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Introduction: Dual Antiplatelet Therapy (DAPT) is a class I guideline indication after Percutaneous Coronary Intervention (PCI). Our population is high-risk for low medication adherence. With a multidisciplinary team we developed a telephone-based intervention to improve DAPT adherence post-PCI. Methods: Patients undergoing PCI at our center were contacted by nursing staff via telephone at 1 week, 30 days, and 60 days post-procedure. Calls included a reminder of the importance of DAPT and elicited any patient concerns. Concerns were relayed to the team who could take appropriate action. For patients filling their medications at any pharmacies within our closed system the proportion of days covered (PDC) was calculated. These were compared to data for patients undergoing PCI in the seven months prior to program initiation. Information on interventions performed as a result of calls was also collected. Results: During the study period, 452 patients underwent PCI. Of these, 70% were contacted and 244 filled their prescription at our system pharmacies. Twelve-month median PDC was 74%, with 45% of patients having PDC >80%. There was no significant difference when compared to the group prior to the intervention, median PDC 79% and 50% of patients having PDC >80%. In 26 patients calls led to interventions, removing barriers that would have otherwise prevented continued adherence. Conclusion: A telephone-based reminder system led to directed interventions in nearly 1 in 10 patients contacted. It was not able to significantly improve PDC when compared to a contemporary sample. This highlights the difficulty in using PDC to detect barriers to adherence.

Background Cardiac troponin concentrations differ in women and men, but how this influences risk prediction and whether a sex-specific approach is required is unclear. We evaluated whether sex influences the predictive ability of cardiac troponin I and T for cardiovascular events in the general population. Methods High-sensitivity cardiac troponin (hs-cTn) I and T were measured in the Generation Scotland Scottish Family Health Study of randomly selected volunteers drawn from the general population between 2006 and 2011. Cox-regression models evaluated associations between hs-cTnI and hs-cTnT and the primary outcome of cardiovascular death, myocardial infarction, or stroke. Results In 19 501 (58% women, mean age 47 years) participants, the primary outcome occurred in 2.7% (306/11 375) of women and 5.1% (411/8126) of men during the median follow-up period of 7.9 (IQR, 7.1–9.2) years. Cardiac troponin I and T concentrations were lower in women than men (P

Background: Out-of-pocket costs are a serious barrier to care and drive suboptimal medical therapy. Understanding of these costs can lead to care oriented around the limits they generate. Despite this, there is minimal attention paid to these costs in post-graduate education. Objective: To define a potential knowledge gap regarding costs experienced by patients by surveying Internal Medicine residents at our large academic institution. Methods: We surveyed Internal Medicine residents in spring 2019 about knowledge and practices surrounding patient out-of-pocket costs. Participants answered questions considering their most recent inpatient panel and their clinic patient panel. Familiarity was ranked on a 5-point Likert scale, and for the purposes of presentation, was divided into “Poor” and “Moderate or Better.” Non-parametric analysis was used to test differences between outpatients and inpatients and by year of training. Results: Of 159 residents, 109 (67%) responded. Familiarity with patient insurance status was moderate or better in 85%. Reported understanding of costs associated with medications, testing, and clinic visits was less common. Respondents had higher familiarity with out-of-pocket costs for clinic patients compared with inpatients. Knowledge of cost of care was not an often-considered factor in decision making. There was no significant difference in response by year of training. Conclusion: Patient out-of-pocket costs are an important dimension of patient care which Internal Medicine Trainees at our institution do not confidently understand or utilize. Improvements in education around this topic may enable more patient-centered care.

Introduction: Out-of-pocket costs (OOPC) are a significant barrier to care and drive suboptimal medical therapy in ASCVD. Despite this, there is minimal attention paid to these costs in post-graduate education. To define a potential knowledge gap, we surveyed trainee understanding of OOPC. Methods: We surveyed Internal Medicine residents at a large academic program comprised of a large county safety-net hospital, a VA, and a private tertiary care hospital, about knowledge and practices surrounding patient OOPC. Residents rotate on services at all sites and the vast majority have primary care clinic at the county or VA hospital. Participants answered questions considering their most recent inpatient panel and their clinic patient panel. Familiarity was ranked on a 5-point Likert scale, and for the purposes of presentation, was divided into “Poor” and “Moderate or Better”. Non-parametric analysis was used to test differences between outpatients v inpatients and by year of training. Results: Of 159 residents, 106 (67%) responded. Familiarity with patient insurance status was moderate or better in 135 of 159 (85%). Moderate or better understanding of costs associated with medications (52% [83 of 159]), testing (19% [30 of 159]) and clinic visits (30% [48 of 159]) was less common. Respondents had higher familiarity with OOPC for clinic patients compared with their most recent inpatient panel: clinic visits (39% v 21% [62 v 33 of 159 p < 0.005]), testing (25.7% v 12.4% [41 v 20 of 159 p = 0.002]), and medications (62% v 42% [99 v 67 of 159 p Discussion: Our survey demonstrates that trainee familiarity with OOPC was low overall but modestly higher for established clinic patients, perhaps reflecting longitudinal experience with them or the heterogeneity of admitted patient funding status. Familiarity with patient OOPC was not an often-considered factor in decision making and did not significantly improve over years of training. This suggests an important gap in trainee education. Teaching greater familiarity with patient OOPC during residency can increase awareness of the financial realities of patients, enabling more patient-centered care.

