Paul Heidenreich, MD

All Publications

• Is Equity Being Traded for Access to Heart Transplant? JAMA Heidenreich, P. A., Lewis, E. F., Khush, K. K. 2024

  View details for DOI 10.1001/jama.2024.0812

  View details for PubMedID 38526454

• An Underappreciated Risk Factor for Heart Failure-Financial Toxicity. JAMA network open Heidenreich, P. 2024; 7 (3): e241403

  View details for DOI 10.1001/jamanetworkopen.2024.1403

  View details for PubMedID 38512258

• Myocardial Infarction Across COVID-19 Pandemic Phases: Insights From the Veterans Health Affairs System. Journal of the American Heart Association Yong, C. M., Graham, L., Beyene, T. J., Sadri, S., Hong, J., Burdon, T., Fearon, W. F., Asch, S. M., Turakhia, M., Heidenreich, P. 2023: e029910

  Abstract

  Background Cardiovascular procedural treatments were deferred at scale during the COVID-19 pandemic, with unclear impact on patients presenting with non-ST-segment-elevation myocardial infarction (NSTEMI). Methods and Results In a retrospective cohort study of all patients diagnosed with NSTEMI in the US Veterans Affairs Healthcare System from January 1, 2019 to October 30, 2022 (n=67 125), procedural treatments and outcomes were compared between the prepandemic period and 6 unique pandemic phases: (1) acute phase, (2) community spread, (3) first peak, (4) post vaccine, (5) second peak, and (6) recovery. Multivariable regression analysis was performed to assess the association between pandemic phases and 30-day mortality. NSTEMI volumes dropped significantly with the pandemic onset (62.7% of prepandemic peak) and did not revert to prepandemic levels in subsequent phases, even after vaccine availability. Percutaneous coronary intervention and coronary artery bypass grafting volumes declined proportionally. Compared with the prepandemic period, patients with NSTEMI experienced higher 30-day mortality during Phases 2 and 3, even after adjustment for COVID-19-positive status, demographics, baseline comorbidities, and receipt of procedural treatment (adjusted odds ratio for Phases 2 and 3 combined, 1.26 [95% CI, 1.13-1.43], P<0.01). Patients receiving Veterans Affairs-paid community care had a higher adjusted risk of 30-day mortality compared with those at Veterans Affairs hospitals across all 6 pandemic phases. Conclusions Higher mortality after NSTEMI occurred during the initial spread and first peak of the pandemic but resolved before the second, higher peak-suggesting effective adaptation of care delivery but a costly delay to implementation. Investigation into the vulnerabilities of the early pandemic spread are vital to informing future resource-constrained practices.

  View details for DOI 10.1161/JAHA.123.029910

  View details for PubMedID 37421288

• Pursuing Equity in Performance Measurement. Circulation Heidenreich, P., Sandhu, A. 2023; 147 (15): 1134-1136

  View details for DOI 10.1161/CIRCULATIONAHA.123.064123

  View details for PubMedID 37036909

• Impact of Patient-Reported Outcome Measurement in Heart Failure Clinic on Clinician Health Status Assessment and Patient Experience: A Sub-Study of the PRO-HF Trial. Circulation. Heart failure Sandhu, A. T., Zheng, J., Kalwani, N., Gupta, A., Calma, J., Skye, M., Lan, R., Yu, B., Spertus, J., Heidenreich, P. 2022

  Abstract

  Background: Clinicians typically estimate heart failure (HF) health status using the New York Heart Association (NYHA) class, which is often discordant with patient-reported health status. It is unknown if collecting patient-reported health status improves the accuracy of clinician assessments. Methods: The Patient-Reported Outcomes in Heart Failure Clinic (PRO-HF) trial is a randomized, non-blinded trial evaluating routine Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) collection in HF clinic. Patients with a scheduled visit to Stanford HF clinic between August 30, 2021, and June 30, 2022 were enrolled and randomized to KCCQ-12 assessment or usual care. In this prespecified sub-study, we evaluated whether access to the KCCQ-12 improved the accuracy of clinicians' NYHA assessment or patients' perspectives on their clinician interaction. We surveyed clinicians regarding their patients' NYHA class, quality of life, and symptom frequency. Clinician responses were compared with patients' KCCQ-12 responses. We surveyed patients regarding their clinician interactions. Results: Of the 1,248 enrolled patients, 1,051 (84.2%) attended a visit during the sub-study. KCCQ-12 results were given to the clinicians treating the 528 patients in the KCCQ-12 arm; the 523 patients in the usual care arm completed the KCCQ-12 without the results being shared. The correlation between NYHA class and KCCQ-12 Overall Summary Score was stronger when clinicians had access to the KCCQ-12 (r=-0.73 vs. r=-0.61, p<0.001). More patients in the KCCQ-12 arm strongly agreed that their clinician understood their symptoms (95.2% vs. 89.7% of respondents; [OR 2.27; 95% CI: 1.32-3.87)]. However, patients in both arms reported similar quality of clinician communication and therapeutic alliance. Conclusions: Collecting the KCCQ-12 in HF clinic improved clinicians' accuracy of health status assessment; correspondingly, patients believed their clinicians better understood their symptoms. Registration: URL: ClinicalTrials.gov; Unique Identifier: NCT04164004.

  View details for DOI 10.1161/CIRCHEARTFAILURE.122.010280

  View details for PubMedID 36334312

• 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation Heidenreich, P. A., Bozkurt, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., Deswal, A., Drazner, M. H., Dunlay, S. M., Evers, L. R., Fang, J. C., Fedson, S. E., Fonarow, G. C., Hayek, S. S., Hernandez, A. F., Khazanie, P., Kittleson, M. M., Lee, C. S., Link, M. S., Milano, C. A., Nnacheta, L. C., Sandhu, A. T., Stevenson, L. W., Vardeny, O., Vest, A. R., Yancy, C. W. 2022: 101161CIR0000000000001063

  Abstract

  The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

  View details for DOI 10.1161/CIR.0000000000001063

  View details for PubMedID 35363499

• 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation Heidenreich, P. A., Bozkurt, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., Deswal, A., Drazner, M. H., Dunlay, S. M., Evers, L. R., Fang, J. C., Fedson, S. E., Fonarow, G. C., Hayek, S. S., Hernandez, A. F., Khazanie, P., Kittleson, M. M., Lee, C. S., Link, M. S., Milano, C. A., Nnacheta, L. C., Sandhu, A. T., Stevenson, L. W., Vardeny, O., Vest, A. R., Yancy, C. W. 2022: 101161CIR0000000000001062

  Abstract

  The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

  View details for DOI 10.1161/CIR.0000000000001062

  View details for PubMedID 35363500

• 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology Heidenreich, P. A., Bozkurt, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., Deswal, A., Drazner, M. H., Dunlay, S. M., Evers, L. R., Fang, J. C., Fedson, S. E., Fonarow, G. C., Hayek, S. S., Hernandez, A. F., Khazanie, P., Kittleson, M. M., Lee, C. S., Link, M. S., Milano, C. A., Nnacheta, L. C., Sandhu, A. T., Stevenson, L. W., Vardeny, O., Vest, A. R., Yancy, C. W. 2022

  Abstract

  The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

  View details for DOI 10.1016/j.jacc.2021.12.012

  View details for PubMedID 35379503

• Economic Issues in Heart Failure in the United States. Journal of cardiac failure Heidenreich, P. A., Fonarow, G. C., Opsha, Y., Sandhu, A. T., Sweitzer, N. K., Warraich, H. J. 1800

  Abstract

  The cost of heart failure care is high due to cost of hospitalization and chronic treatments. Heart failure treatments vary in their benefit and cost. The cost-effectiveness of therapies can be determined by comparing the cost of treatment required to obtain a certain benefit, often defined as an increase in one year of life. This review was sponsored by the Heart Failure Society of America and describes the growing economic burden of heart failurefor patientsand the health care system in the UnitedStates. It also provides a summary of the cost-effectiveness of drugs, devices, diagnostic tests, hospital care, and transitions of care for patients with heart failure. Many medications that are no longer under patent are inexpensive and highly cost-effective. These include ACE inhibitors, beta-blockers and mineralocorticoid receptor antagonists. In contrast, more recently developed medications and devices, vary in cost effectiveness, and often have high out of pocket expenses for patients.

  View details for DOI 10.1016/j.cardfail.2021.12.017

  View details for PubMedID 35085762

• Renin-Angiotensin-Aldosterone System Inhibitors and SARS-CoV-2 Infection: An Analysis from the Veteran's Affairs Healthcare System: Sandhu. ACEI, ARB, and Association with COVID. American heart journal Sandhu, A. T., Kohsaka, S., Lin, S., Woo, C. Y., Goldstein, M. K., Heidenreich, P. A. 2021

  Abstract

  BACKGROUND: Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) are known to impact the functional receptor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The association between chronic therapy with these medications and infection risk remains unclear.OBJECTIVES: The objective was to determine the association between prior ACEI or ARB therapy and SARS-CoV-2 infection among patients with hypertension in the U.S. Veteran's Affairs health system.METHODS: We compared the odds of SARS-CoV-2 infection among three groups: patients treated with ACEI, treated with ARB, or treated with alternate first-line anti-hypertensives without ACEI/ARB. We excluded patients with alternate indications for ACEI or ARB therapy. We performed an augmented inverse propensity weighted analysis with adjustment for demographics, region, comorbidities, vitals, and laboratory values.RESULTS: Among 1,724,723 patients with treated hypertension, 659,180 were treated with ACEI, 310,651 with ARB, and 754,892 with neither. Before weighting, patients treated with ACEI or ARB were more likely to be diabetic and use more anti-hypertensives. There were 13,278 SARS-CoV-2 infections (0.8%) between February 12, 2020 and August 19, 2020. Patients treated with ACEI had lower odds of SARS-CoV-2 infection (odds ratio [OR] 0.93; 95% CI: 0.89-0.97) while those treated with ARB had similar odds (OR 1.02; 95% CI: 0.96-1.07) compared with patients treated with alternate first-line anti-hypertensives without ACEI/ARB. In falsification analyses, patients on ACEI did not have a difference in their odds of unrelated outcomes.CONCLUSIONS: Our results suggest the safety of continuing ACEI and ARB therapy. The association between ACEI therapy and lower odds of SARS-CoV-2 infection requires further investigation.

  View details for DOI 10.1016/j.ahj.2021.06.004

  View details for PubMedID 34126079

• 2020 ACC/AHA Clinical Performance and Quality Measures for Adults With Heart Failure A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES Heidenreich, P. A., Fonarow, G. C., Breathett, K., Jurgens, C. Y., Pisani, B. A., Pozehl, B. J., Spertus, J. A., Taylor, K. G., Thibodeau, J. T., Yancy, C. W., Ziaeian, B. 2020; 13 (11): e000099

  View details for DOI 10.1161/HCQ.0000000000000099

  View details for Web of Science ID 000591405400001

  View details for PubMedID 33136435

• Video-based AI for beat-to-beat assessment of cardiac function NATURE Ouyang, D., He, B., Ghorbani, A., Yuan, N., Ebinger, J., Langlotz, C. P., Heidenreich, P. A., Harrington, R. A., Liang, D. H., Ashley, E. A., Zou, J. Y. 2020

  View details for DOI 10.1038/s41586-020-2145-8

  View details for Web of Science ID 000521531000001

• Perils of Performance Measurement. Circulation. Cardiovascular quality and outcomes Heidenreich, P. A. 2020; 13 (3): e006455

  View details for DOI 10.1161/CIRCOUTCOMES.120.006455

  View details for PubMedID 32148100

• Association Between Current and Future Annual Hospital Percutaneous Coronary Intervention Mortality Rates JAMA CARDIOLOGY Sandhu, A. T., Kohsaka, S., Bhattacharya, J., Fearon, W. F., Harrington, R. A., Heidenreich, P. A. 2019; 4 (11): 1077–83

  View details for DOI 10.1001/jamacardio.2019.3221

  View details for Web of Science ID 000501300400005

• Association of Statin Adherence With Mortality in Patients With Atherosclerotic Cardiovascular Disease. JAMA cardiology Rodriguez, F. n., Maron, D. J., Knowles, J. W., Virani, S. S., Lin, S. n., Heidenreich, P. A. 2019

  Abstract

  Statins decrease mortality in those with atherosclerotic cardiovascular disease (ASCVD), but statin adherence remains suboptimal.To determine the association between statin adherence and mortality in patients with ASCVD who have stable statin prescriptions.This retrospective cohort analysis included patients who were between ages 21 and 85 years and had 1 or more International Classification of Diseases, Ninth Revision, Clinical Modification codes for ASCVD on 2 or more dates in the previous 2 years without intensity changes to their statin prescription who were treated within the Veterans Affairs Health System between January 1, 2013, and April 2014.Statin adherence was defined by the medication possession ratio (MPR). Adherence levels were categorized as an MPR of less than 50%, 50% to 69%, 70% to 89%, and 90% or greater. For dichotomous analyses, adherence was defined as an MPR of 80% or greater.The primary outcome was death of all causes adjusted for demographic and clinical characteristics, as well as adherence to other cardiac medications.Of 347 104 eligible adults with ASCVD who had stable statin prescriptions, 5472 (1.6%) were women, 284 150 (81.9%) were white, 36 208 (10.4%) were African American, 16 323 (4.7%) were Hispanic, 4093 (1.2%) were Pacific Islander, 1293 (0.4%) were Native American, 1145 (0.3%) were Asian, and 1794 (0.5%) were other races. Patients taking moderate-intensity statin therapy were more adherent than patients taking high-intensity statin therapy (odds ratio [OR], 1.18; 95% CI, 1.16-1.20). Women were less adherent (OR, 0.89; 95% CI, 0.84-0.94), as were minority groups. Younger and older patients were less likely to be adherent compared with adults aged 65 to 74 years. During a mean (SD) of 2.9 (0.8) years of follow-up, there were 85 930 deaths (24.8%). Compared with the most adherent patients (MPR ≥ 90%), patients with an MPR of less than 50% had a hazard ratio (HR; adjusted for clinical characteristics and adherence to other cardiac medications) of 1.30 (95% CI, 1.27-1.34), those with an MPR of 50% to 69% had an HR of 1.21 (95% CI, 1.18-1.24), and those with an MPR of 70% to 89% had an HR of 1.08 (95% CI, 1.06-1.09).Using a national sample of Veterans Affairs patients with ASCVD, we found that a low adherence to statin therapy was associated with a greater risk of dying. Women, minorities, younger adults, and older adults were less likely to adhere to statins. Our findings underscore the importance of finding methods to improve adherence.

  View details for PubMedID 30758506

• Validity of Performance and Outcome Measures for Heart Failure. Circulation. Heart failure Patel, J., Sandhu, A., Parizo, J., Moayedi, Y., Fonarow, G. C., Heidenreich, P. A. 2018; 11 (9): e005035

  Abstract

  Background Numerous quality metrics for heart failure (HF) care now exist based on process and outcome. What remains unclear, however, is if the correct quality metrics are being emphasized. To determine the validity of certain measures, we compared correlations between measures and reliability over time. Measures assessed include guideline-recommended beta-blocker (BB), any BB, angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker, mineralocorticoid receptor antagonist, and hydralazine/isosorbide dinitrate (in blacks) use among candidates, 30-day mortality, 1-year mortality, and 30-day readmission. Methods and Results This was an observational cohort analysis using chart review and electronic resources for 55735 patients from 102 Veterans Affairs medical centers hospitalized with HF from 2008 to 2013. Assessments of convergent validity and reliability were performed. Significant correlations were found between in-hospital rates of ACE inhibitor use and the following measures: BB use, 30-day mortality, and 1-year mortality. Guideline-recommended BB use was also significantly correlated with mineralocorticoid receptor antagonists, 30-day mortality, and 1-year mortality. There was no correlation between 30-day readmission rates and any therapy or mortality. Measure reliability over time was seen for guideline-recommended BBs ( r=0.57), mineralocorticoid receptor antagonists ( r=0.50), 30-day mortality ( r=0.29), and 1-year mortality ( r=0.31). ACE inhibitor and readmission rates were not reliable measures over time. Conclusions BB use, ACE inhibitor use, mortality, and mineralocorticoid receptor antagonist use are valid measures of HF quality. Thirty-day readmission rate did not seem to be a valid measure of HF quality of care. If the goal is to identify high-quality HF care, the emphasis on decreasing readmission rates might be better directed towards improving usage of the recommended therapies.

  View details for PubMedID 30354367

• Association Between Offering Limited Left Ventricular Ejection Fraction Echocardiograms and Overall Use of Echocardiography. JAMA internal medicine Sandhu, A. T., Parizo, J., Moradi-Ragheb, N., Heidenreich, P. A. 2018

  View details for PubMedID 30039163

• Association Between Intensity of Statin Therapy and Mortality in Patients With Atherosclerotic Cardiovascular Disease. JAMA cardiology Rodriguez, F., Maron, D. J., Knowles, J. W., Virani, S. S., Lin, S., Heidenreich, P. A. 2017; 2 (1): 47-54

  Abstract

  High-intensity statin therapy is recommended for the secondary prevention of atherosclerotic cardiovascular disease (ASCVD). Nevertheless, statin therapy in general, and high-intensity statin therapy in particular, is underused in patients with established ASCVD.To determine the association between all-cause mortality and intensity of statin therapy in the Veterans Affairs health care system.A retrospective cohort analysis was conducted of patients aged 21 to 84 years with ASCVD treated in the Veterans Affairs health care system from April 1, 2013, to April 1, 2014. Patients who were included had 1 or more International Classification of Diseases, Ninth Revision codes for ASCVD on 2 or more different dates in the prior 2 years.Intensity of statin therapy was defined by the 2013 American College of Cardiology/American Heart Association guidelines, and use was defined as a filled prescription in the prior 6 months. Patients were excluded if they were taking a higher statin dose in the prior 5 years.The primary outcome was death from all causes adjusted for the propensity to receive high-intensity statins.The study sample included 509 766 eligible adults with ASCVD at baseline (mean [SD] age, 68.5 [8.8] years; 499 598 men and 10 168 women), including 150 928 (29.6%) receiving high-intensity statin therapy, 232 293 (45.6%) receiving moderate-intensity statin therapy, 33 920 (6.7%) receiving low-intensity statin therapy, and 92 625 (18.2%) receiving no statins. During a mean follow-up of 492 days, there was a graded association between intensity of statin therapy and mortality, with 1-year mortality rates of 4.0% (5103 of 126 139) for those receiving high-intensity statin therapy, 4.8% (9703 of 200 709) for those receiving moderate-intensity statin therapy, 5.7% (1632 of 28 765) for those receiving low-intensity statin therapy, and 6.6% (4868 of 73 728) for those receiving no statin (P < .001). After adjusting for the propensity to receive high-intensity statins, the hazard ratio for mortality was 0.91 (95% CI, 0.88-0.93) for those receiving high- vs moderate-intensity statins. The magnitude of benefit of high- vs moderate-intensity statins was similar, for an incident cohort hazard ratio of 0.93 (95% CI, 0.85-1.01). For patients aged 76 to 84 years, the hazard ratio was 0.91 (95% CI, 0.87-0.95). Patients treated with maximal doses of high-intensity statins had lower mortality (hazard ratio, 0.90; 95% CI, 0.87-0.94) compared with those receiving submaximal doses.We found a graded association between intensity of statin therapy and mortality in a national sample of patients with ASCVD. High-intensity statins were associated with a small but significant survival advantage compared with moderate-intensity statins, even among older adults. Maximal doses of high-intensity statins were associated with a further survival benefit.

  View details for DOI 10.1001/jamacardio.2016.4052

  View details for PubMedID 27829091

• Cost-Effectiveness of Sacubitril-Valsartan in Patients With Heart Failure With Reduced Ejection Fraction ANNALS OF INTERNAL MEDICINE Sandhu, A. T., Ollendorf, D. A., Chapman, R. H., Pearson, S. D., Heidenreich, P. A. 2016; 165 (10): 681-?

  Abstract

  Sacubitril-valsartan therapy reduces cardiovascular mortality compared with enalapril therapy in patients with heart failure with reduced ejection fraction.To evaluate the cost-effectiveness of sacubitril-valsartan versus angiotensin-converting enzyme inhibitor therapy in patients with chronic heart failure.Markov decision model.Clinical trials, observational analyses, reimbursement data from the Centers for Medicare & Medicaid Services, drug pricing databases, and Centers for Disease Control and Prevention life tables.Patients at an average age of 64 years, New York Heart Association (NYHA) class II to IV heart failure, and left ventricular ejection fraction of 0.40 or less.Lifetime.Societal.Treatment with sacubitril-valsartan or lisinopril.Life-years, quality-adjusted life-years (QALYs), costs, heart failure hospitalizations, and incremental cost-effectiveness ratios.The sacubitril-valsartan group experienced 0.08 fewer heart failure hospitalization, 0.69 additional life-year, 0.62 additional QALY, and $29 203 in incremental costs, equating to a cost per QALY gained of $47 053. The cost per QALY gained was $44 531 in patients with NYHA class II heart failure and $58 194 in those with class III or IV heart failure.Sacubitril-valsartan treatment was most sensitive to the duration of improved outcomes, with a cost per QALY gained of $120 623 if the duration was limited to the length of the trial (median, 27 months). No variations in other parameters caused the cost to exceed $100 000 per QALY gained.The benefit of sacubitril-valsartan is based on a single clinical trial.Treatment with sacubitril-valsartan provides reasonable value in reducing cardiovascular mortality and morbidity in patients with NYHA class II to IV heart failure.U.S. Department of Veterans Affairs and Institute for Clinical and Economic Review.

  View details for DOI 10.7326/M16-0057

  View details for Web of Science ID 000387970500012

  View details for PubMedID 27571284

• 2016 ACC/AHA Clinical Performance and Quality Measures for Adults With Atrial Fibrillation or Atrial Flutter: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. Circulation. Cardiovascular quality and outcomes Heidenreich, P. A., Solis, P., Mark Estes, N. A., Fonarow, G. C., Jurgens, C. Y., Marine, J. E., McManus, D. D., McNamara, R. L. 2016; 9 (4): 443-488

  View details for DOI 10.1161/HCQ.0000000000000018

  View details for PubMedID 27354018

• Cost-Effectiveness of Implantable Pulmonary Artery Pressure Monitoring in Chronic Heart Failure JACC-HEART FAILURE Sandhu, A. T., Goldhaber-Fiebert, J. D., Owens, D. K., Turakhia, M. P., Kaiser, D. W., Heidenreich, P. A. 2016; 4 (5): 368-375

  Abstract

  This study aimed to evaluate the cost-effectiveness of the CardioMEMS (CardioMEMS Heart Failure System, St Jude Medical Inc, Atlanta, Georgia) device in patients with chronic heart failure.The CardioMEMS device, an implantable pulmonary artery pressure monitor, was shown to reduce hospitalizations for heart failure and improve quality of life in the CHAMPION (CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in NYHA Class III Heart Failure Patients) trial.We developed a Markov model to determine the hospitalization, survival, quality of life, cost, and incremental cost-effectiveness ratio of CardioMEMS implantation compared with usual care among a CHAMPION trial cohort of patients with heart failure. We obtained event rates and utilities from published trial data; we used costs from literature estimates and Medicare reimbursement data. We performed subgroup analyses of preserved and reduced ejection fraction and an exploratory analysis in a lower-risk cohort on the basis of the CHARM (Candesartan in Heart failure: Reduction in Mortality and Morbidity) trials.CardioMEMS reduced lifetime hospitalizations (2.18 vs. 3.12), increased quality-adjusted life-years (QALYs) (2.74 vs. 2.46), and increased costs ($176,648 vs. $156,569), thus yielding a cost of $71,462 per QALY gained and $48,054 per life-year gained. The cost per QALY gained was $82,301 in patients with reduced ejection fraction and $47,768 in those with preserved ejection fraction. In the lower-risk CHARM cohort, the device would need to reduce hospitalizations for heart failure by 41% to cost <$100,000 per QALY gained. The cost-effectiveness was most sensitive to the device's durability.In populations similar to that of the CHAMPION trial, the CardioMEMS device is cost-effective if the trial effectiveness is sustained over long periods. Post-marketing surveillance data on durability will further clarify its value.

  View details for DOI 10.1016/j.jchf.2015.12.015

  View details for PubMedID 26874380

• A validated risk model for 1-year mortality after primary prevention implantable cardioverter defibrillator placement. American heart journal Heidenreich, P. A., Tsai, V., Curtis, J., Wang, Y., Turakhia, M. P., Masoudi, F. A., Varosy, P. D., Goldstein, M. K. 2015; 170 (2): 281-289 e2

  Abstract

  We sought to determine survival for patients with heart failure after an implantation of an implantable cardioverter defibrillator (ICD) for primary prevention in the United States and to develop a simple model that would predict mortality risk.Clinical trials have found that patients with heart failure with a 1-year mortality risk near 20% may not benefit from an ICD.We identified patients from the ICD Registry of the National Cardiovascular Disease Registries who underwent ICD implantation for primary prevention from 2007 to 2009. Two risk scores for mortality were developed in 2 cohorts: one limited to those with a B-type natriuretic peptide (BNP) value and a second for all patients. The scores were obtained from derivation datasets and tested in a validation sets using logistic regression models and classification and regression trees.In a primary prevention population with BNP available (18,725) the 6 variables most predictive of 1-year mortality were age ≥75, BNP ≥700 pg/mL, chronic lung disease, dialysis, blood urea nitrogen ≥30 mg/dL, and systolic blood pressure <120 mmHg. Patients with zero risk factors had a 3.3% one-year mortality compared to a 66.7% one-year mortality for those with all 6 risk factors. Those with ≥3 risk factors (24.0% of the population) had a 25.8% one-year mortality. A second score using a larger cohort that did not consider BNP identified similar risk factors.A simple validated risk score can identify patients at high and low risk for death within a year after ICD placement. A large fraction of those currently implanted with an ICD in the United States have a high 1-year mortality and may not benefit from ICD therapy.

  View details for DOI 10.1016/j.ahj.2014.12.013

  View details for PubMedID 26299225

• A validated risk model for 1-year mortality after primary prevention implantable cardioverter defibrillator placement AMERICAN HEART JOURNAL Heidenreich, P. A., Tsai, V., Curtis, J., Wang, Y., Turakhia, M. P., Masoudi, F. A., Varosy, P. D., Goldstein, M. K. 2015; 170 (2): 281-U119

  Abstract

  We sought to determine survival for patients with heart failure after an implantation of an implantable cardioverter defibrillator (ICD) for primary prevention in the United States and to develop a simple model that would predict mortality risk.Clinical trials have found that patients with heart failure with a 1-year mortality risk near 20% may not benefit from an ICD.We identified patients from the ICD Registry of the National Cardiovascular Disease Registries who underwent ICD implantation for primary prevention from 2007 to 2009. Two risk scores for mortality were developed in 2 cohorts: one limited to those with a B-type natriuretic peptide (BNP) value and a second for all patients. The scores were obtained from derivation datasets and tested in a validation sets using logistic regression models and classification and regression trees.In a primary prevention population with BNP available (18,725) the 6 variables most predictive of 1-year mortality were age ≥75, BNP ≥700 pg/mL, chronic lung disease, dialysis, blood urea nitrogen ≥30 mg/dL, and systolic blood pressure <120 mmHg. Patients with zero risk factors had a 3.3% one-year mortality compared to a 66.7% one-year mortality for those with all 6 risk factors. Those with ≥3 risk factors (24.0% of the population) had a 25.8% one-year mortality. A second score using a larger cohort that did not consider BNP identified similar risk factors.A simple validated risk score can identify patients at high and low risk for death within a year after ICD placement. A large fraction of those currently implanted with an ICD in the United States have a high 1-year mortality and may not benefit from ICD therapy.

  View details for DOI 10.1016/j.ahj.2014.12.013

  View details for Web of Science ID 000360360100015

• Does Age Influence Cardiac Resynchronization Therapy Use and Outcome? JACC. Heart failure Heidenreich, P. A., Tsai, V., Bao, H., Curtis, J., Goldstein, M., Curtis, L., Hernandez, A., Peterson, P., Turakhia, M. P., Masoudi, F. A. 2015; 3 (6): 497-504

  Abstract

  This study sought to describe the use of CRT-D and its association with survival for older patients.Many patients who receive cardiac resynchronization therapy with defibrillator (CRT-D) in practice are older than those included in clinical trials.We identified patients undergoing ICD implantation in the National Cardiovascular Disease Registry (NCDR) ICD registry from 2006 to 2009, who also met clinical trial criteria for CRT, including left ventricular ejection fraction (LVEF) ≤35%, QRS ≥120 ms, and New York Heart Association (NYHA) functional class III or IV. NCDR registry data were linked to the social security death index to determine the primary outcome of time to death from any cause. We identified 70,854 patients from 1,187 facilities who met prior trial criteria for CRT-D. The mean age of the 58,147 patients receiving CRT-D was 69.4 years with 6.4% of patients age 85 or older. CRT use was 80% or higher among candidates in all age groups. Follow-up was available for 42,285 patients age ≥65 years at 12 months.Receipt of CRT-D was associated with better survival at 1 year (82.1% vs. 77.1%, respectively) and 4 years (54.0% vs. 46.2% , respectively) than in those receiving only an ICD (p < 0.001). The CRT association with improved survival was not different for different age groups (p = 0.86 for interaction).More than 80% of older patients undergoing ICD implantation who were candidates for a CRT-D received the combined device. Mortality in older patients undergoing ICD implantation was high but was lower for those receiving CRT-D.

  View details for DOI 10.1016/j.jchf.2015.01.012

  View details for PubMedID 25982109

• ACC/AHA Statement on Cost/Value Methodology in Clinical Practice Guidelines and Performance Measures A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and Task Force on Practice Guidelines CIRCULATION Anderson, J. L., Heidenreich, P. A., Barnett, P. G., Creager, M. A., Fonarow, G. C., Gibbons, R. J., Halperin, J. L., Hlatky, M. A., Jacobs, A. K., Mark, D. B., Masoudi, F. A., Peterson, E. D., Shaw, L. J. 2014; 129 (22): 2329-?

  View details for DOI 10.1161/CIR.0000000000000042

  View details for Web of Science ID 000337276500018

• Clinical reminders to providers of patients with reduced left ventricular ejection fraction increase defibrillator referral: a randomized trial. Circulation. Heart failure Gupta, A., Gholami, P., Turakhia, M. P., Friday, K., Heidenreich, P. A. 2014; 7 (1): 140-145

  Abstract

  Background- Many patients who are candidates for implantable cardioverter defibrillators (ICDs) are not referred for potential implantation. We sought to determine if a simple provider reminder would increase referrals. Methods and Results- We identified consecutive patients from January 2007 through July 2010 in the VA Palo Alto Health Care System with a left ventricular ejection fraction <35% on echocardiography. Patients were excluded using available administrative data only (no chart review) if they were known to have an ICD, if they were ≥80 years old, or if they did not have a current primary care or cardiology provider within the system. We randomized patients to no intervention or a clinical note to the provider in the medical record. The outcomes were referral for consideration of defibrillator implantation (primary) and documented discussion (secondary). Of 330 patients with left ventricular ejection fraction ≤35%, 128 were known to have an ICD, 85 were no longer followed in the healthcare system, and 28 were ≥80 years old, leaving 89 patients to be randomized. Forty-six patients were randomized to intervention and 43 to control. Eleven of 46 (24%) intervention patients were referred for consideration of ICD implantation during the following 6 months versus 1 of 43 (2%) control patients (P=0.004). Overall, 31 of 46 (67%) intervention patients versus 19 of 43 (44%) control patients had documentation discussing potential candidacy for defibrillators (P=0.05). Conclusions- In patients with low left ventricular ejection fraction, a simple electronic medical record-based intervention directed to their providers improved the rates of referral for ICD implantation. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT01217827.

  View details for DOI 10.1161/CIRCHEARTFAILURE.113.000753

  View details for PubMedID 24319096

• Variation in Use of Left Ventriculography in the Veterans Affairs Health Care System CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES Heidenreich, P. A., Lin, S., Knowles, J. W., Perez, M., Maddox, T. M., Ho, M. P., Rumsfeld, J. S., Sahay, A., Massie, B. M., Tsai, T. T., Witteles, R. M. 2013; 6 (6): 687-693

  Abstract

  Contrast left ventriculography is a method of measuring left ventricular function usually performed at the discretion of the invasive cardiologist during cardiac catheterization. We sought to determine variation in the use of left ventriculography in the Veterans Affairs (VA) Health Care System.We identified adult patients who underwent cardiac catheterization including coronary angiography between 2000 and 2009 in the VA Health Care System. We determined patient and hospital predictors of the use of left ventriculography as well as the variation in use across VA facilities. Results were validated using data from the VA's Clinical Assessment, Reporting, and Tracking (CART) program. Of 457 170 cardiac catheterization procedures among 336 853 patients, left ventriculography was performed on 263 695 (58%) patients. Use of left ventriculography decreased over time (64% in 2000 to 50% in 2009) and varied markedly across facilities (<1->95% of cardiac catheterizations). Patient factors explained little of the large variation in use between facilities. When the cohort was restricted to those with an echocardiogram in the prior 30 days and no intervening event, left ventriculography was still performed in 50% of cases.There is large variation in the use of left ventriculography across VA facilities that is not explained by patient characteristics.

  View details for DOI 10.1161/CIRCOUTCOMES.113.000199

  View details for Web of Science ID 000330362400017

  View details for PubMedID 24192569

• Forecasting the impact of heart failure in the United States: a policy statement from the american heart association. Circulation. Heart failure Heidenreich, P. A., Albert, N. M., Allen, L. A., Bluemke, D. A., Butler, J., Fonarow, G. C., Ikonomidis, J. S., Khavjou, O., Konstam, M. A., Maddox, T. M., Nichol, G., Pham, M., Piña, I. L., Trogdon, J. G. 2013; 6 (3): 606-619

  Abstract

  Background- Heart failure (HF) is an important contributor to both the burden and cost of national healthcare expenditures, with more older Americans hospitalized for HF than for any other medical condition. With the aging of the population, the impact of HF is expected to increase substantially. Methods and Results- We estimated future costs of HF by adapting a methodology developed by the American Heart Association to project the epidemiology and future costs of HF from 2012 to 2030 without double counting the costs attributed to comorbid conditions. The model assumes that HF prevalence will remain constant by age, sex, and race/ethnicity and that rising costs and technological innovation will continue at the same rate. By 2030, >8 million people in the United States (1 in every 33) will have HF. Between 2012 and 2030, real (2010$) total direct medical costs of HF are projected to increase from $21 billion to $53 billion. Total costs, including indirect costs for HF, are estimated to increase from $31 billion in 2012 to $70 billion in 2030. If one assumes all costs of cardiac care for HF patients are attributable to HF (no cost attribution to comorbid conditions), the 2030 projected cost estimates of treating patients with HF will be 3-fold higher ($160 billion in direct costs). Conclusions- The estimated prevalence and cost of care for HF will increase markedly because of aging of the population. Strategies to prevent HF and improve the efficiency of care are needed.

  View details for DOI 10.1161/HHF.0b013e318291329a

  View details for PubMedID 23616602

• Measuring the Quality of Echocardiography Using the Predictive Value of the Left Ventricular Ejection Fraction JOURNAL OF THE AMERICAN SOCIETY OF ECHOCARDIOGRAPHY Heidenreich, P. A., Maddox, T. M., Nath, J. 2013; 26 (3): 237-242

  Abstract

  One of the main challenges for imaging laboratories is demonstrating the quality of their studies. The aim of this study was to determine if echocardiographic training and experience are associated with the accuracy of left ventricular ejection fraction (LVEF) reporting using all-cause mortality as the gold standard.Survival was determined for consecutive patients undergoing echocardiography at one of four academic facilities. The relationship between LVEF and survival was determined for different groups of physician readers and sonographers on the basis of board certification and experience. Studies of physicians reading <200 studies were excluded.Data from 63,108 patients and 40 physicians were included. There was moderate variation across physicians in the relationship between LVEF and 1-year mortality (area under the receiver operating characteristic curve interquartile range, 0.56-0.64). The relationship between LVEF and 1-year mortality was stronger for physicians board certified in echocardiography (area under the receiver operating characteristic curve, 0.60; 95% confidence interval, 0.59-0.61) compared with those not certified (area under the receiver operating characteristic curve, 0.56; 95% confidence interval, 0.55-0.57; P < .0001). Physician experience, years since training, and sonographer experience and certification were not clearly associated with the predictive value of LVEF. After adjustment for patient characteristics, the LVEF-mortality association of board-certified physicians remained stronger than the LVEF-mortality association of those not certified.LVEF as determined by physicians board certified in echocardiography was associated with a stronger relationship with mortality than as determined by those not certified. The LVEF-mortality relationship may be useful as one measure of the quality of imaging.

  View details for DOI 10.1016/j.echo.2012.12.011

  View details for Web of Science ID 000315290200004

  View details for PubMedID 23337738

• Survival of patients receiving a primary prevention implantable cardioverter-defibrillator in clinical practice vs clinical trials. JAMA-the journal of the American Medical Association Al-Khatib, S. M., Hellkamp, A., Bardy, G. H., Hammill, S., Hall, W. J., Mark, D. B., Anstrom, K. J., Curtis, J., Al-Khalidi, H., Curtis, L. H., Heidenreich, P., Peterson, E. D., Sanders, G., Clapp-Channing, N., Lee, K. L., Moss, A. J. 2013; 309 (1): 55-62

  Abstract

  Randomized clinical trials have shown that implantable cardioverter-defibrillator (ICD) therapy saves lives. Whether the survival of patients who received an ICD in primary prevention clinical trials differs from that of trial-eligible patients receiving a primary prevention ICD in clinical practice is unknown.To determine whether trial-eligible patients who received a primary prevention ICD as documented in a large national registry have a survival rate that differs from the survival rate of similar patients who received an ICD in the 2 largest primary prevention clinical trials, MADIT-II (n = 742) and SCD-HeFT (n = 829).Retrospective analysis of data for patients enrolled in the National Cardiovascular Data Registry ICD Registry between January 1, 2006, and December 31, 2007, meeting the MADIT-II criteria (2464 propensity score-matched patients) or the SCD-HeFT criteria (3352 propensity score-matched patients). Mortality data for the registry patients were collected through December 31, 2009.Cox proportional hazards models were used to compare mortality from any cause.The median follow-up time in MADIT-II, SCD-HeFT, and the ICD Registry was 19.5, 46.1, and 35.2 months, respectively. Compared with patients enrolled in the clinical trials, patients in the ICD Registry were significantly older and had a higher burden of comorbidities. In the matched cohorts, there was no significant difference in survival between MADIT-II-like patients in the registry and MADIT-II patients randomized to receive an ICD (2-year mortality rates: 13.9% and 15.6%, respectively; adjusted ICD Registry vs trial hazard ratio, 1.06; 95% CI, 0.85-1.31; P = .62). Likewise, the survival among SCD-HeFT-like patients in the registry was not significantly different from survival among patients randomized to receive ICD therapy in SCD-HeFT (3-year mortality rates: 17.3% and 17.4%, respectively; adjusted registry vs trial hazard ratio, 1.16; 95% CI, 0.97-1.38; P = .11).There was no significant difference in survival between clinical trial patients randomized to receive an ICD and a similar group of clinical registry patients who received a primary prevention ICD. Our findings support the continued use of primary prevention ICDs in similar patients seen in clinical practice.clinicaltrials.gov Identifier: NCT00000609.

  View details for DOI 10.1001/jama.2012.157182

  View details for PubMedID 23280225

  View details for PubMedCentralID PMC3638257

• Use and overuse of left ventriculography AMERICAN HEART JOURNAL Witteles, R. M., Knowles, J. W., Perez, M., Morris, W. M., Spettell, C. M., Brennan, T. A., Heidenreich, P. A. 2012; 163 (4): 617-?

  Abstract

  Left ventriculography provided the first imaging of left ventricular function and was historically performed as part of coronary angiography despite a small but significant risk of complications. Because modern noninvasive imaging techniques are more accurate and carry smaller risks, the routine use of left ventriculography is of questionable utility. We sought to analyze the frequency that left ventriculography was performed during coronary angiography in patients with and without a recent alternative assessment of left ventricular function.We performed a retrospective analysis of insurance claims data from the Aetna health care benefits database including all adults who underwent coronary angiography in 2007. The primary outcome was the concomitant use of left ventriculography during coronary angiography.Of 96,235 patients who underwent coronary angiography, left ventriculography was performed in 78,705 (81.8%). Use of left ventriculography was high in all subgroups, with greatest use in younger patients, those with a diagnosis of coronary disease, and those in the Southern United States. In the population who had undergone a very recent ejection fraction assessment by another modality (within 30 days) and who had had no intervening diagnosis of new heart failure, myocardial infarction, hypotension, or shock (37,149 patients), left ventriculography was performed in 32,798 patients (88%)-a rate higher than in the overall cohort.Left ventriculography was performed in most coronary angiography cases and often when an alternative imaging modality had been recently completed. New clinical practice guidelines should be considered to decrease the overuse of this invasive test.

  View details for DOI 10.1016/j.ahj.2011.12.018

  View details for PubMedID 22520528

• Get With The Guidelines Program Participation, Process of Care, and Outcome for Medicare Patients Hospitalized With Heart Failure CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES Heidenreich, P. A., Hernandez, A. F., Yancy, C. W., Liang, L., Peterson, E. D., Fonarow, G. C. 2012; 5 (1): 37-43

  Abstract

  Hospitals enrolled in the American Heart Association's Get With The Guidelines Program for heart failure (GWTG-HF) have improved their process of care. However, it is unclear if process of care and outcomes are better in the GWTG-HF hospitals compared with hospitals not enrolled.We compared hospitals enrolled in GWTG-HF from 2006 to 2007 with other hospitals using data on 4 process of heart failure care measures, 5 noncardiac process measures, risk-adjusted 30-day mortality, and 30-day all-cause readmission after a heart failure hospitalization, as reported by the Center for Medicare and Medicaid Services (CMS). Among the 4460 hospitals reporting data to CMS, 215 (5%) were enrolled in GWTG-HF. Of the 4 CMS heart failure performance measures, GWTG-HF hospitals had significantly higher documentation of the left ventricular ejection fraction (93.4% versus 88.8%), use of angiotensin-converting enzyme inhibitor or angiotensin receptor antagonist (88.3% versus 86.6%), and discharge instructions (74.9% versus 70.5%) (P<0.005 for all). Smoking cessation counseling rates were similar (94.1% versus 94.0%; P=0.51). There was no significant difference in compliance with noncardiac process of care. After heart failure discharge, all-cause readmission at 30 days was 24.5% and mortality at 30 days after admission was 11.1%. After adjustment for hospital characteristics, 30-day mortality rates were no different (P=0.45). However, 30-day readmission was lower for GWTG hospitals (-0.33%; 95% CI, -0.53% to -0.12%; P=0.002).Although there was evidence that hospitals enrolled in the GTWG-HF program demonstrated better processes of care than other hospitals, there were few clinically important differences in outcomes. Further identification of opportunities to improve outcomes, and inclusion of these metrics in GTWG-HF, may further support the value of GTWG-HF in improving care for patients with HF.

  View details for DOI 10.1161/CIRCOUTCOMES.110.959122

  View details for Web of Science ID 000299411100008

  View details for PubMedID 22235067

• Age and Receipt of Guideline-Recommended Medications for Heart Failure: A Nationwide Study of Veterans JOURNAL OF GENERAL INTERNAL MEDICINE Steinman, M. A., Harlow, J. B., Massie, B. M., Kaboli, P. J., Fung, K. Z., Heidenreich, P. A. 2011; 26 (10): 1152-1159

  Abstract

  Older patients often receive less guideline-concordant care for heart failure than younger patients.To determine whether age differences in heart failure care are explained by patient, provider, and health system characteristics and/or by chart-documented reasons for non-adherence to guidelines.Retrospective cohort study of 2,772 ambulatory veterans with heart failure and left ventricular ejection fraction <40% from a 2004 nationwide medical record review program (the VA External Peer Review Program).Ambulatory use of ACE inhibitors, angiotensin receptor blockers (ARBs), and beta blockers.Among 2,772 patients, mean age was 73 +/- 10 years, 87% received an ACE inhibitor or ARB, and 82% received a beta blocker. When patients with explicit chart-documented reasons for not receiving these drugs were excluded, 95% received an ACE inhibitor or ARB and 89% received a beta blocker. In multivariable analyses controlling for a variety of patient and health system characteristics, the adjusted odds ratio for ACE-inhibitor and ARB use was 0.43 (95% CI 0.24-0.78) for patients age 80 and over vs. those age 50-64 years, and the adjusted odds ratio for beta blocker use was 0.66 (95% CI 0.48-0.93) between the two age groups. The magnitude of these associations was similar but not statistically significant after excluding patients with chart-documented reasons for not prescribing ACE inhibitors or ARBs and beta blockers.A high proportion of veterans receive guideline-recommended medications for heart failure. Older veterans are consistently less likely to receive these drugs, although these differences were no longer significant when accounting for patients with chart-documented reasons for not prescribing these drugs. Closely evaluating reasons for non-prescribing in older adults is essential to assessing whether non-treatment represents good clinical judgment or missed opportunities to improve care.

  View details for DOI 10.1007/s11606-011-1745-2

  View details for Web of Science ID 000295329600016

  View details for PubMedID 21604076

  View details for PubMedCentralID PMC3181303

• Influence of Age on Perioperative Complications Among Patients Undergoing Implantable Cardioverter-Defibrillators for Primary Prevention in the United States CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES Tsai, V., Goldstein, M. K., Hsia, H. H., Wang, Y., Curtis, J., Heidenreich, P. A. 2011; 4 (5): 549-U111

  Abstract

  BACKGROUND- The majority of current implantable cardioverter-defibrillator (ICD) recipients are significantly older than those in the ICD trials. Data on periprocedural complications among the elderly are insufficient. We evaluated the influence of age on perioperative complications among primary prevention ICD recipients in the United States. METHODS AND RESULTS- Using the National Cardiovascular Data's ICD Registry, we identified 150 264 primary prevention patients who received ICDs from January 2006 to December 2008. The primary end point was any adverse event or in-hospital mortality. Secondary end points included major adverse events, minor adverse events, and length of stay. Of 150 264 patients, 61% (n=91 863) were 65 years and older. A higher proportion of patients ≥65 years had diabetes, congestive heart failure, atrial fibrillation, renal disease, and coronary artery disease. Approximately 3.4% of the entire cohort had any complication, including death, after ICD implant. Any adverse event or death occurred in 2.8% of patients under 65 years old; 3.1% of 65- to 69-year-olds; 3.5% of 70- to 74-year-olds; 3.9% of 75- to 79-year-olds, 4.5% of 80- to 84-year-olds; and 4.5% of patients 85 years and older. After adjustment for clinical covariates, multivariate analysis found an increased odds of any adverse event or death among 75- to 79-year-olds (1.14 [95% confidence interval, 1.03 to 1.25], 80-to 84-year-olds (1.22 [95% confidence interval, 1.10 to 1.36], and patients 85 years and older (1.15 [95% confidence interval, 1.01 to 1.32], compared with patients under 65 years old. CONCLUSIONS- Older patients had a modestly increased-but acceptably safe-risk of periprocedural complications and in-hospital mortality, driven mostly by increased comorbidity.

  View details for DOI 10.1161/CIRCOUTCOMES.110.959205

  View details for Web of Science ID 000295028800012

  View details for PubMedID 21878667

• Age Differences in Primary Prevention Implantable Cardioverter-Defibrillator Use in US Individuals JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Tsai, V., Goldstein, M. K., Hsia, H. H., Wang, Y., Curtis, J., Heidenreich, P. A. 2011; 59 (9): 1589-1595

  Abstract

  To estimate the potentially inappropriate use of implantable cardioverter-defibrillator ICDs in older U.S. adults.Retrospective study.The National Cardiovascular Data ICD Registry.Forty-four thousand eight hundred five individuals in the National Cardiovascular Data's ICD Registry(™) who had received ICDs for primary prevention from January 2006 to December 2008. Individuals with a prior myocardial infarction and ejection fraction less than 30% were included.Mortality risk was categorized using the Multicenter Automatic Defibrillator Implantation (MADIT) II risk-stratification system. Low-risk and very-high-risk individuals were considered potentially inappropriate recipients.Of 44,805 individuals, 67% (n = 29,893) were aged 65 and older, of whom 51% were aged 75 and older. A significant proportion of ICD recipients had a low risk of death (16%, n = 6,969) or very high risk of nonarrhythmic death (8%, n = 3,693). Potentially inappropriate ICD use was 10% in those aged 75 and older, much less than in younger groups (40%, <65; 21%, 65-74, P < .001). Although age was associated with a high risk of nonarrhythmic death, its influence was markedly attenuated after adjusting for comorbidities and timing of ICD implantation (odds ratio = 1.02, 95% confidence interval = 1.02-1.03, P < .001).Potentially inappropriate ICD use appears significantly less--and at modest rates--in older Americans than in younger age groups. Overall, almost one-quarter of individuals may have received ICDs inappropriately based on their risk of death. Physicians appear to be conservatively referring older adults and wisely deferring those with high comorbid burden.

  View details for DOI 10.1111/j.1532-5415.2011.03542.x

  View details for Web of Science ID 000295615000003

  View details for PubMedID 21883101

• Characteristics and Outcomes of Very Elderly Patients After First Hospitalization for Heart Failure CIRCULATION-HEART FAILURE Shah, R. U., Tsai, V., Klein, L., Heidenreich, P. A. 2011; 4 (3): 301-307

  Abstract

  The very elderly (age 80 years and older) with heart failure (HF) is a growing population that is rarely included in clinical trials. The aim of this investigation was to describe the characteristics and outcomes of very elderly patients after a first HF hospitalization.We identified very elderly patients (age 80 years and older) discharged with HF from the Veteran's Administration National Patient Care Database from 1999 to 2008. Outcomes of interest were death during index admission, 30-day and 1-year mortality, and 30-day all-cause and HF readmissions. We used generalized estimating equations to evaluate outcome differences between age groups within the very elderly cohort (ages 80 to 84, 85 to 89, and 90 and older), adjusting for comorbidities, demographics, and clustering by treatment facility. We identified 21 397 very elderly veterans with a first HF hospitalization during the study period. Thirty-day mortality decreased from 14% to 7% (both P<0.001) and 1-year mortality decreased from 49% to 27% (P<0.001). Although these improvements were most notable for patients age 90 and older (1-year mortality improved by 25.9%), the adjusted odds of death within 1 year were highest for the oldest veterans (odds ratio, 1.85; 95% confidence interval, 1.64 to 2.09, using the 80- to 85-year age group as reference). For all patients, 30-day all-cause readmissions remained largely unchanged and did not differ between age groups.Mortality for very elderly HF patients has improved over time, but 30-day readmissions remain frequent. Future studies should identify interventions to reduce cardiac and noncardiac rehospitalization of very elderly HF patients.

  View details for DOI 10.1161/CIRCHEARTFAILURE.110.959114

  View details for Web of Science ID 000292869800014

  View details for PubMedID 21467294

• Forecasting the Future of Cardiovascular Disease in the United States A Policy Statement From the American Heart Association CIRCULATION Heidenreich, P. A., Trogdon, J. G., Khavjou, O. A., Butler, J., Dracup, K., Ezekowitz, M. D., Finkelstein, E. A., Hong, Y., Johnston, S. C., Khera, A., Lloyd-Jones, D. M., Nelson, S. A., Nichol, G., Orenstein, D., Wilson, P. W., Woo, Y. J. 2011; 123 (8): 933-944

  Abstract

  Cardiovascular disease (CVD) is the leading cause of death in the United States and is responsible for 17% of national health expenditures. As the population ages, these costs are expected to increase substantially.To prepare for future cardiovascular care needs, the American Heart Association developed methodology to project future costs of care for hypertension, coronary heart disease, heart failure, stroke, and all other CVD from 2010 to 2030. This methodology avoided double counting of costs for patients with multiple cardiovascular conditions. By 2030, 40.5% of the US population is projected to have some form of CVD. Between 2010 and 2030, real (2008$) total direct medical costs of CVD are projected to triple, from $273 billion to $818 billion. Real indirect costs (due to lost productivity) for all CVD are estimated to increase from $172 billion in 2010 to $276 billion in 2030, an increase of 61%.These findings indicate CVD prevalence and costs are projected to increase substantially. Effective prevention strategies are needed if we are to limit the growing burden of CVD.

  View details for DOI 10.1161/CIR.0b013e31820a55f5

  View details for Web of Science ID 000287801300021

  View details for PubMedID 21262990

• Long-Term Outcome After ICD and CRT Implantation and Influence of Remote Device Follow-Up The ALTITUDE Survival Study CIRCULATION Saxon, L. A., Hayes, D. L., Gilliam, F. R., Heidenreich, P. A., Day, J., Seth, M., Meyer, T. E., Jones, P. W., Boehmer, J. P. 2010; 122 (23): 2359-2367

  Abstract

  Outcome data for patients receiving implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy-defibrillator (CRT-D) devices treated outside of clinical trials are lacking. No clinical trial has evaluated mortality after device implantation or after shock therapy in large numbers of patients with implanted devices that regularly transmit device data over a network.Survival status in patients implanted with ICD and CRT devices across the United States from a single manufacturer was assessed. Outcomes were compared between patients followed in device clinic settings and those who regularly transmit remote data collected from the device an average of 4 times monthly. Shock delivery and electrogram analysis could be ascertained from patients followed on the network, enabling survival after ICD shock to be evaluated. One- and 5-year survival rates in 185,778 patients after ICD implantation were 92% and 68% and were 88% and 54% for CRT-D device recipients. In 8228 patients implanted with CRT-only devices, survival was 82% and 48% at 1 and 5 years, respectively. For the 69,556 ICD and CRT-D patients receiving remote follow-up on the network, 1- and 5-year survival rates were higher compared with those in the 116,222 patients who received device follow-up in device clinics only (50% reduction; P<0.0001). There were no differences between patients followed on or off the remote network for the characteristics of age, gender, implanted device year or type, and economic or educational status. Shock therapy was associated with subsequent mortality risk for both ICD and CRT-D recipients.Survival after ICD and CRT-D implantation in patients treated in naturalistic practice compares favorably with survival rates observed in clinical trials. Remote follow-up of device data is associated with excellent survival, but arrhythmias that result in device therapy in this population are associated with a higher mortality risk compared with patients who do not require shock therapy.

  View details for DOI 10.1161/CIRCULATIONAHA.110.960633

  View details for Web of Science ID 000285002100009

  View details for PubMedID 21098452

• Divergent Trends in Survival and Readmission Following a Hospitalization for Heart Failure in the Veterans Affairs Health Care System 2002 to 2006 JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Heidenreich, P. A., Sahay, A., Kapoor, J. R., Pham, M. X., Massie, B. 2010; 56 (5): 362-368

  Abstract

  This study sought to determine recent trends over time in heart failure hospitalization, patient characteristics, treatment, rehospitalization, and mortality within the Veterans Affairs health care system.Use of recommended therapies for heart failure has increased in the U.S. However, it is unclear to what extent hospitalization rates and the associated mortality have improved.We compared rates of hospitalization for heart failure, 30-day rehospitalization for heart failure, and 30-day mortality following discharge from 2002 to 2006 in the Veterans Affairs Health Care System. Odds ratios for outcome were adjusted for patient diagnoses within the past year, laboratory data, and for clustering of patients within hospitals.We identified 50,125 patients with a first hospitalization for heart failure from 2002 to 2006. Mean age did not change (70 years), but increases were noted for most comorbidities (mean Charlson score increased from 1.72 to 1.89, p < 0.0001). Heart failure admission rates remained constant at about 5 per 1,000 veterans. Mortality at 30 days decreased (7.1% to 5.0%, p < 0.0001), whereas rehospitalization for heart failure at 30 days increased (5.6% to 6.1%, p = 0.11). After adjustment for patient characteristics, the odds ratio for rehospitalization in 2006 (vs. 2002) was 0.54 (95% confidence interval [CI]: 0.47 to 0.61) for mortality, but 1.21 (95% CI: 1.04 to 1.41) for heart failure rehospitalization at 30 days.Recent mortality and rehospitalization rates in the Veterans Affairs Health Care System have trended in opposite directions. These results have implications for using rehospitalization as a measure of quality of care.

  View details for DOI 10.1016/j.jacc.2010.02.053

  View details for Web of Science ID 000280109400003

  View details for PubMedID 20650356

• Relationship Between Early Physician Follow-up and 30-Day Readmission Among Medicare Beneficiaries Hospitalized for Heart Failure JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Hernandez, A. F., Greiner, M. A., Fonarow, G. C., Hammill, B. G., Heidenreich, P. A., Yancy, C. W., Peterson, E. D., Curtis, L. H. 2010; 303 (17): 1716-1722

  Abstract

  Readmission after hospitalization for heart failure is common. Early outpatient follow-up after hospitalization has been proposed as a means of reducing readmission rates. However, there are limited data describing patterns of follow-up after heart failure hospitalization and its association with readmission rates.To examine associations between outpatient follow-up within 7 days after discharge from a heart failure hospitalization and readmission within 30 days.Observational analysis of patients 65 years or older with heart failure and discharged to home from hospitals participating in the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure and the Get With the Guidelines-Heart Failure quality improvement program from January 1, 2003, through December 31, 2006.All-cause readmission within 30 days after discharge.The study population included 30,136 patients from 225 hospitals. Median length of stay was 4 days (interquartile range, 2-6) and 21.3% of patients were readmitted within 30 days. At the hospital level, the median percentage of patients who had early follow-up after discharge from the index hospitalization was 38.3% (interquartile range, 32.4%-44.5%). Compared with patients whose index admission was in a hospital in the lowest quartile of early follow-up (30-day readmission rate, 23.3%), the rates of 30-day readmission were 20.5% among patients in the second quartile (risk-adjusted hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.78-0.93), 20.5% among patients in the third quartile (risk-adjusted HR, 0.87; 95% CI, 0.78-0.96), and 20.9% among patients in the fourth quartile (risk-adjusted HR, 0.91; 95% CI, 0.83-1.00).Among patients who are hospitalized for heart failure, substantial variation exists in hospital-level rates of early outpatient follow-up after discharge. Patients who are discharged from hospitals that have higher early follow-up rates have a lower risk of 30-day readmission.clinicaltrials.gov Identifier: NCT00344513.

  View details for Web of Science ID 000277276600024

  View details for PubMedID 20442387

• Cost-Effectiveness of Preparticipation Screening for Prevention of Sudden Cardiac Death in Young Athletes ANNALS OF INTERNAL MEDICINE Wheeler, M. T., Heidenreich, P. A., Froelicher, V. F., Hlatky, M. A., Ashley, E. A. 2010; 152 (5): 276-W91

  Abstract

  Inclusion of 12-lead electrocardiography (ECG) in preparticipation screening of young athletes is controversial because of concerns about cost-effectiveness.To evaluate the cost-effectiveness of ECG plus cardiovascular-focused history and physical examination compared with cardiovascular-focused history and physical examination alone for preparticipation screening.Decision-analysis, cost-effectiveness model.Published epidemiologic and preparticipation screening data, vital statistics, and other publicly available data.Competitive athletes in high school and college aged 14 to 22 years.Lifetime.Societal.Nonparticipation in competitive athletic activity and disease-specific treatment for identified athletes with heart disease.Incremental health care cost per life-year gained.Addition of ECG to preparticipation screening saves 2.06 life-years per 1000 athletes at an incremental total cost of $89 per athlete and yields a cost-effectiveness ratio of $42 900 per life-year saved (95% CI, $21 200 to $71 300 per life-year saved) compared with cardiovascular-focused history and physical examination alone. Compared with no screening, ECG plus cardiovascular-focused history and physical examination saves 2.6 life-years per 1000 athletes screened and costs $199 per athlete, yielding a cost-effectiveness ratio of $76 100 per life-year saved ($62 400 to $130 000).Results are sensitive to the relative risk reduction associated with nonparticipation and the cost of initial screening.Effectiveness data are derived from 1 major European study. Patterns of causes of sudden death may vary among countries.Screening young athletes with 12-lead ECG plus cardiovascular-focused history and physical examination may be cost-effective.Stanford Cardiovascular Institute and the Breetwor Foundation.

  View details for PubMedID 20194233

• Hospital performance recognition with the Get With The Guidelines Program and mortality for acute myocardial infarction and heart failure AMERICAN HEART JOURNAL Heidenreich, P. A., Lewis, W. R., LaBresh, K. A., Schwamm, L. H., Fonarow, G. C. 2009; 158 (4): 546-553

  Abstract

  Many hospitals enrolled in the American Heart Association's Get With The Guidelines (GWTG) Program achieve high levels of recommended care for heart failure, acute myocardial infarction (MI) and stroke. However, it is unclear if outcomes are better in those hospitals recognized by the GWTG program for their processes of care.We compared hospitals enrolled in GWTG and receiving achievement awards for high levels of recommended processes of care with other hospitals using data on risk-adjusted 30-day survival for heart failure and acute MI reported by the Center for Medicare and Medicaid Services.Among the 3,909 hospitals with 30-day data reported by Center for Medicare and Medicaid Services 355 (9%) received GWTG achievement awards. Risk-adjusted mortality for hospitals receiving awards was lower for both heart failure (11.0% vs 11.2%, P = .0005) and acute MI (16.1% vs 16.5%, P < .0001) compared to those not receiving awards. After additional adjustment for hospital characteristics and noncardiac performance measures, the reduction in mortality remained significantly lower for GWTG award hospitals for acute myocardial infraction (-0.19%, 95% CI -0.33 to -0.05), but not for heart failure (-0.11%, 95% CI -0.25 to 0.02). Additional adjustment for cardiac processes of care reduced the benefit of award hospitals by 28% for heart failure mortality and 43% for acute MI mortality.Hospitals receiving achievement awards from the GWTG program have modestly lower risk adjusted mortality for acute MI and to a lesser extent, heart failure, explained in part by better process of care.

  View details for DOI 10.1016/j.ahj.2009.07.031

  View details for Web of Science ID 000270706100009

  View details for PubMedID 19781413

• Assessing the Value of a Diagnostic Test ARCHIVES OF INTERNAL MEDICINE Heidenreich, P. A. 2009; 169 (14): 1262-1264

  View details for Web of Science ID 000268373000002

  View details for PubMedID 19636026

• Association of Physician Certification and Outcomes Among Patients Receiving an Implantable Cardioverter-Defibrillator 81st Annual Scientific Session of the American-Heart-Association Curtis, J. P., Luebbert, J. J., Wang, Y., Rathore, S. S., Chen, J., Heidenreich, P. A., Hammill, S. C., Lampert, R. I., Krumholz, H. M. AMER MEDICAL ASSOC. 2009: 1661–70

  Abstract

  Allowing nonelectrophysiologists to perform implantable cardioverter-defibrillator (ICD) procedures is controversial. However, it is not known whether outcomes of ICD implantation vary by physician specialty.To determine the association of implanting physician certification with outcomes following ICD implantation.Retrospective cohort study using cases submitted to the ICD Registry performed between January 2006 and June 2007. Patients were grouped by the certification status of the implanting physician into mutually exclusive categories: electrophysiologists, nonelectrophysiologist cardiologists, thoracic surgeons, and other specialists. Hierarchical logistic regression models were developed to determine the independent association of physician certification with outcomes.In-hospital procedural complication rates and the proportion of patients meeting criteria for a defibrillator with cardiac resynchronization therapy (CRT-D) who received that device.Of 111,293 ICD implantations included in the analysis, 78,857 (70.9%) were performed by electrophysiologists, 24,399 (21.9%) by nonelectrophysiologist cardiologists, 1862 (1.7%) by thoracic surgeons, and 6175 (5.5%) by other specialists. Compared with patients whose ICD was implanted by electrophysiologists, patients whose ICD was implanted by either nonelectrophysiologist cardiologists or thoracic surgeons were at increased risk of complications in both unadjusted (electrophysiologists, 3.5% [2743/78,857]; nonelectrophysiologist cardiologists, 4.0% [970/24,399]; thoracic surgeons, 5.8% [108/1862]; P < .001) and adjusted analyses (relative risk [RR] for nonelectrophysiologist cardiologists, 1.11 [95% confidence interval {CI}, 1.01-1.21]; RR for thoracic surgeons, 1.44 [95% CI, 1.15-1.79]). Among 35,841 patients who met criteria for CRT-D, those whose ICD was implanted by physicians other than electrophysiologists were significantly less likely to receive a CRT-D device compared with patients whose ICD was implanted by an electrophysiologist in both unadjusted (electrophysiologists, 83.1% [21 303/25,635]; nonelectrophysiologist cardiologists, 75.8% [5950/7849]; thoracic surgeons, 57.8% [269/465]; other specialists, 74.8% [1416/1892]; P < .001) and adjusted analyses (RR for nonelectrophysiologist cardiologists, 0.93 [95% CI, 0.91-0.95]; RR for thoracic surgeons, 0.81 [95% CI, 0.74-0.88]; RR for other specialists, 0.97 [95% CI, 0.94-0.99]).In this registry, nonelectrophysiologists implanted 29% of ICDs. Overall, implantations by a nonelectrophysiologist were associated with a higher risk of procedural complications and lower likelihood of receiving a CRT-D device when indicated compared with patients whose ICD was implanted by an electrophysiologist.

  View details for Web of Science ID 000265350700022

  View details for PubMedID 19383957

  View details for PubMedCentralID PMC2805129

• Radiation induced heart disease: systemic disorders in heart disease. Heart Heidenreich, P. A., Kapoor, J. R. 2009; 95 (3): 252-258

  View details for DOI 10.1136/hrt.2008.149088

  View details for PubMedID 19144884

• Cost-effectiveness of chlorthalidone, amlodipine, and lisinopril as first-step treatment for patients with hypertension: An analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) JOURNAL OF GENERAL INTERNAL MEDICINE Heidenreich, P. A., Davis, B. R., Cutler, J. A., Furberg, C. D., Lairson, D. R., Shlipak, M. G., Pressel, S. L., Nwachuku, C., Goldman, L. 2008; 23 (5): 509-516

  Abstract

  To evaluate the cost-effectiveness of first-line treatments for hypertension.The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) found that first-line treatment with lisinopril or amlodipine was not significantly superior to chlorthalidone in terms of the primary endpoint, so differences in costs may be critical for optimizing decision-making.Cost-effectiveness analysis was performed using bootstrap resampling to evaluate uncertainty.Over a patient's lifetime, chlorthalidone was always least expensive (mean $4,802 less than amlodipine, $3,700 less than lisinopril). Amlodipine provided more life-years (LYs) than chlorthalidone in 84% of bootstrap samples (mean 37 days) at an incremental cost-effectiveness ratio of $48,400 per LY gained. Lisinopril provided fewer LYs than chlorthalidone in 55% of bootstrap samples (mean 7-day loss) despite a higher cost. At a threshold of $50,000 per LY gained, amlodipine was preferred in 50%, chlorthalidone in 40%, and lisinopril in 10% of bootstrap samples, but these findings were highly sensitive to the cost of amlodipine and the cost-effectiveness threshold chosen. Incorporating quality of life did not appreciably alter the results. Overall, no reasonable combination of assumptions led to 1 treatment being preferred in over 90% of bootstrap samples.Initial treatment with chlorthalidone is less expensive than lisinopril or amlodipine, but amlodipine provided a nonsignificantly greater survival benefit and may be a cost-effective alternative. A randomized trial with power to exclude "clinically important" differences in survival will often have inadequate power to determine the most cost-effective treatment.

  View details for DOI 10.1007/s11606-008-0515-2

  View details for Web of Science ID 000255195300001

  View details for PubMedID 18228109

  View details for PubMedCentralID PMC2324142

• Clinical significance of high-density lipoprotein cholesterol in patients with low low-density lipoprotein cholesterol JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY deGoma, E. M., Leeper, N. J., Heidenreich, P. A. 2008; 51 (1): 49-55

  Abstract

  We sought to evaluate the significance of high-density lipoprotein cholesterol (HDL-C) in the context of low low-density lipoprotein cholesterol (LDL-C).Earlier studies support an inverse correlation between circulating HDL-C and coronary risk in patients with normal or elevated LDL-C.This study involved 4,188 patients attending the Palo Alto Veterans Administration Medical Center or affiliated clinics with LDL-C levels below 60 mg/dl. Outcomes were examined 1 year after the index LDL-C date. The combined primary end point was myocardial injury or hospitalization from ischemic heart disease. The secondary end point was all-cause mortality.Mean HDL-C levels (mg/dl) by quartile (Q) were: Q1 28 mg/dl, Q2 36 mg/dl, Q3 43 mg/dl, and Q4 63 mg/dl. The rate of myocardial injury or hospitalization for ischemic heart disease showed an inverse relationship to HDL-C (adjusted odds ratios: Q1 1.59 [95% confidence interval (CI) 1.16 to 2.19], Q2 1.39 [95% CI 1.01 to 1.92], Q3 1.33 [95% CI 0.96 to 1.84], and Q4 reference) that persisted regardless of statin use or recent myocardial injury. Analyzing HDL-C as a continuous variable revealed a 10% [95% CI 3% to 17%] increase in the combined end point of myocardial injury or hospitalization for ischemic heart disease for every 10-mg/dl decrease in HDL-C. The unadjusted and adjusted incidence of all-cause mortality demonstrated a U-shaped relationship to HDL-C (adjusted odds ratios: Q1 1.13 [95% CI 0.79 to 1.62], Q2 0.97 [95% CI 0.67 to 1.40], Q3 0.74 [95% CI 0.50 to 1.09], and Q4 reference).The inverse relationship between HDL-C and coronary risk persists even among patients with LDL-C below 60 mg/dl, although a U-shaped relationship is observed between HDL-C and all-cause mortality.

  View details for DOI 10.1016/j.jacc.2007.07.086

  View details for Web of Science ID 000252510300008

  View details for PubMedID 18174036

• Statin use in patients with extremely low low-density lipoprotein levels is associated with improved survival CIRCULATION Leeper, N. J., Ardehali, R., DeGoma, E. M., Heidenreich, P. A. 2007; 116 (6): 613-618

  Abstract

  Aggressive lipid management has recently become the standard of care for patients with coronary heart disease. The safety and effectiveness of statin usage for patients with extremely low low-density lipoprotein (LDL) levels are less clear, however. The aim of this study was to investigate the safety and clinical outcomes of statin treatment in patients with LDL cholesterol levels below 60 mg/dL.A total of 6107 consecutive patients with LDL levels less than 60 mg/dL were identified from a tertiary care medical center or affiliated community clinic. Statin therapy was defined as a prescription during the 150 days after the low LDL value was obtained. The propensity to be treated with a statin was used to adjust the association of statin therapy and survival. A total of 4295 patients (70%) had at least 1 prescription for any medication during the 150-day observation period after the low LDL value. Their mean age was 65 years, 43% had prior ischemic heart disease, and 47% had diabetes mellitus. Statins were prescribed in 2564 patients (60%) after the low LDL value was observed. During a mean follow-up of 2.0+/-1.4 years after the observation period, there were 510 deaths. After controlling for the propensity to receive a statin, statin therapy was associated with improved survival (hazard ratio [HR], 0.65; 95% CI, 0.53 to 0.80). This lower mortality was also observed for subgroups of patients already taking statins at baseline (HR, 0.58; 95% CI, 0.38 to 0.88), those with extremely low LDL levels (<40 mg/dL, n=623; HR, 0.51; 95% CI, 0.33 to 0.79), and those without a history of ischemic heart disease (n=2438; HR, 0.58; 95% CI, 0.42 to 0.80). Statin use was not associated with an increase in malignancy, transaminase elevation, or rhabdomyolysis.Statin therapy in the setting of a very low LDL level appears to be safe and is associated with improved survival.

  View details for DOI 10.1161/CIRCULATIONAHA.107.694117

  View details for Web of Science ID 000248572300010

  View details for PubMedID 17664373

• Clinical reminders attached to echocardiography reports of patients with reduced left ventricular ejection fraction increase use of beta-blockers - A randomized trial CIRCULATION Heidenreich, P. A., Gholami, P., Sahay, A., Massie, B., Goldstein, M. K. 2007; 115 (22): 2829-2834

  Abstract

  Although beta-blockers are known to prolong survival for patients with reduced left ventricular ejection fraction, they are often underused. We hypothesized that a reminder attached to the echocardiography report would increase the use of beta-blockers for patients with reduced left ventricular ejection fraction.We randomized 1546 consecutive patients with a left ventricular ejection fraction <45% found on echocardiography at 1 of 3 laboratories to a reminder for use of beta-blockers or no reminder. Patients were excluded from analysis if they died within 30 days of randomization (n=89), did not receive medications through the Veterans Affairs system after 30 days (n=180), or underwent echocardiography at >1 laboratory (n=6). The primary outcome was a prescription for an oral beta-blocker between 1 and 9 months after randomization. The mean age of the 1271 included patients was 69 years; 60% had a history of heart failure, and 51% were receiving treatment with beta-blockers at the time of echocardiography. More patients randomized to the reminder had a subsequent beta-blocker prescription (74%, 458 of 621) compared with those randomized to no reminder (66%, 428 of 650; P=0.002). The effect of the reminder was not significantly different for subgroups based on patient location (inpatient versus outpatient) or prior use of beta-blockers.A reminder attached to the echocardiography report increased the use of beta-blockers in patients with depressed left ventricular systolic function.

  View details for DOI 10.1161/CIRCULATIONAHA.106.684753

  View details for Web of Science ID 000246972600008

  View details for PubMedID 17515459

• Screening for coronary artery disease after mediastinal irradiation for Hodgkin's disease JOURNAL OF CLINICAL ONCOLOGY Heidenreich, P. A., Schnittger, I., Strauss, H. W., Vagelos, R. H., Lee, B. K., Mariscal, C. S., Tate, D. J., Horning, S. J., Hoppe, R. T., Hancock, S. L. 2007; 25 (1): 43-49

  Abstract

  Incidental cardiac irradiation during treatment of thoracic neoplasms has increased risks for subsequent acute myocardial infarction or sudden cardiac death. Identifying patients who have a high risk for a coronary event may decrease morbidity and mortality. The objective of this study was to evaluate whether stress imaging can identify severe, unsuspected coronary stenoses in patients who had prior mediastinal irradiation for Hodgkin's disease.We enrolled 294 outpatients observed at a tertiary care cancer treatment center after mediastinal irradiation doses 35 Gy for Hodgkin's disease who had no known ischemic cardiac disease. Patients underwent stress echocardiography and radionuclide perfusion imaging at one stress session. Coronary angiography was performed at the discretion of the physician.Among the 294 participants, 63 (21.4%) had abnormal ventricular images at rest, suggesting prior myocardial injury. During stress testing, 42 patients (14%) developed perfusion defects (n = 26), impaired wall motion (n = 8), or both abnormalities (n = 8). Coronary angiography showed stenosis 50% in 22 patients (55%), less than 50% in nine patients (22.5%), and no stenosis in nine patients (22.5%). Screening led to bypass graft surgery in seven patients. Twenty-three patients developed coronary events during a median of 6.5 years of follow-up, with 10 acute myocardial infarctions (two fatal).Stress-induced signs of ischemia and significant coronary artery disease are highly prevalent after mediastinal irradiation in young patients. Stress testing identifies asymptomatic individuals at high risk for acute myocardial infarction or sudden cardiac death.

  View details for DOI 10.1200/JCO.2006.07.0805

  View details for Web of Science ID 000243725900009

  View details for PubMedID 17194904

• Health status identifies heart failure outpatients at risk for hospitalization or death JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Heidenreich, P. A., Spertus, J. A., Jones, P. G., Weintraub, W. S., Rumsfeld, J. S., Rathore, S. S., Peterson, E. D., Masoudi, F. A., Krumholz, H. M., Havranek, E. P., Conard, M. W., Williams, R. E. 2006; 47 (4): 752-756

  Abstract

  We tested the hypothesis that one health status measure, the Kansas City Cardiomyopathy Questionnaire (KCCQ), provides prognostic information independent of other clinical data in outpatients with heart failure (HF).Health status measures are used to describe a patient's clinical condition and have been shown to predict mortality in some populations. Their prognostic value may be particularly useful among patients with HF for identifying candidates for disease management in whom increased care may reduce hospitalizations and prevent death.We evaluated 505 HF patients from 13 outpatient clinics who had an ejection fraction <40% using the KCCQ summary score. Proportional hazards regression was used to evaluate the association between the KCCQ summary score (range, 0 to 100; higher scores indicate better health status) and the primary outcome of death or HF admission, adjusting for baseline patient characteristics, 6-min walk distance, and B-type natriuretic peptide (BNP).The mean age was 61 years, 76% of patients were male, 51% had an ischemic HF etiology, and 5% were New York Heart Association functional class IV. At 12 months, among the 9% of patients with a KCCQ score <25, 37% had been admitted for HF and 20% had died, compared with 7% (HF admissions) and 5% (death) of those with a KCCQ score > or =75 (33% of patients, p < 0.0001 for both comparisons). In sequential multivariable models adjusting for clinical variables, 6-min walk, and BNP levels, the KCCQ score remained significantly associated with survival free of HF hospitalization.A low KCCQ score is an independent predictor of poor prognosis in outpatients with HF.

  View details for DOI 10.1016/j.jacc.2005.11.021

  View details for Web of Science ID 000235422900011

  View details for PubMedID 16487840

• ACE inhibitor reminders attached to echocardiography reports of patients with reduced left ventricular ejection fraction AMERICAN JOURNAL OF MEDICINE Heidenreich, P. A., Chacko, M., