challenging. In fact, over the course of the last 20 years, the number of cardiac surgery RCTs has declined significantly. In this review, a team of surgeons, trialists, and epidemiologists discusses the most important challenges faced by RCTs in cardiac surgery and provides a list of suggestions for the successful design and completion of cardiac surgery RCTs.

Thoracic aortic aneurysms (TAA) are usually a silent disease that can prove fatal if complications (i.e., rupture or dissection) arise. Aortic diameter has been described as a major risk factor for TAA adverse outcomes or surgical intervention. Other comorbidities and importantly socioeconomic factors are less well-analyzed variables in large population studies. Using the New York State (NYS) Statewide Planning and Research Cooperative Systems (SPARCS) database, the purpose of this retrospective cohort study is to identify the risk factors associated with adverse outcomes in a patient population with newly diagnosed non-ruptured TAA between the time range of 2005-2018. &nbsp

Introduction: Posttraumatic stress disorder (PTSD) is associated with greater risk of ischemic heart disease (IHD). Women veterans represent a growing, yet understudied, population with high trauma exposure and a unique cardiovascular risk profile, but research on the PTSD-IHD relation in this group is lacking. Hypothesis: PTSD is associated with incident IHD in women veterans. Methods: Veterans Administration (VA) electronic medical records (EMR) was used to identify women veterans who received care from any VA from 1/1/2000-12/31/2017. Exclusion criteria included: no VA follow-up(s) after index visit; IHD diagnosis at or before index visit; IHD diagnosis within 90 days of index visit. Propensity score matching on age at index visit, year of index visit, number of visits before index visit, and presence of traditional and female-specific cardiovascular risk factors and mental and physical health conditions was conducted in a 1:2 ratio to identify 129,510 women veterans with PTSD and 259,020 women veterans without PTSD. PTSD was defined by International Classification of Disease (ICD)-9/ICD-10 diagnosis codes and inpatient or outpatient encounters. Incident IHD was defined as new-onset coronary artery disease, angina, or myocardial infarction diagnoses based on ICD-9/ICD-10 diagnosis codes and inpatient or outpatient encounters. Results: The analytic sample was relatively young (mean age=40.3 ( SD =12.5)). Median length of follow-up was 1,921 days (interquartile range=884-3,547 days). In a propensity score-adjusted Cox proportional hazards model, PTSD was significantly associated with greater risk of developing IHD (HR=1.15, 95% CI 1.10-1.19; P Conclusions: Findings demonstrate that PTSD is an independent predictor of incident IHD in women veterans, especially in younger women and racial and ethnic minorities. Results may have implications for IHD risk assessment in these vulnerable populations.

Opiates and benzodiazepines are commonly used during invasive coronary angiography (ICA) to address pain and anxiety. In the United States (US), these medications are used in more than 90% of such cases. The utility of these medications during ICA has not been addressed by the scientific societies. The goals of this study were to evaluate the impact of music on the use of opiates and benzodiazepines and levels of pain and anxiety in patients undergoing ICA.In this prospective pilot study, a total of 72 subjects undergoing elective ICA were randomized to receive planned pharmacologic standard conscious sedation (SCS), including opiates and/or benzodiazepines pre-ICA vs music plus opiates and/or benzodiazepines as needed. Pain and anxiety levels, as well as use of SCS medications, were monitored during the periprocedural period.Baseline characteristics, including rates of anxiety, depression, and other psychiatric disorders, were similar between the SCS and music groups. The levels of pain and anxiety were relatively low and similar between the two cohorts during the peri-ICA period. There was a trend toward less frequent use of SCS medications in the music group (62.2% in the SCS group vs 40.0% in the music group; P=.06) and significantly less use of midazolam per case in the music group (0.68 mg in the SCS group vs 0.37 mg in the music group; P=.048). SCS medication use also differed significantly between the two operators.Listening to patient-selected music during the peri-ICA period may reduce the need for pharmacologic conscious sedation without adversely affecting pain and anxiety levels.

Objective Occurrence of a stroke within 30 days following coronary artery bypass grafting (CABG) is an uncommon, but often devastating, complication. This study aimed to identify factors associated with long-term survival (beyond 30 days) in patients with stroke after CABG. Methods De-identified patients’ records from the Veterans Affairs Surgical Quality Improvement Program database were used to identify risk factors and perioperative complications associated with survival for up to 20 years in patients with post-CABG stroke. The multivariable Cox proportional hazards model was used for analyzing survival. Results The median survival time for patients with stroke (n = 1422) was 6.7 years. The mortality rate for these patients was highest in the first year post-CABG and was significantly elevated compared with non-stroke patients. Survival rates at 1, 5, and 10 years for stroke versus non-stroke patients were 79% vs. 96%, 58% vs. 83%, and 36% vs. 63%, respectively. High preoperative serum creatinine levels, postoperative occurrence of renal failure, prolonged ventilation, coma, and reoperation for bleeding were important predictors of 1-year mortality of patients with post-CABG stroke. Conclusions Veterans with post-CABG stroke have a considerably higher risk for mortality during the first year compared with patients without stroke.

Compared with randomized controlled trials (RCTs) in medical specialties, RCTs in cardiac surgery face specific issues. Individual and collective equipoise, rapid evolution of the surgical techniques, as well as difficulties in obtaining funding, and limited education in clinical epidemiology in the surgical community are among the most important challenges in the design phase of the trial. Use of complex interventions and learning curve effect, differences in individual operators' expertise, difficulties in blinding, and slow recruitment make the successful completion of cardiac surgery RCTs particularly challenging. In fact, over the course of the last 20 years, the number of cardiac surgery RCTs has declined significantly. In this review, a team of surgeons, trialists, and epidemiologists discusses the most important challenges faced by RCTs in cardiac surgery and provides a list of suggestions for the successful design and completion of cardiac surgery RCTs.

Aim: In the US, postoperative atrial fibrillation (POAF) is the most common complication after cardiac surgery and a frequent complication after non-cardiac surgery, causing excess patient length of stay and costs. After a comprehensive review looking for validated statistically significant data sets, too few data, particularly from outside of the US and Europe, could be found to perform a conclusive analysis, but there is enough data for a well-informed, educated opinion. Methods: A systematic review analyzing 28 international and US studies of POAF hospital length of stay were identified; from this excess and % excess along with total patient length of stay were calculated, where excess patient length of stay is defined as the difference in post-operative stay between POAF and non-POAF patients in days. Geographic variabilities were calculated using chi-square analyses for US regions and international comparisons for a variety of surgical procedures with POAF. Results: Geographic variability analyses when corrected for total hospital stay showed a 325% longer excess patient length of stay (days) in the US vs. Europe (3.4 days vs. 0.8 days) for coronary artery bypass grafting (CABG). It also showed a 27.3% longer excess patient length of stay (days) in the US vs. Europe (4.2 days vs. 3.3 days) for lung resections. These were both statistically significant at P < 0.001. Conclusion: There appear to be substantial variations in POAF-related care practices worldwide. In all practice settings, POAF causes increased patient length of stay. Europeans appear to do better than the US in POAF patients’ length of stay for CABG but not for lung resections. POAF is a worldwide problem where international cooperation in research and development of best practice guidelines would be particularly fruitful.

Postoperative atrial fibrillation (POAF) is the most common complication after cardiac surgery, yet there is no consistent cardiothoracic professional society-based definition of new-onset POAF, nor a broadly accepted consensus on how to prevent or treat it. Importantly, there is an ever-growing body of evidence that new-onset POAF is associated with worse patient outcomes. Given the lack of evidence-based guidelines, detection and treatment of POAF, in addition to understanding how POAF is related to these worse outcomes, represents an unaddressed quality of care concern. In the United States, the annual cardiac surgical POAF patient costs are estimated at ~$1 billion. The entire US Medicare annual budget has been reported at ~$141.2 billion for all hospital-related care; thus, the administrative challenges uniquely posed by POAF have been exposed for the first time. Mapping future tactics, this Vessel Plus special atrial fibrillation publication, swings the pendulum from impromptu observations towards action. A new strategic framework is proposed to begin the tedious but necessary task of taking on this elephant in the room. With ideal collaboration between clinical providers, health care systems, professional societies and insurers, a five-step approach is proposed to overcome these POAF patient care challenges.

Aim: Impacts of pre-operative atrial fibrillation or flutter (AF/AFL) upon repeat aortic valve replacement (r-AVR) patients’ risk-adjusted short-term outcomes is unknown. Methods: From 2005-2018, New York State AF/AFL versus non-AF/AFL adults’ risk-adjusted r-AVR outcomes were compared. Primary endpoints included the Society of Thoracic Surgeons’ 30-day operative mortality or major morbidity (MM) composite and 30-day readmission (READMIT); the MM sub-components were secondary endpoints. Multivariable logistic regression models evaluated AF/AFL impact upon these endpoints while holding other factors constant. Results: Of 36,783 adults initially undergoing aortic valve replacement, 334 subsequently underwent r-AVR. Within this r-AVR group, 42.4% of repeat surgical (r-SAVR) patients had AF/AFL; 50.4% of repeat transcatheter (viv-TAVR) patients had AF/AFL. R-SAVR AF/AFL patients were older and had more comorbidities than those without AF/AFL. Viv-TAVR AF/AFL patients were similar to those without AF/AFL except for lower rates of chronic obstructive pulmonary disease. Comparing risk-adjusted r-AVR outcomes, AF/AFL did not impact MM [odds ratio (OR), 95% confidence interval (CI): 1.23, 0.66-2.28, P = 0.512] or READMIT (OR, 95% CI: 1.15, 0.60-2.19, P = 0.681). Black race (OR, 95% CI: 2.89, 1.01-8.32, P = 0.049) and Elixhauser mortality score (OR, 95% CI: 1.07, 1.04-1.10, P < 0.0001) predicted MM risk. Cerebrovascular disease (OR, 95% CI: 2.54, 1.23-5.25, P = 0.012) predicted READMIT risk, while viv-TAVR was protective compared to r-SAVR (OR, 95% CI: 0.44, 0.21-0.91, P = 0.027). Conclusion: AF/AFL was not associated with risk-adjusted short-term r-AVR outcomes. Black race, Elixhauser mortality score, and cerebrovascular disease predicted adverse outcomes.

Atrial fibrillation (AF) is among the most frequent cardiac surgical arrhythmias documented. The global AF prevalence is estimated at over 33 million cases, with estimates ranging up to 6.1 million cases in the United States. Among cardiac surgical patients, the risk factors for new-onset post-operative AF (POAF) include Caucasian race with increased prevalence documented in older men. Due to trends of earlier thoracic aortic aneurysm (TAA) detection and treatment, it is timely to review the AF association with adverse TAA clinical outcomes. Towards this goal, a comprehensive PubMed literature review was performed. For this initial Medline literature search, the MeSH search strategy included “thoracic aortic aneurysm” and “atrial fibrillation”. Based on the pertinent articles identified, the limited literature available for preoperative TAA AF and the predictors of POAF following TAA procedures were reviewed. Given only a handful of publications addressing these pre-/post-operative AF topics were identified using this very broad initial search approach, a knowledge chasm exists–as very little is known about TAA patients with pre-operative or new-onset post-operative AF. Given the paucity of evidence-based information available, clinically relevant TAA-specific research questions have been raised to guide future TAA AF-related investigations.

Atrial fibrillation (AF) is a common preoperative comorbidity and post-operative complication associated with cardiac surgery and is recognized as a significant predictor of adverse clinical outcomes. This review aims to highlight the current literature regarding the incidence, risk factors, and outcomes of atrial fibrillation in patients undergoing surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) procedures. A literature search of relevant articles was conducted via PubMed, Medline, and EMBASE. Pre-existing AF is seen in 6.3%-35.2% of SAVR patients and 15.7%-48.9% of TAVR patients and is associated with increased risk of mortality (OR = 2.2) and stroke (OR = 5.9). Postoperative AF (POAF) is more common after SAVR and in patients with hemodynamic instability. The rates for POAF range from 11.1%-84% following SAVR and range from 3.0%-55.6% following TAVR. In-hospital mortality (7.8% vs. 3.4%; P < 0.01) and stroke (4.7% vs. 2.0%; P < 0.01) are higher in the POAF group. POAF can be prevented via prophylactic antiarrhythmic medications and atrial pacing. Therapeutic anticoagulation is recommended as it reduces the risk of thrombotic complications following SAVR and TAVR procedures in the setting of POAF. Compared to those not on anticoagulant therapies, patients on anticoagulation have decreased rates of stroke (1.7% vs. 5.5%) and fewer 30-day thrombotic complications (3% vs. 40%). These preventive measures are essential as POAF is associated with more thromboembolic events, longer hospital stays, and higher overall morbidity and mortality rates.

Laparoscopic surgical procedures (LSP) have grown in popularity due to their purported benefits of improved effectiveness and efficiency. This study summarizes the Cochrane systematic reviews’ (CSRs’) evidence comparing the use of LSP versus open procedures used for surgical patient management and comparing the CSRs’ quality and consistency of LSP evidence reported across time and different surgical specialties. The Cochrane Database was searched to identify CSRs comparing LSP versus open procedures; 36 CSRs and 15 CSR protocols were found as of February 16, 2016. Each CSR’s clinical outcomes and major conclusions were evaluated; CSR’s quality and completeness were assessed using PRISMA and AMSTAR criteria. Overall, CSRs’ reporting variations across specialties and trends over time were summarized. A weighted analysis across all 36 CSRs found improved outcomes with LSP (odds ratio 0.90; 95% confidence interval 0.88, 0.92). Substantial CSR variation was found in the patient inclusion/exclusion criteria and clinical endpoints used. Individually, most CSR analyses showed no significant difference (65.4%) between LSP versus open procedures; 25.8% showed a LSP benefit versus 8.9% an open benefit. As a major conclusion, a positive LSP impact was documented by 8/36 (22.2%) CSRs; but only half of these CSRs decisively concluded that there was a LSP advantage. Undeclared conflicts of interest were identified in 9/36 CSRs (25.0%), raising the potential for a reporting bias. Both CSR variabilities (i.e., missing population, intervention, comparison, outcome, study design statements) and PRISMA-related deficiencies were documented. Overall, CSR evidence supports a LSP advantage; however, clinical decisions must be driven by CSR procedure-specific evidence. Variations and inconsistencies in CSR design and reporting identified future opportunities to improve CSR quality by increasing the methodological transparency, standardizing CSR reporting, and documenting comprehensively any non-financial conflicts of interest (i.e., ongoing research and historical publications) for all CSR team members.

Optimal antiplatelet therapy after coronary artery bypass graft (CABG) surgery remains controversial. This study evaluated the role of dual antiplatelet therapy using aspirin and clopidogrel (DAPT) versus antiplatelet therapy using aspirin only (ASA) on post-CABG clinical outcomes and costs. In the Department of Veterans Affairs Randomized On/Off Bypass (ROOBY) trial, clopidogrel use after CABG was prospectively collected beginning in year 2 of this study to include 1,525 of the 2,203 original ROOBY patients who received aspirin after CABG. Discretionarily, surgeons after CABG administered either DAPT or ASA treatments. The ROOBY trial's primary 30-day composite (mortality or perioperative morbidity), 1-year composite (all-cause death, repeat revascularization, or nonfatal myocardial infarction), and costs were compared for these 2 strategies. Of the 1,525 subjects, 511 received DAPT and 1,014 received ASA. DAPT subjects, compared with ASA subjects, had lower rates of preoperative left ventricular ejection fraction of ≥45% (78.8% vs 85.7%, p 0.001), on-pump CABG (36.6% vs 57.1%, p = 0.001), and endoscopic vein harvesting (30.0% vs 42.8%, p 0.001). ASA patients were more likely to have earlier aspirin administration and receive 325 versus 81 mg dosages. The 30-day composite outcome rate was significantly lower for DAPT patients compared with ASA patients (3.3% vs 7.1%, p = 0.003), but the 1-year composite outcome was equal between the 2 groups (12.0% vs12.0%, p = 1.0). At 1 year, there were no cost differences between the 2 groups. Propensity analyses did not significantly alter the results. In conclusion, DAPT appeared safe and was associated with fewer 30-day adverse outcomes than aspirin only and with no 1-year outcome or cost differences.

Lung cancer ranks as the top cancer killer in the United States. Using The Society of Thoracic Surgeons General Thoracic Surgery Database (GTSD), the geographic variability of lung cancer lobectomy for operative mortality and major morbidity were examined.From January 2009 to June 2015, the GTSD lung cancer lobectomy records (excluding robotic procedures) were assigned to a US Census region using hospital location. Surgeons performing fewer than seven lung cancer lobectomies per year were categorized as "low volume." The American College of Surgeons Oncology Group criteria were used to classify patients as "high risk." Applying the published GTSD risk algorithms, regional unadjusted and adjusted odds ratios were computed using univariable and multivariable generalized estimating equation logistic regression. Across geographic regions, patient risk factors and outcomes were compared using Kruskal-Wallis and χFrom 2009 to 2015, there were 39,078 lung cancer lobectomies that met study inclusion criteria (31.5% Northeast, 23.5% Midwest, 31.1% South, and 14.0% West). Fewer high-risk cases were seen in the West region (18.9% Northeast, 19.6% Midwest, 19.9% South, and 15.9% West; p 0.001). Across geographic regions, there was no statistically significant difference in the proportion of low-volume surgeons (39.8% Northeast, 44.8% Midwest, 45.8% South, and 56.3% West; p = 0.0512). Adjusted odds ratios for operative mortality and major perioperative morbidity did not show statistically significant differences across regions (p = 0.761 and p = 0.600, respectively).Despite geographic variations in the proportion of high-risk lobectomies, the risk-adjusted mortality and morbidity outcomes did not vary by region.

Importance Posttraumatic stress disorder (PTSD) is associated with greater risk of ischemic heart disease (IHD) in predominantly male populations or limited community samples. Women veterans represent a growing, yet understudied, population with high levels of trauma exposure and unique cardiovascular risks, but research on PTSD and IHD in this group is lacking. Objective To determine whether PTSD is associated with incident IHD in women veterans. Design, Setting, and Participants In this retrospective, longitudinal cohort study of the national Veterans Health Administration (VHA) electronic medical records, the a priori hypothesis that PTSD would be associated with greater risk of IHD onset was tested. Women veterans 18 years or older with and without PTSD who were patients in the VHA from January 1, 2000, to December 31, 2017, were assessed for study eligibility. Exclusion criteria consisted of no VHA clinical encounters after the index visit, IHD diagnosis at or before the index visit, and IHD diagnosis within 90 days of the index visit. Propensity score matching on age at index visit, number of prior visits, and presence of traditional and female-specific cardiovascular risk factors and mental and physical health conditions was conducted to identify women veterans ever diagnosed with PTSD, who were matched in a 1:2 ratio to those never diagnosed with PTSD. Data were analyzed from October 1, 2018, to October 30, 2020. Exposures PTSD, defined byInternational Classification of Diseases, Ninth Revision(ICD-9), orInternational Statistical Classification of Diseases and Related Health Problems, Tenth Revision(ICD-10), diagnosis codes from inpatient or outpatient encounters. Main Outcomes and Measures Incident IHD, defined as new-onset coronary artery disease, angina, or myocardial infarction, based onICD-9andICD-10diagnosis codes from inpatient or outpatient encounters, and/or coronary interventions based onCurrent Procedural Terminologycodes. Results A total of 398 769 women veterans, 132 923 with PTSD and 265 846 never diagnosed with PTSD, were included in the analysis. Baseline mean (SD) age was 40.1 (12.2) years. During median follow-up of 4.9 (interquartile range, 2.1-9.2) years, 4381 women with PTSD (3.3%) and 5559 control individuals (2.1%) developed incident IHD. In a Cox proportional hazards model, PTSD was significantly associated with greater risk of developing IHD (hazard ratio [HR], 1.44; 95% CI, 1.38-1.50). Secondary stratified analyses indicated that younger age identified women veterans with PTSD who were at greater risk of incident IHD. Effect sizes were largest for those younger than 40 years at baseline (HR, 1.72; 95% CI, 1.55-1.93) and decreased monotonically with increasing age (HR for ≥60 years, 1.24; 95% CI, 1.12-1.38). Conclusions and Relevance This cohort study found that PTSD was associated with increased risk of IHD in women veterans and may have implications for IHD risk assessment in vulnerable individuals.

Objectives Previous work in our laboratory identified keratin 17 (K17) as a specific and sensitive biomarker for high-grade squamous intraepithelial lesions and cervical squamous cell carcinoma (SCC). K17, however, has not been previously evaluated in endocervical glandular neoplasia. Based on the similar pathogenesis of squamous and glandular lesions of the cervix, we hypothesized that K17 overexpression could also be a diagnostic and/or prognostic biomarker for endocervical neoplasia. Methods Cases of endocervical adenocarcinoma (n = 90), adenocarcinoma in situ (AIS) (n = 32), benign glandular lesions (n = 36), and normal endocervical mucosa (n = 5) were selected from Stony Brook Medicine and the University of Massachusetts from 2002 to 2013. Immunohistochemical staining for K17 was performed by an indirect immunoperoxidase method and was scored based on the proportion of cells that showed strong (2+) staining. Results K17 was highly expressed in 21 (65.6%) of 32 AIS and in 75 (83.0%) of 90 adenocarcinoma cases. In adenocarcinomas, K17 staining was detected in a mean of 33.9% of malignant cells. Staining tended to be strongest at the periphery of pseudoglandular groups and at the invasive front of tumors. K17 was not detected in the epithelial cells of benign glandular lesions, but groups of cuboidal cells, residing beneath the epithelial layer of benign glands, were frequently positive for K17, especially in cases of microglandular hyperplasia. High levels of K17 expression were significantly associated with decreased patient survival. Conclusions K17 is highly expressed in most cases of both invasive adenocarcinoma and in AIS and is a powerful, negative prognostic marker for patient survival.

Objective The impact of new-onset postoperative atrial fibrillation (POAF) following coronary artery bypass grafting (CABG) surgery on long-term clinical outcomes and costs is not known. This subanalysis of the Veterans Affairs “Randomized On/Off Bypass Follow-up Study” compared 5-year outcomes and costs between patients with and without POAF. Methods Of the 2203 veterans in the study, 100 with pre-CABG atrial fibrillation (93) or missing data (7) were excluded (4.8%). Unadjusted and risk-adjusted outcomes were compared between new-onset POAF (n = 551) and patients without POAF (n = 1552). Five-year clinical outcomes included mortality, major adverse cardiovascular events (MACE, comprising mortality, repeat revascularization, and myocardial infarction), MACE subcomponents, stroke, and costs. A stringent P value of ≤.01 was required to identify statistical significance. Results Patients with POAF were older and had more complex comorbidities. Unadjusted 5-year all-cause mortality was 16.3% POAF versus 11.9% no-POAF, P = .008. Unadjusted cardiac-mortality was 7.4% versus 4.8%, P = .022. There were no differences between groups in any other unadjusted outcomes including MACE or stroke. After risk adjustment, there were no significant differences between groups in 5-year all-cause mortality (POAF odds ratio, 1.19; 99% confidence interval, 0.81-1.75) or cardiac mortality (odds ratio, 1.51, 99% confidence interval, 0.88-2.60). Adjusted first-year post-CABG costs were $15,300 greater for patients with POAF, but 2- through 5-year costs were similar. Conclusions No 5-year risk-adjusted outcome differences were found between patients with and without POAF after CABG. Although first-year costs were greater in patients with POAF, this difference did not persist in subsequent years.

Background: While post-traumatic stress disorder (PTSD) has been associated with increased risk of coronary artery disease (CAD), the association between PTSD and outcomes in Veterans with CAD remains unclear. Methods: The study population included 168 Veterans with CAD who were seen in Cardiology Clinic in January 2015. Demographics, clinical history, medications, lab and echocardiographic testing, and outcomes were recorded and compared in Veterans with PTSD versus those without. The primary outcome of interest was major adverse cardiovascular events (MACE) at 1 year, which was a composite of all-cause mortality, cardiovascular hospitalization, and emergency room presentation for chest pain and/or dyspnea. Results: Of the 168 Veterans with CAD, 26 (15%) had PTSD while 142 (85%) did not. No differences in age, cardiac risk factors, or comorbidities were noted in Veterans with and without PTSD. Veterans with PTSD were more likely to have served in the Vietnam War and had higher prevalence of agent orange exposure. They also had higher rates of depressive disorders (50% vs 26%, p=0.01) and were more often prescribed a selective serotonin receptor inhibitor (42% vs 15%, p=0.0002) and benzodiazepine (35% vs 9%, p=0.012). Veterans with PTSD were more often prescribed long-acting nitroglycerin (39% vs 14%, p=0.003) and had a trend toward higher rates of ranolazine (8% vs 0.7%, p=0.06). They were also had higher LDL cholesterol (84 vs 71, p=0.04), and a trend towards higher total cholesterol (157 vs 141, p=0.09) and lower serum creatinine (1.0 vs 1.2, p=0.08). Echocardiographic characteristics were similar in both groups. Rates of MACE were signficantly lower in Veterans with PTSD (12% vs 32%, p=0.03), primarily driven by lower rates of cardiovascular hospitalization (4% vs 21%, p=0.05). In multivariable logistic regression, PTSD was not associated with 1-year MACE rates (OR 0.32, 95%CI 0.09-1.21). Conclusions: In Veterans with CAD, presence of PTSD was not independently associated with MACE at 1 year. Further research on PTSD and its relation to CAD outcomes in the Veteran population however is warranted.

Background: Studies of the relationship between patient self-reported angina symptoms using the Seattle Angina Questionnaire (SAQ) and angiographic findings after coronary artery bypass grafting surgery (CABG) are lacking. Nested within a randomized controlled trial, this prospective observational cohort comparison study aimed to assess which clinical characteristics and angiographic findings are associated with self-reported angina 1 year after CABG. Methods and Results: Patients from the ROOBY trial (Randomized On/Off Bypass) with protocol-specified 1-year post-CABG coronary angiography and SAQ assessments were included (n=1258). Patients reporting no angina (62.3%) within 4 weeks before the 1-year post-CABG study visit on the SAQ angina frequency domain were compared with patients reporting angina (37.7%). Multivariable modeling identified clinical variables and angiographic findings associated with angina. Sequential univariate and multivariable modeling found the following demographic and clinical factors were associated with angina after CABG: younger age, worse preoperative SAQ angina frequency score, smoking, diabetes mellitus, and pre-CABG depression. The only 1-year angiographic finding significantly associated with angina was incomplete revascularization of the left anterior descending (LAD) territory. Graft occlusions, incomplete revascularization of non-LAD territories, and ≥70% lesions in nonrevascularized native coronary arteries were not correlated with the presence or absence of angina. Further, only 30.6% of subjects reporting angina at 1 year had a residual major coronary artery stenosis of ≥70%. Conclusions: Self-reported angina 1 year after CABG is associated with younger age, worse baseline SAQ angina frequency score, smoking, diabetes mellitus, and depression. The only angiographic finding associated with angina was a poorly revascularized LAD territory. These results may help guide physicians when counseling patients on expected improvements in angina symptoms and in making decisions regarding the need for coronary angiography after CABG. Whether intensive treatment of these comorbidities improves post-CABG angina symptoms requires further study. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT00032630.

Background: The impact of valvular heart disease (VHD) on outcomes in the Veteran population has not been well studied, especially in the contemporary era. Methods: The study population included 244 Veterans who were seen in Cardiology Clinic in January 2015 - of which 190 had a recent echocardiogram at the time of visit. Veterans with evidence of VHD (defined as any evidence of aortic stenosis (AS), > 2+ moderate mitral regurgitation (MR), and/or > 2+ tricuspid regurgitation(TR)) were identified and characteristics of Veterans with and without VHD were evaluated. Differences in one-year rates of major adverse cardiac events (MACE) (a composite of all-cause mortality or cardiovascular hospitalization) were compared for Veterans with VHD versus those without. Results: Of these 190 Veterans, 39 (20.5%) had evidence of valvular heart disease - 19 (10.0%) has any grade of AS, 15 (7.4%) has > 2+ MR, and 18 (9.5%) has > 2+ TR. Veterans with VHD were older (77 vs 68 years, p Conclusions: In Veterans with cardiovascular disease, presence of VHD is associated with higher rates of MACE and all-cause mortality at 1 year. Further research on VHD specifically in the Veteran population is warranted.

Robotic technology is one of the most recent technological changes in coronary artery bypass graft (CABG) operations. The current analysis was conducted to identify trends in the use and outcomes of robotic-assisted CABG (RA-CABG).A retrospective analysis was performed using data from The Society of Thoracic Surgeons Adult Cardiac Surgery Database between 2006 and 2012. Patient and site-level characteristics were compared between traditional CABG and RA-CABG. Operative death, postoperative length of stay, and postoperative complications were compared between the two groups.The number of sites using RA-CABG remained relatively constant during the study period (from 148 in 2006 to 151 in 2012). The volume of RA-CABG as a percentage of the total CABG procedures increased slightly from 0.59% (872 RA-CABG of 127,717 total CABG) in 2006 to 0.97% (1,260 RA-CABG of 97,249 total CABG) in 2012. The RA-CABG patients were significantly younger (64 vs 65 years, p0.0001), had fewer comorbidities, and had lower rates of cardiopulmonary bypass use (22.4% vs 80.4%, p0.0001). RA-CABG patients had significantly lower unadjusted major complication rates (10.2% vs 13.5%, p0.0001), including postoperative renal failure (2.2% vs 2.9%, p 0.0001), and shorter length of stay (4 vs 5 days, p 0.0001). The difference in operative death was not significant (odds ratio, 1.10; 95% confidence interval, 0.92 to 1.30, p = 0.29).RA-CABG use remained relatively stagnant during the analysis period despite lower rates of major perioperative complications and no difference in operative deaths. Additional analysis is needed to fully understand the role that robotic technology will play in CABG operations in the future.

Posttraumatic stress disorder (PTSD) is associated with ischemic heart disease (IHD) in men. Despite sex differences in the prevalence and pathophysiology of PTSD and IHD, research on this association in women is limited. The goal of this study was to evaluate the association of PTSD with IHD in

Background: It is unclear whether access to health care for veterans with cardiovascular disease (CVD) vary among U.S. regions. This study sought to determine the extent of regional variations in access to medical care in a cohort of U.S. veterans with CVD. Methods: The 2016 Centers for Disease Control Behavioral Risk Factor Surveillance Survey was utilized to identify a cohort of veterans with cardiovascular disease. Participants were classified based on four U.S. regions: (1) Northeast, (2) Midwest, (3) South, and (4) West. Presence of CVD was noted with a single affirmative response to the following questions: “Has a health care professional ever told you that you had any of the following:” (1) a heart attack or myocardial infarction, (2) angina or coronary heart disease, (3) a stroke? Demographic data, baseline medical history, and access to care for veterans of each U.S. region were compared. Results: Among the 13,835 veterans with CVD, 18.3% were from the Northeast, while 23.5%, 37.1%, and 21.0% were from the Midwest, South, and West respectively. Veterans from South were more likely to be younger (21.4% vs 18.5% in the Northeast vs 18.6% in the Midwest vs 19.1% in the West, p=0.0018) and Black (9.7% vs 2% in the Northeast vs 3.3% in the Midwest vs 1.9% in the West, p Conclusions: In this observational study involving U.S. veterans with CVD, West region was independently associated with lower rates of medical checkup within the past year. Further large-scale studies examining the prevalence of impaired access to care in U.S. veterans with CVD are warranted.

Background For diabetic patients who require coronary artery bypass graft (CABG) operation, controversy persists whether an off-pump or an on-pump approach may be advantageous. This US-based, multicenter, randomized, controlled trial, Department of Veterans Affairs Randomization On versus Off Bypass Follow-up Study, compared diabetic patients’ 5-year clinical outcomes for off-pump versus on-pump procedures. Methods From 2002 to 2008, 835 medically treated (ie, oral hypoglycemic agent or insulin) diabetic patients underwent either off-pump (n = 402) or on-pump (n = 433) CABG. Five-year primary end points included all-cause death and major adverse cardiovascular events (MACE; composite included all-cause death, myocardial infarction, or repeat revascularization). Secondary 5-year end points included cardiac death and MACE-related components. With baseline risk factors balanced, outcomes were evaluated by using a p value less than or equal to 0.01; nonsignificant trends were reported for p values greater than 0.01 and less than or equal to 0.15. Results Five-year all-cause death rates were 20.2% off pump versus 14.1% on pump (p = 0.0198). No differences were seen in MACE (32.6% off-pump approach versus 28.6% on-pump approach, p = 0.216), repeat revascularization (12.4% off-pump approach versus 11.8% on-pump approach, p = 0.770), and nonfatal myocardial infarction (12.7% off-pump approach versus 10.4% on-pump approach, p = 0.299). Cardiac death trended worse with off-pump CABG (9.0%) than with on-pump CABG (6.25%, p = 0.137). Sensitivity analyses that removed conversions confirmed these findings. Conclusions With a 6.1% absolute difference, a strong trend toward improved 5-year survival was observed with on-pump CABG for medically treated diabetic patients. No off-pump advantage was found for any 5-year end points. A future clinical trial now appears warranted to rigorously compare off-pump versus on-pump longer term outcomes for diabetic patients.

Studies examining utilization and impact of venous thromboembolism (VTE) chemoprophylaxis for patients undergoing bariatric surgery are limited. Determination of the optimal prophylactic regimen to minimize complications is crucial. The Cerner Health Facts database from 2003 to 2013 was queried using ICD-9 codes to identify patients undergoing laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB). VTE chemoprophylaxis regimens were divided into pre-operative alone (PreP), post-operative alone (PostP), both pre-operative and post-operative (PPP), or no prophylaxis (NP). Specific chemoprophylaxis agents were compared. Comparisons in inpatient clinical outcomes were based on univariate analysis and multivariable logistic regression when appropriate. We identified 11,860 patients who underwent LSG and RYGB. 634 (5.35%) had PreP, 4593 (38.73%) had PostP, 2646 (22.31%) had PPP, and 3987 (33.62%) had NP. The overall rates of transfusion, DVT, and PE were 2.48, 0.27, and 0.18%, respectively. Patients without chemoprophylaxis had higher rate of DVT compared to any chemoprophylaxis (0.58 vs 0.11%, p

Although depressive disorders have been associated with increased risk of worse outcomes with cardiovascular diseases (CVDs), its relation with access to and quality of cardiovascular care is not well studied. Accordingly, we sought to assess the association between depressive disorders and access and quality of care among United States veterans with CVD. The 2013 Centers for Disease Control's Behavioral Risk Factor Surveillance Survey was utilized to identify a cohort of 13,126 veterans with CVD. Demographic and clinical history were recorded in adults with and without a depressive disorder (defined as self-reported diagnosis of depression, major depression, minor depression, or dysthymia). Among 13,126 veterans studied, a total of 2,889 (22.0%) adults had a depressive disorder whereas 10,237 (78.0%) did not. The veterans with a depressive disorder were younger, more often female and non-white, and had higher rates of multiple medical co-morbidities. They were more likely to report a delay in receiving medical care and financial barriers to seeking care and taking prescription drugs. They also reported significantly lower rates of aspirin and antihypertensive drug use. In multivariate analysis, depressive disorder was independently associated with higher risk of delay in receiving medical care (OR [odds ratio] 2.07, 95% CI [confidence interval] 1.65 to 2.60), financial barriers to medical care (OR 1.96, 95% CI 1.45 to 2.65), and prescription drugs (OR 1.45, 95% CI 1.02 to 2.08). In conclusion, depressive disorders were associated with impaired access to care among United States veterans with CVD.

Objective To assess the usefulness of two definitions of acute clinical chorioamnionitis (ACCA) in predicting risk of neonatal infectious outcomes (NIO) and mortality, the first definition requiring maternal fever alone (Fever), and the second requiring ≥ 1 Gibbs criterion besides fever (Fever + 1). Study Design PubMed, Web of Science, and the Cochrane Database of Systematic Reviews were searched from January 1, 1979 to April 9, 2013. Twelve studies were reviewed (of 316 articles identified): three studies with term patients, four with preterm premature rupture of membranes (PPROM) patients, and five mixed studies with mixed gestational ages and/or membrane status (intact and/or ruptured). Results Both definitions demonstrated an increased NIO risk for ACCA versus non-ACCA patients, with an odds ratio increase for the Fever + 1 definition that was about twofold larger than the Fever definition. Conclusion As the Fever definition demonstrated increased NIO risk for ACCA versus non-ACCA patients, the Fever alone ACCA definition should be used to trigger future clinical treatment in many clinical situations.

Background Overexpression of keratin 17 (K17) is highly associated with poor prognosis in squamous cell carcinoma (SCC) of the cervix. This study was performed to (1) determine whether K17 may be a prognostic biomarker in head and neck squamous cell carcinoma (HNSCC) and (2) to establish if K17 expression is associated with human papillomavirus (HPV) status. Methods Immunohistochemical staining was performed for K17 of oral, oropharyngeal, and laryngeal SCCs, and normal oropharyngeal mucosa. The HPV status was determined using polymerase chain reaction (PCR). Results Elevated K17 expression was significantly associated with an overall decreased patient survival (P = .02) and, more specifically, in patients with oropharyngeal SCC (P = .01). When controlling for HPV status and tumor location K17 was still a significant predictor of survival (P = .01). Conclusion Therefore, K17 is a novel prognostic biomarker of poor survival for patients with HNSCCs, controlling for anatomic site and HPV status.

Since 2010, 460+ hospital mergers have occurred in the United States, rerouting historical coronary artery bypass graft (CABG) referral patterns. The goals of this study were: (1) to compare risk-adjusted CABG outcomes between single-center versus multicenter surgeons; and (2) for multicenter surgeons, to evaluate the risk-adjusted outcomes between their home (primary) versus satellite (secondary) hospitals.Using The Society of Thoracic Surgeons Adult Cardiac Surgery Database, nonemergent, first-time CABG procedures (n = 543,403) performed in the US between 2011 and 2014 were extracted across 1,120 centers and for 2,676 surgeons. Surgeons were classified as multicenter if they performed operations at two separate hospitals for ≥ 2 consecutive quarters; their home hospital was identified as their highest volume center. Observed-to-expected outcome ratios were reported using approved multivariable risk models for 30-day operative mortality and major morbidity.Of 2,676 cardiac surgeons, 668 (25.0%) operated at multiple centers. The observed-to-expected mortality ratios were 1.06 (95% confidence interval [CI], 1.01 to 1.12) and 0.97 (95% CI, 0.94 to 1.00) for multi- and single-center surgeons (p0.001). For multicenter surgeons, the observed-to-expected mortality ratios were 1.17 (95% CI, 1.09 to 1.27) versus 1.01 (95% CI, 0.96 to 1.07), p 0.001, for their satellite versus home facilities, respectively.Single-center surgeons performing CABG had lower risk-adjusted outcome rates compared with multicenter surgeons, who performed better at their home versus satellite hospitals. To improve future quality of care, surgeons, health care networks, and health policy makers should now more closely scrutinize their single versus multicenter performance.

Background: Improved access to care and quality of care can mitigate population level risk of heart disease and improve health outcomes. We sought to compare access to care in veterans versus non-veterans with cardiovascular disease (CVD) in the U.S. Methods: The 2013 Centers for Disease Control’s Behavioral Risk Factor Surveillance Survey was utilized to identify a cohort of 57,171 adults with CVD. Presence of CVD was noted with a single affirmative response to the following questions: “Has a health care professional ever told you that you had any of the following:” (1) a heart attack or myocardial infarction, (2) angina or coronary heart disease, (3) a stroke? Demographic data, clinical history and medication use were recorded in these patients. Access to care variables included report of financial barriers to medical care and/or prescription drug costs and report of delay in receiving medical care. Quality of care variables included annual blood cholesterol check, blood sugar testing, flu shot administration, antihypertensive use, and aspirin use. Results: Among 57,171 adults with CVD studied, 13,205 (23.1%) were veterans while 43,966 (76.9%) were non-veterans. Veterans with CVD tended to be older (p Conclusion: Veterans with CVD receive improved access to care and quality of care compared to their non-veteran counterparts.

Background: Depressive disorders have been independently associated with increased morbidity and mortality in adults with cardiovascular disease (CVD). We sought to assess the association between depressive disorder and access to care and quality of care among U.S. veterans with CVD. Methods: The 2013 Centers for Disease Control’s Behavioral Risk Factor Surveillance Survey was utilized to identify a cohort of 13,126 veterans with CVD. Presence of CVD was noted with a single affirmative response to the following questions: “Has a health care professional ever told you that you had any of the following:” (1) a heart attack or myocardial infarction, (2) angina or coronary heart disease, (3) a stroke? Access to care variables included report of financial barriers to medical care and/or prescription drug costs and report of delay in receiving medical care. Quality of care variables included annual blood cholesterol check, blood sugar testing, flu shot administration, antihypertensive use, and aspirin use. Results: Among 13,126 veterans studied, a total of 2,889 (22%) adults had a depressive disorder while 10,237 (78%) did not. Veterans with a depressive disorder tended to be younger (p Conclusions: Depressive disorder was associated with higher rates of financial barriers to care and prescription drugs, and patient-reported delays in medical care in U.S. veterans with CVD. Further research appears warranted to evaluate the impact of mental health disease upon cardiovascular care in veterans with CVD.

The Randomized Endo-vein Graft Prospective (REGROUP) trial (ClinicalTrials.gov NCT01850082) is a randomized, intent-to-treat, 2-arm, parallel-design, multicenter study funded by the Cooperative Studies Program (CSP No. 588) of the US Department of Veterans Affairs. Cardiac surgeons at 16 Veterans Affairs (VA) medical centers with technical expertise in performing both endoscopic vein harvesting (EVH) and open vein harvesting (OVH) were recruited as the REGROUP surgeon participants. Subjects requiring elective or urgent coronary artery bypass grafting using cardiopulmonary bypass with use of ≥1 saphenous vein graft will be screened for enrollment using pre-established inclusion/exclusion criteria. Enrolled subjects (planned N = 1150) will be randomized to 1 of the 2 arms (EVH or OVH) after an experienced vein harvester has been assigned. The primary outcomes measure is the rate of major adverse cardiac events (MACE), including death, myocardial infarction, or revascularization. Subject assessments will be performed at multiple times, including at baseline, intraoperatively, postoperatively, and at discharge (or 30 days after surgery, if still hospitalized). Assessment of leg-wound complications will be completed at 6 weeks after surgery. Telephone follow-ups will occur at 3-month intervals after surgery until the participating sites are decommissioned after the trial's completion (approximately 4.5 years after the full study startup). To assess long-term outcomes, centralized follow-up of MACE for 2 additional years will be centrally performed using VA and non-VA clinical and administrative databases. The primary MACE outcome will be compared between the 2 arms, EVH and OVH, at the end of the trial duration.

Clopidogrel use post coronary artery bypass grafting (CABG) has become more popular under the assumption that it improves graft patency. The purpose of this sub-analysis from the Randomized On and Off-Pump Bypass (ROOBY) trial is to evaluate the role of clopidogrel use post CABG to improve graft patency when added to standard aspirin therapy.The ROOBY trial was a multi-center, randomized, controlled clinical trial that compared on-pump versus off-pump coronary artery bypass grafting (CABG). Clopidogrel use post CABG was left at the discretion of the operator. Detailed data regarding the use and timing of clopidogrel post CABG were collected prospectively, along with 1-year angiograms to evaluate graft status.Of the 2,203 subjects undergoing CABG, 953 patient records had complete clopidogrel use and 1-year angiographic data. Of these, 345 (36.2%) received clopidogrel post CABG prior to discharge. Compared with patients with no post-CABG clopidogrel use, baseline characteristics were similar for the clopidogrel group except for the following: lower preoperative aspirin use (80.2% vs 86.7%, p = 0.009); higher preoperative clopidogrel use (23.5% vs 14.0%, p0.001), less on-pump (35.9% vs 55.9%, p0.0001); and lower endoscopic vein harvesting (30.8% vs 42.5%, p0.001) rates. Overall 1-year graft patency rates were not different between the clopidogrel and no-clopidogrel groups (86.5% vs 85.3%, p = 0.43). Multivariable analyses did not alter these findings.This study suggests that routine post-CABG clopidogrel use may not translate to improved 1-year graft patency. Future studies appear warranted to better define the role of more aggressive antiplatelet therapy post CABG on graft patency and clinical outcomes.

Patients with chronic obstructive pulmonary disease (COPD) are at inherent risk for higher rates of adverse events after coronary artery bypass graft surgery (CABG). As compared with on-pump CABG (ONCAB), it has been suggested that beating heart or off-pump CABG (OPCAB) may differentially benefit high-risk COPD patients.Intraoperative, 30-day and 1-year outcomes were compared for COPD patients randomized to OPCAB (n = 220) versus ONCAB (n = 238) within the Veterans Affairs' Randomized On/Off Bypass (ROOBY) trial. As COPD patients may more likely incur adverse post-CABG outcomes, a propensity analysis was performed comparing all ROOBY patients with COPD (n = 458) versus those without COPD (n = 1,745).For COPD patients, the baseline characteristics were similar between the 2 revascularization approaches. In these patients, the intraoperative complication rate was higher with OPCAB than ONCAB (21.9% vs 10.1%, respectively; p0.001), but there were no significant differences in the 30-day (7.3% vs 7.6%, p = 1.00) or 1-year composite outcome rates (9.5% vs 7.1%, p = 0.39) between the groups. Comparing the COPD patients with propensity-matched non-COPD patients, there was no difference in 1-year major adverse cardiovascular events (including the 1-year composite major adverse cardiac events (MACE) outcome, as well as the individual MACE outcomes for all cause death, acute myocardial infarction, or repeat revascularization).In COPD patients, there were more intraoperative complications and no differences in 30-day or 1-year outcomes with OPCAB as compared with ONCAB. Similar to patients without COPD, there was no benefit to using an OPCAB approach in COPD patients.

Stony Brook University School of Medicine (SBU SOM) used a Liaison Committee on Medical Education (LCME) site visit to design a change management approach that engaged students, revitalized faculty, and enabled significant, positive institutional transformation while flexibly responding to concurrent leadership transitions. This "from-the-trenches" description of novel LCME site-visit-related processes may provide an educational program quality improvement template for other U.S. medical schools. The SBU SOM site visit processes were proactively organized within five phases: (1) planning (4 months), (2) data gathering (12 months), (3) documentation (6 months), (4) visit readiness (2 months), and (5) visit follow-up (16 months). The authors explain the key activities associated with each phase.The SBU SOM internal leadership team designed new LCME-driven educational performance reports to identify challenging aspects of the educational program (e.g., timeliness of grades submitted, midcourse feedback completeness, clerkship grading variability across affiliate sites, learning environment or student mistreatment incidents). This LCME process increased institutional awareness, identified the school's LCME vulnerabilities, organized corrective actions, engaged key stakeholders in communication, ensured leadership buy-in, and monitored successes. The authors' strategies for success included establishing a strong internal LCME leadership team, proactively setting deadlines for all phases of the LCME process, assessing and communicating vulnerabilities and action plans, building multidisciplinary working groups, leveraging information technology, educating key stakeholders through meetings, retreats, and consultants, and conducting a mock site visit. The urgency associated with an impending high-stakes LCME site visit can facilitate positive, local, educational program quality improvement.

Studies investigating lipid-lowering medication (LLM) use and LDL levels in coronary artery bypass grafting patients are limited.The Veterans Affairs Randomized On/Off Bypass Trial's patient records were analyzed for LLM use and 1-year LDL levels. Mortality, acute MI (AMI), and repeat revascularization rates were compared at 1 year between patients with and without LLM at discharge. In addition, AMI, repeat revascularization, and graft patency were compared between patients that did and did not achieve a 1-year LDL target level of100 mg/dL.The LLM data were available for 86.4% (1,904 of 2,203) of patients. Rates of LLM use were 83.4% (1,316 of 1,577) at discharge and 90.0% (1,713 of 1,904) at 1 year. Patients discharged after coronary artery bypass grafting on LLMs had a significantly lower 1-year mortality rate (1.9% vs 5.4%; p0.01) than those not discharged on LLM, and 1-year AMI and repeat revascularization rates were not significantly different. Of the patients with 1-year LDL measurements, 69.4% (1,200 of 1,729) achieved an LDL target level of100 mg/dL. No differences were seen in AMI, revascularization, or graft occlusion rates between patients who achieved target LDL levels and those who did not.Rates of LLM use among veterans post-coronary artery bypass grafting are high. Discharge on LLM might be associated with improved intermediate-term survival. Patients who achieved an LDL target of100 mg/dL at 1-year did not experience improved 1-year clinical outcomes or graft patency. Longer-term follow-up might reveal differences in cardiac outcomes related to achievement of target LDL levels.