Key Points Question Is implementation of a novel high-sensitivity cardiac troponin T protocol in patients with chest pain associated with less resource use and within acceptable safety parameters? Findings This cohort study of 31 543 emergency department encounters found that implementation of the protocol was associated with a shorter length of stay in the emergency department and a higher proportion of patients discharged. There was no difference in the rate of 30-day hospitalization for myocardial infarction or death. Meaning This or similar protocols that rapidly rule out myocardial infarction have the potential to reduce emergency department overcrowding and improve health care quality., This cohort study of patients at a large US safety net hospital examines the safety of and resource use associated with a new protocol for excluding myocardial infarction from diagnosis of patients with chest pains through the use of high-sensitivity troponin., Importance High-sensitivity cardiac troponin T (hs-cTnT) protocols for the evaluation of chest pain in the emergency department (ED) may reduce unnecessary resource use and overcrowding. Objective To determine whether the implementation of a novel hs-cTnT protocol, which incorporated troponin values drawn at 0, 1, and 3 hours after ED presentation and the modified HEART score (history, electrocardiogram, age, risk factors), was associated with improvements in resource use while maintaining safety. Design, Setting, and Participants This retrospective cohort study from Parkland Health and Hospital System, a large safety net hospital in Dallas, Texas, included data on 31 543 unique ED encounters in which patients underwent electrocardiographic and troponin testing from January 1, 2017, to October 16, 2018. The hs-cTnT protocol was implemented in December 2017. Main Outcomes and Measures Resource use outcomes included trends in ED dwell time, troponin to disposition decision time (the difference between the first troponin draw time and the time an order was placed for inpatient admission, admission to observation, or discharge), and final patient disposition. Safety outcomes included readmission for myocardial infarction and death. Results In 31 543 encounters, mean (SD) patient age was 54 (14.4) years and 14 675 patients (48%) were female. Department dwell time decreased by a mean of −1.09 (95% CI, −2.81 to 0.64) minutes per month in the preintervention period. The decline was steeper after the intervention (−4.69 [95% CI, −9.05 to −0.33] minutes per month) (P for interaction = .007). The troponin to disposition time was increasing in the preintervention period by 1.72 (95% CI, 1.08 to 2.36) minutes per month; postintervention, the mean difference increased more slowly (0.37 [95% CI, −1.25 to 1.99 minutes per month; P value for interaction = .007]). The proportion of patients discharged from the ED increased after the intervention (48% vs 54%, P

We describe the validation and implementation of the new 5th generation high sensitivity Troponin T assay (Roche Diagnostics®). In addition to the assay improved sensitivity, the numerical values, reporting units, reference intervals, and critical limits are markedly different. We describe the use of clinical correlation as the basis for implementation and validation of the fifth-generation hs-TnT assay at a large teaching county hospital.

Background Acute coronary syndrome (ACS) is a common diagnosis in the emergency department (ED). Missing this diagnosis may lead to increased morbidity or mortality. With improved cardiac biomarkers tests, it is unknown if that has decreased the prevalence of ACS diagnoses in ED patients who were recently evaluated in the ED. Methods This is a retrospective review of ED patients who were diagnosed with ACS and seen in the ED 7 and 30 days before that visit in North Texas between 2009 and 2015. The demographics and temporal trends of missed ACS rates are described. Logistic regression was used to evaluate if any factors (ie, age, ethnicity, sex, insurance status) were significant. Results Between December 26, 2008 and June 29, 2015, there were 24,914 diagnoses of ACS in the ED. The overall prevalence of patients diagnosed with ACS 7 days after their ED visit was 3.2% and 8.8% at 30 days. For patients diagnosed with ACS 7 days and 30 days after an ED visit, the most common initial ED diagnoses were nonspecific chest pain (57.7%), atherosclerotic disease (19.5%), and heart failure (12.8%). Between 2009 and 2015, there was no overall change in the rate of ACS diagnoses in patients seen 7 or 30 days before an ED visit. Conclusions The prevalence of missed ACS in the North Texas region at 7 and 30 days after the initial ED visit is low and has not changed over the past several years.

Context: Poor adherence to dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) is associated with poor outcomes including stent thrombosis, rehospitalization, and mortality. Safety-net patients are at high risk for low adherence due to poor health literacy and financial constraints. Understanding and overcoming barriers to patient adherence to DAPT after PCI may reduce the risk of adverse outcomes in safety-net patients. Objective: A multidisciplinary team of Nurses, Pharmacists, Internal Medicine Residents, and Cardiologists designed and implemented a telephone-based intervention to improve adherence to DAPT after PCI at Parkland Health & Hospital System (PHHS), a safety-net hospital system in Dallas, Texas. Methods: Beginning 9/1/17, nurses from the Parkland Cardiac Catheterization Laboratory called all PCI patients 7, 30, and 90 days post-PCI. Patients were reminded of the importance of DAPT and asked if they had concerns about their medications. Specific issues that arose were handled by the multidisciplinary team via interventions such as: provision of vouchers for reduced-cost medications, change in pharmacy or medication to lower cost, appointment with Pharmacy or Cardiology clinicians to discuss medication, confirmation of active refills. The total number of patients with self-reported nonadherence was quantified, as was proportion of days covered (PDC) on DAPT at 6 months, defined as the total number of days filled in the first 6 months post-PCI divided by 180 days. Results: From 9/1/17 - 2/28/18, 189 patients underwent PCI at Parkland. Of these patients, 67% (127 of 189) were able to be contacted, with 10% (13 of 127) of contacted patients reporting problems with medications resulting in complete nonadherence and requiring intervention. Of the total treated patients, 65% (123 of 189) had prescriptions filled at PHHS pharmacies which allowed for manual calculation of adherence data and 72% (89 of 123) of these patients were successfully contacted. Median PDC was 94% at 6 months, with PDC >90% in 59% (72 of 123) of all patients and 62% (55 of 89) of successfully contacted patients. A historical control sample (N=154) who underwent PCI at Parkland from 1/1/16 - 8/31/17 and filled prescriptions at PHHS pharmacies had a median PDC of 92% at 6 months, with PDC >90% in 55% (84 of 154). There was no significant difference in median PDC (p=0.4) or proportion of patients with PDC >90% in either all-study (p=0.37) or successful contact (p=0.19) patient populations compared to this control. Conclusion: A telephone-based intervention allowed for identification and resolution of potentially catastrophic barriers to DAPT adherence in 1 in 10 contacted patients within 6 months post-PCI. However, it was unable to significantly improve medication adherence as measured by PDC, indicating that this adherence metric may not be an adequate measure of impact in this context.

IMPORTANCE: Higher coronary artery calcium (CAC) identifies individuals at increased atherosclerotic cardiovascular disease (ASCVD) risk. Whether it can also identify individuals likely to derive net benefit from aspirin therapy is unclear. OBJECTIVE: To examine the association between CAC, bleeding, and ASCVD and explore the net estimated effect of aspirin at different CAC thresholds. DESIGN, SETTING, AND PARTICIPANTS: Prospective population-based cohort study of Dallas Heart Study participants, free from ASCVD and not taking aspirin at baseline. Data were analyzed between February 1, 2020, and July 15, 2020. EXPOSURES: Coronary artery calcium score in the following categories: 0, 1-99, and 100 or higher. MAIN OUTCOMES AND MEASURES: Major bleeding and ASCVD events were identified from International Statistical Classification of Diseases and Related Health Problems, Ninth Revision codes. Meta-analysis–derived aspirin effect estimates were applied to observed ASCVD and bleeding rates to model the net effect of aspirin at different CAC thresholds. RESULTS: A total of 2191 participants (mean [SD], age 44 [9.1] years, 1247 women [57%], and 1039 black individuals [47%]) had 116 major bleeding and 123 ASCVD events over a median follow-up of 12.2 years. Higher CAC categories (CAC 1-99 and ≥100 vs CAC 0) were associated with both ASCVD and bleeding events (hazard ratio [HR], 1.6; 95% CI, 1.1-2.4; HR, 2.6; 95% CI, 1.5-4.3; HR, 4.8; 95% CI, 2.8-8.2; P

Background: Although hospitalization for acute decompensated heart failure (HF) is common and associated with poor outcomes and high costs, few evidence-based recommendations are available to guide patient management. Thus, management of inpatient HF remains heterogeneous. We evaluated if physician-specific self-reported HF practice patterns were associated with 2 important contributors to resource utilization: length of stay (LOS) and 30-day readmission. Methods and Results: A 5-point Likert scale survey was created to assess physician-specific HF discharge strategies and administered to all cardiologists and hospitalists at a single large academic teaching hospital. Practice patterns potentially impacting LOS and discharge decisions were queried, including use of physical examination findings, approaches to diuretic use and influence of kidney function. Likert scale responses are reported as means with any value above 3.00 considered more influential and any value below 3.00 considered less influential. Physician-specific LOS and 30-day readmission rates from July 1, 2015, to June 30, 2016, were extracted from the electronic record. We received survey responses and HF utilization metrics from 58 of 69 surveyed physicians (32 hospitalists and 26 cardiologists), encompassing 753 HF discharges over a 1-year period. Median LOS was 4.5 days (interquartile range, 4.0–5.8) and total 30-day readmission rate was 17.0% (128 unique readmissions). Physicians with below-median LOS placed less importance on observing a patient on oral diuretics for 24 hours before discharge (Likert 2.54 versus 3.30, P =0.01), reaching documented dry weight (Likert 2.93 versus 3.60, P =0.02), and complete resolution of dyspnea on exertion (Likert 3.64 versus 4.10, P =0.03) when compared with those above-median LOS. In contrast, no surveyed discharge practices were associated with physician-specific 30-day readmission. Conclusions: We identified specific inpatient HF discharge practice patterns that associated with shorter LOS but not with readmission rates. These may be targets for future interventions aimed at cost reduction; additional larger studies are needed for further exploration.

Background: Coronary angiography is frequently performed after the initial diagnosis of heart failure to determine etiology and revascularization strategy. Current body of evidence suggests that surgical revascularization conveys a mortality benefit as compared to medical therapy alone, and the role of percutaneous coronary intervention (PCI) is not yet established. The aim of this study is to describe revascularization patterns among patients presenting with systolic heart failure who underwent diagnostic angiography at a large urban county hospital. Methods: We evaluated patients presenting to the emergency department with symptomatic heart failure with reduced ejection fraction (HFrEF) without acute coronary syndrome (n=150; average left ventricular ejection fraction of 25%) who underwent coronary angiography between January 2011 and January 2015. We defined surgical coronary artery disease (CAD) as: 1) three-vessel disease, 2) two-vessel disease including the proximal LAD artery, or 3) two-vessel disease including the left main coronary artery. Primary outcomes included intervention (PCI, CABG, or medical therapy [MT] alone) as well as referral for CABG. Results: Of patients presenting with HFrEF who underwent diagnostic angiography, 80% (n=120) of patients had obstructive CAD with 36% (n=43) of those patients having surgical CAD. Of those with surgical CAD, 74% (n=32) underwent PCI, 18% (n=8) underwent CABG and 7% (n=3) received MT alone. Of patients with 1-vessel CAD, or 2-vessel CAD without involvement of the proximal LAD artery or left main coronary artery, 81% (n=63) underwent PCI while 19% (n=14) received MT alone. Conclusion: Patients presenting with symptomatic HFrEF referred for cardiac catheterization have a high prevalence of obstructive CAD. Most patients with evidence of either surgical or non-surgical CAD during coronary angiography underwent revascularization, with PCI being the dominant revascularization method.

Background: Focused cardiac ultrasound (FCU) has been used to answer clinical questions. Chemotherapy-related cardiotoxicity (CRR) is an entity that requires serial echocardiography. It is unknown whether FCU can be used to screen for CRR using advanced practice providers (APPs). The goal of this study is to determine if FCU can be used to reliably evaluate left ventricular ejection fraction (EF) by an APP to assess for CRR. Methods: The study was conducted at the Echo lab and the Oncology clinic. An Oncology APP was trained on the use of FCU and EF analysis. The APP was trained to obtained standard 2D views for EF assessment and on EF interpretation. The EF assessment was compared to sonographer echocardiogram on the same day. EF was assessed by a cardiologist and this was deemed to be the gold standard. The studies were all analyzed by two separate blinded cardiologists and the degree of correlation was analyzed. Linear regression modeling to analyze correlation between EF interpretation between all blinded observers and Bland Altman analysis was performed. Image quality was evaluated for all FCU images by a single blinded cardiologist and segmental endocardial border delineation was scored. Results: A total of 91 patients were scanned in Phase I of the study. The correlation coefficient between cardiologists was r=0.93. The correlation between cardiologist and APP were r=0.79 and 0.76 respectively. For the images obtained by the APP, the correlation between the APP and cardiologists were =0.83 and re=0.78. The correlation between APP and EF gold standard was r=0.77. The correlation between experienced cardiologists interpreting the FCU images was r=0.87. All images were determined to be interpretable. Conclusions: There was good correlation between cardiologists with respect to EF analysis. There was also good correlation between APP and cardiologists for EF analysis. Image quality from FCU was found to be good and acceptable for interpretation. This study demonstrates it is feasible to train an APP on obtaining images for EF analysis and they can be trained on EF interpretation with good correlation with experienced echocardiographers. We will evaluate outcomes associated with its use including delays to chemotherapy imposed by traditional echocardiography, cost to the health care system and patient-reported outcomes.

Large randomized trials have provided inconsistent evidence regarding the benefit of intensive blood pressure (BP) lowering in hypertensive patients. Identifying which patients derive a higher net benefit is essential in informing clinical decision-making. We used patient-level data from 2 trials that tested intensive versus standard BP lowering, Systolic Blood Pressure Intervention Trial (SPRINT) and Action to Control Cardiovascular Risk in Diabetes (ACCORD), to assess whether stratification by cardiovascular disease (CVD) risk will identify patients with a more favorable risk-benefit profile for intensive BP lowering. Within SPRINT, we selected a subset of patients at the extremes of major adverse cardiovascular event rates to develop a decision tree using recursive partitioning modeling. We then validated its predictive effects in the remaining ‘intermediate’ SPRINT subset (n = 8,357) and externally in ACCORD (n = 2,258). Recursive partitioning produced a 3-variable decision tree model consisting of age ≥74 years, urinary albumin-creatinine ratio ≥34, and history of clinical CVD. It classified 48.6% of SPRINT and 55.3% of ACCORD patients as “high-risk.” Compared with standard treatment, intensive BP lowering was associated with lower rates of major adverse cardiovascular event in this high-risk population in both SPRINT cross-validation data (hazard ratio [HR] 0.66, 95% confidence interval [CI] 0.52 to 0.85) and ACCORD (HR 0.67, 95% CI 0.50 to 0.90), but not in the remaining low-risk patients (SPRINT: HR 0.83, 95% CI 0.56 to 1.25; ACCORD: HR 1.09, 95% CI 0.64 to 1.83). Additionally, intensive BP lowering did not confer an excess risk of serious adverse events in the high-risk group. In conclusion, this simple risk prediction model consisting of age, urinary albumin-creatinine ratio, and clinical CVD history successfully identified a subset of hypertensive patients who derived a more favorable risk-benefit profile for intensive BP lowering.

Background: Large randomized trials have provided inconsistent evidence regarding the benefit of intensive BP lowering in hypertensive patients. Identifying which patients derive a higher net benefit is essential in informing clinical decision-making. Objectives: To assess whether stratification by cardiovascular disease (CVD) risk will identify patients with a more favorable risk/benefit profile for intensive BP lowering. Methods: We used patient-level data from two trials that tested intensive vs. standard BP lowering: SPRINT and ACCORD. Within SPRINT, we selected a subset of patients at extremes of major adverse cardiovascular event (MACE) rates to develop a decision-tree using recursive partitioning modeling. We then validated its predictive effects in the remaining ‘intermediate’ SPRINT subset (n=8,357) and externally in ACCORD (n=2,258). Results: Recursive partitioning produced a three-variable decision-tree model consisting of age≥74 years, urinary albumin/creatinine ratio (UACR) ≥34, and history of clinical CVD. It classified 48.6% of SPRINT and 55.3% of ACCORD patients as “high-risk”. Compared with standard treatment, intensive BP lowering was associated with lower rates of MACE in this high-risk population in both SPRINT cross-validation data (HR=0.66, 95% CI 0.52-0.85) and ACCORD (HR=0.67, 95% CI 0.50-0.90), but not in the remaining low-risk patients (SPRINT: HR=0.83, 95% CI 0.56-1.25; ACCORD: HR=1.09, 95% CI 0.64-1.83). Additionally, intensive BP lowering did not confer an excess risk of serious adverse events in the high-risk group. Conclusions: A simple risk prediction model consisting of age, UACR, and clinical CVD history successfully identified a subset of hypertensive patients who derived a more favorable risk/benefit profile for intensive BP lowering.

Background: Therapeutic anticoagulation with Warfarin among patients with atrial fibrillation reduces the risk of stroke. To achieve this risk reduction, it is important that the TTR is > 65%. Novel oral anticoagulants are noninferior or superior to Warfarin in reducing the risk of stroke and do not require maintaining a narrow therapeutic window. The goals of this study were to determine the TTR in a safety-net hospital system as well as predictors of poor TTR. Second, we set out to determine the association between medication nonadherence and TTR. If nonadherence is a significant independent predictor of TTR, this implies that a universal policy of switching to NOACs without considering patient adherence may not improve outcomes. Methods: We queried the Parkland Health and Hospital System electronic medical record for all patients from January 2010 to 2016 with a diagnosis of atrial fibrillation or flutter on EKG who were on warfarin and had INR results available during the study period. TTR was calculated using the Rosendaal method. Patients were grouped into TTR quartiles. Adherence to Warfarin was defined by the proportion of days covered to the medication (0 – 100%). Multivariable linear regression modeling was used to assess the associations between demographic, comorbid conditions, and adherence and TTR. Results: A total of 2,626 patients were included in the analysis. There was significant variability in the TTR with the median TTR of 50% and IQR of 31 - 66. Younger age, black race, alcohol and drug use history, use of antiplatelet medications, and systolic blood pressure >160 was associated with having TTR in the lowest quartile ( Conclusions: TTR to Warfarin in this underserved population is suboptimal. Given that adherence to Warfarin is independently associated with poor TTR, in the absence of strong adherence interventions, a policy of universal NOAC adoption is unlikely to significantly improve outcomes. If patients are transitioned to NOACs, this data implies that a targeted adherence intervention will be necessary to ensure that the medication is effective in reducing the risk of stroke.

Background Premature clopidogrel discontinuation after drug‐eluting stent placement is associated with adverse outcomes. Little is known about patient and hospital factors associated with premature discontinuation or whether less variation in premature discontinuation exists in integrated health care systems such as the Veterans Affairs (VA). Methods and Results We evaluated the frequency of premature clopidogrel discontinuation, defined as a gap between clopidogrel refills of ≥90 days during the first 6 months of treatment, among 12 707 patients who received drug‐eluting stents in VA hospitals between 2008 and 2010. We evaluated the association between premature discontinuation and all‐cause mortality and/or acute myocardial infarction, variation in the proportion of premature discontinuation among hospitals, the patient and hospital characteristics associated with premature discontinuation, and the extent to which unexplained hospital characteristics contribute to premature discontinuation. Of the patients, 963 (7.6%) discontinued clopidogrel prematurely. Premature discontinuation was associated with acute myocardial infarction and all‐cause mortality (hazard ratio 1.65, 95% CI 1.37–1.99, P P Conclusion One in 13 patients prematurely discontinued clopidogrel, and variation in discontinuation across hospitals was observed. Patient factors were associated with premature discontinuation that may represent targets for quality improvement.

Background— The inverse, dose-dependent association between cardiorespiratory fitness and mortality is well-established; however, the pattern of the association between low fitness and mortality across short- (0 to 10 years), intermediate- (10 to 20 years), and long-term (>20 years) follow-up has not been studied. Methods and Results— We included 46 575 men and 16 151 women (mean age 44 years) from the Cooper Center Longitudinal Study. Participants were categorized as either “low fit” or “not low fit,” based on age- and sex- adjusted treadmill times, and were followed for mortality, determined from the National Death Index. Multivariable-adjusted Cox proportional hazards models were constructed to compare the association between fitness and traditional risk factors, with mortality outcomes across short-, intermediate-, and long-term follow-up. After a median follow-up of 16 years, there were 1295 cardiovascular disease and 2840 noncardiovascular disease deaths. Low fitness was associated with all-cause mortality across all periods in men [0 to 10 years: hazard ratios (HR), 1.99 (95% confidence interval [CI], 1.66 to 2.40); 10 to 20 years: HR, 1.61 (95% CI, 1.41 to 1.84); and >20 years: HR, 1.42 (95% CI, 1.27 to 1.60)] and in women [0 to 10 years: HR, 1.98 (95% CI, 1.27 to 3.10); 10 to 20 years: HR, 1.90 (95% CI, 1.40 to 2.56); and >20 years: HR, 1.54 (95% CI, 1.15 to 2.07)]. Similar results were seen for both cardiovascular disease and noncardiovascular disease mortality. Although these associations were also consistent across most subgroups, low fitness appeared to be most strongly associated with mortality in the short term among individuals at highest short-term risk (ie, older age, abnormal exercise test). Conclusions— Similar to traditional risk factors, fitness is associated with mortality across short-, intermediate-, and long-term follow-up.

Anabolic hormone use is increasingly common and includes replacement in patients with hormone deficiencies, questionable uses in those with borderline-low levels, and clear abuses among athletes aiming to gain a competitive advantage. Recently, direct-to-consumer marketing touting the benefits of

In the 1980s a change occurred in hydrochlorothiazide prescribing practices for hypertension from high-dose (50 mg/day) to low-dose (12.5-25 mg/day) therapy. However, randomized controlled trials (RCT) for prevention of calcium-containing kidney stones (CCKS) employed only high doses (≥ 50 mg/day). We hypothesized that these practices have resulted in underdosing of hydrochlorothiazide for prevention of CCKS. Patients with a filled prescription for thiazide diuretics that underwent a 24-h urine stone risk factor analysis were eligible. Those with evidence that thiazide was prescribed for CCKS were further analyzed. Of 107 patients, 102 were treated with hydrochlorothiazide, 4 with indapamide, and one with chlorthalidone. Only 35% of hydrochlorothiazide-treated patients received 50 mg/day; a dose previously shown to reduce stone recurrence. Fifty-two percent were prescribed 25 mg and 13% 12.5 mg daily, doses that were not studied in RCT. Evidence-based hydrochlorothiazide use was suboptimal regardless of where the patient received care (Nephrology or Endocrinology clinic). In a small subset of patients (n = 6) with 24-h urinary calcium excretion measured at baseline and after 2 hydrochlorothiazide doses (25 and ≥ 50 mg), there was a trend toward decreased urinary calcium excretion as the dose was increased from 25 to ≥ 50 mg/day (p = 0.051). Low-dose hydrochlorothiazide was often used for prevention of CCKS despite the fact that there is no evidence that it is effective in this setting. This may have resulted from a practice pattern of using lower doses for hypertension therapy or a lack of knowledge of RCT results in treatment of CCKS.

Background— Despite calls to expand measurement of acute myocardial infarction (AMI) outcomes to include symptom burden, little has been done to describe hospital-level variation in this patient-centered outcome, or its association with mortality. Understanding the relationship between symptoms and longer-term mortality could inform the importance of these outcomes for monitoring quality of care. Methods and Results— Among 4316 patients with AMI treated at 24 hospitals participating in the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH) study, we assessed risk-standardized 1-year symptom burden as measured by the Seattle Angina Questionnaire Angina Frequency Score and mortality attributed to the hospital that provided AMI care. Median odds ratios were used to assess outcome variation and reflect the relative odds of an outcome for 2 patients with identical covariates at different, randomly selected, hospitals. We then evaluated the correlation between hospital-level mortality and angina. Finally, we determined the extent to which variation in mortality and angina was explained by achievement of AMI performance measures. We observed hospital variation in risk-adjusted 1-year mortality (range, 4.9%–8.6%; median odds ratio, 1.30; P =0.01) and angina (range, 17.7%–29.4%; median odds ratio, 1.34; P r =0.40; 95% confidence interval, 0.00–0.68; P =0.05). Accounting for the quality of AMI care did not attenuate variation in risk-adjusted 1-year mortality or angina. Conclusions— Symptom burden and mortality vary at the hospital level after AMI and are only weakly correlated. These findings suggest that symptom burden should be considered a separate quality domain that is not well captured by current quality metrics.

Background: ACC/AHA guidelines recommend that patients with acute myocardial infarction (AMI) follow-up within several weeks of hospital discharge. Recommendations regarding intensity of following-up in the year following AMI are not provided. The relationship between frequency of follow-up and use of evidence-based therapies following AMI is unknown. Methods: 6,838 patients from 2 multicenter prospective AMI registries, PREMIER and TRIUMPH registries were studied. We divided the number of patient self-reported outpatient follow-up visits with cardiologists, primary care providers, or both into tertiles: low, medium, and high. The primary outcome was use of statins, beta blockers, aspirin, ACE/ARBs, and a composite of all four medications at 12 months among eligible patients. The association between tertiles of visits following AMI among patients who had at least one visit and primary outcome was evaluated using hierarchical multivariable modified Poisson models. Results: Mean number of follow-up visits in the year following AMI was 6 (IQR 3 - 8) and 189 (4%) of patients had no visits. In lowest tertile, patients had 1 to < 4 visits, in the medium tertile, 4 to < 7 visits, and in highest tertile, 7 to 59 visits. Patients in medium and high intensity tertiles were older, more likely to have insurance, and had higher GRACE 6-month mortality risk scores compared to the lowest tertile. In multivariable analyses, patients in the medium tertile were more likely to use statins and ASA than those in the lowest tertile (Figure). There were no differences in use of individual medications when comparing the highest and medium tertiles although individuals in the highest tertile were less likely to use all four medications. Conclusions: Significant variability exists in follow-up frequency following AMI and 4% of the cohort had no follow-up. Patients who had medium intensity visits were more likely to use some evidence-based medications than those with low intensity. Higher intensity visits was not associated with greater medication use. It is possible that the observed differences may be attributed to unmeasured differences among patients rather than the actual follow-up visits. Prospective studies are needed to assess key elements of outpatient visits that may lead to better utilization of evidence-based therapies.

Background: Studies demonstrating variation in hospital quality of care using longitudinal outcomes have been limited in the amount of clinical data used to stratify patients’ risks and have not examined health status outcomes. We sought to describe hospital-level variation in risk-adjusted health status and mortality in the year following myocardial infarction (MI) and describe the extent to which hospital quality of care explains this variation. Methods: 4,316 patients from the TRIUMPH registry, a prospective cohort study of MI patients at 24 hospitals, were included for analysis. Using hierarchical models, we described the hospital-level variation in angina (yes/no) and 1-year mortality rates. We then added hospital quality of care measures for MI applicable to the time period studied (ASA and beta blockers within 24 hours of arrival and at discharge, ACE/ARB at discharge, thrombolytics within 30 minutes, PCI within 90 minutes, and smoking cessation instructions at discharge) to these models to determine if hospital variation in one-year mortality and angina were explained by index MI quality of care. Results: The mortality rate at one year was 6.2% and the incidence of angina at one year was 23.0%. Unadjusted hospital-level 1-year mortality ranged from 0% to 10.8% and unadjusted presence of angina ranged from 9.3% to 66.7%. Statistically significant hospital-level variation in one-year mortality and angina was observed, with risk-adjusted mortality rates ranging from 5% to 8.3% (p Conclusions: Hospital-level variation in 1-year mortality and angina was observed among the 24 hospitals participating in this MI registry. However, this variation was not explained by in-hospital MI performance measures. Future studies should assess care delivery factors that impact longitudinal outcomes following MI.

The United States population, particularly among older age groups, continues to expand. Because the incidence of heart failure increases with age, largely due to the development of heart failure risk factors such as hypertension and coronary artery disease, the epidemic of heart failure is likely to grow further in the coming decades. This article will review the epidemiology of heart failure among older adults, the influence of an aging population on heart failure prevalence and phenotype, the complications in management for a larger and older heart failure population, and the potential implications of these changes for health care costs and delivery. Ultimately, these challenges demand research into optimal therapeutic strategies for older heart failure patients, including improved prevention and treatment of the major causes of heart failure, an increasing role forpalliative care, and innovations in patient-centered health care delivery.

The transradial (TRI) approach reduces bleeding, vascular complications and mortality in patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI), as compared with the transfemoral approach (TFI). However, no study has examined the costs

Electronic health records (EHRs) have been identified as a key tool for quality improvement (QI) in health care. However, EHR data must be of sufficient quality to support QI efforts. In 2005, the Department of Veterans Affairs (VA) began using a novel EHR tool-the CART Program-to support QI in cardiac catheterization laboratories. We evaluated whether data collected by the CART Program were of sufficient quality to support QI.We evaluated the data validity, completeness, and timeliness of CART Program data using a random sample of 200 coronary procedures performed in 10 geographically diverse VA medical centers.Of 1690 observations in the CART Program data repository, 1664 (98.5%) were valid, as compared to the VA medical record. The CART Program reports were more complete than cardiac catheterization laboratory reports generated prior to CART Program implementation (79% vs. 63.1%, P.001). Finally, there was a trend toward earlier availability of completed procedure reports to treating providers after CART Program implementation, with 75% of CART Program reports available within 1 day compared to 4 days for reports generated prior to CART Program implementation (P = .06).Cardiac catheterization reports generated by the VA's CART Program demonstrate excellent data validity, superior completeness, and a trend toward more timely availability to referring providers relative to cardiac catheterization laboratory reports generated prior to CART Program implementation. This demonstration of data quality is a key step in realizing CART Program's aim of supporting QI efforts in VA catheter laboratories.

Background— Medication adherence and treatment intensification have been advocated as performance measures to assess the quality of care provided. Whereas previous studies have shown that adherence and treatment intensification (TI) of antihypertensive medications is associated with blood pressure (BP) control at the patient level, less is known about whether adherence and TI is associated with BP control at the clinic level. Methods and Results— We included 162 879 patients among 89 clinics in the Cardiovascular Research Network Hypertension Registry with incident hypertension who were started on antihypertensive medications. Adherence was measured by the proportion of days covered (PDC). TI was defined by the standard based method with scores ranging between −1 to 1 and categorized as: −1 indicated no TI occurred when BP was elevated; 0 indicated TI occurred when BP was elevated; and 1 indicated that TI was made at all visits, even when BP was not elevated. Logistic regression models assessed the association between adherence and TI with blood pressure control (BP ≤140/90 at the clinic visit closest to 12 months after study entry) at the patient and clinic levels. Mean adherence was 0.77±0.28 (PDC±SD) at the patient level and 0.78±0.05 at the clinic level. Mean TI was 0.026±0.23 at the patient level and 0.01±0.04 at the clinic level. At the patient level, for each 0.25 increase in adherence and TI, the odds (OR) of achieving blood pressure control increased by 28% and 55%, respectively [OR for adherence, 1.28 (1.26–1.29), and for TI, 1.55 (1.53–1.57)]. At the clinic level, each 0.04 increment increase in treatment intensification was associated with a 25% increased odds of achieving blood pressure control (OR, 1.24; 95% CI, 1.21–1.27). In contrast, there was an inverse association between increasing adherence and BP control (OR, 0.93; 95% confidence interval, 0.90–0.95). Conclusions— Patient adherence to antihypertensive medications is not associated with BP control at the clinic level and may not be suitable as a performance measure. TI is associated with BP control, but its use as a performance measure may be constrained by challenges in measuring it and by concerns about unintended consequences of aggressive hypertension treatment in some subgroups of patients.

Background: Medication adherence and treatment intensification have been advocated as performance measures to assess the quality of care. While previous studies have shown that adherence and treatment intensification (TI) of antihypertensive medications is associated with blood pressure control at the patient level, less is known about whether adherence and TI is associated with blood pressure control assessed at the clinic level. Methods: We included 162,879 patients from 89 clinics in the CVRN Hypertension Registry with incident hypertension who were started on antihypertensive medications. Medication adherence was calculated by the proportion of days covered for five different classes of antihypertensive medications. TI was calculated as the number of observed medication intensifications minus the number of expected medication intensifications divided by the number of clinic visits in the observation period. TI is expected whenever measured blood pressure during a clinic visit is higher than the blood pressure goal. A TI score of -1 indicates that no treatment intensification was made when the BP was elevated, a score of 0 indicates that treatment intensification was made only when the blood pressure was elevated, and a score of 1 indicates that treatment intensification was made when the blood pressure was normal. Multivariable logistic regression assessed the association between medication adherence and treatment intensification with blood pressure control at the patient and clinic levels. Results: The average patient age was 56 years, 13.6% had diabetes, 1.0% had previous MI, 3.8% had chronic kidney disease, 1.7% had a previous ischemic stroke, and 0.9% had CHF. Adherence measured by proportion of days covered was 0.77 ± 0.28 at the patient level and 0.78± 0.05 at the clinic level. The average patient TI score was 0.026 ± 0.23 and the average clinic TI score was 0.01± 0.04. Both adherence and treatment intensification were associated with blood pressure control at the patient level [OR for adherence of 1.28 (1.26 - 1.29) and OR for treatment intensification of 1.55 (1.53 - 1.57)]. In contrast, treatment intensification, but not adherence, was associated with blood pressure control at the clinic level [OR for TI at the clinic level 1.21 (1.17 - 1.25) and OR for adherence at the clinic level 1.01 (0.98 - 1.04)]. Conclusion: In this study, patient adherence to antihypertensive medications was not related to blood pressure control at the clinic level and may not be suitable as a performance measure. Treatment intensification was associated with BP control, but its use as a performance measure may be constrained by challenges in measuring it and by concerns about unintended consequences of aggressive hypertension treatment in some subgroups of patients.

Background: Clopidogrel is recommended for 1 year following drug eluting stent (DES) placement and premature discontinuation has been associated with adverse outcomes. The extent of variation in premature discontinuation across hospitals within an integrated healthcare system is unknown. Accordingly, we assessed variation in premature clopidogrel discontinuation across all VA PCI sites and whether there was an association between hospitals with higher rates of premature discontinuation and adverse outcomes. Methods: We used the VA CART-CL registry which includes all PCIs with drug eluting stents performed between 10/01/08 and 09/30/09 at 55 VA cath labs that used CART. We evaluated the frequency of patients who prematurely discontinue clopidogrel at 6 and 9 months using pharmacy refill data. Multivariable regression assessed the association between premature discontinuation and all-cause mortality and/or myocardial infarction (MI). We then grouped sites into quartiles of premature discontinuation and evaluated the association between hospital level premature discontinuation and adverse outcomes. Results: Of the 7,022 patients who received a DES, 6.3% discontinued by 6 months, and 10.2% by 9 months. After risk adjustment, patients who discontinued clopidogrel prematurely had increased risk of adverse events with HR of 5.42 at 6 months (95% CI 4.22 – 6.99), and 6.24 at 9 months (95% CI 4.98 – 7.83). There was a significant trend in the unadjusted rates within quartiles toward increased risk of adverse outcomes among hospitals with greater rates of patients who discontinue prematurely by 6 months (p < 0.01 for trend, OR 1.65 CI 1.07 – 2.62 for comparison between quartile 1 and 4). Conclusion: Premature discontinuation of clopidogrel is associated with adverse outcomes among patients who receive drug eluting stents. Hospitals with higher rates of premature discontinuation of clopidogrel have higher rates of adverse outcomes. Hospital-level interventions to reduce early discontinuation of clopidogrel therapy have the potential to improve outcomes of patients who receive a DES.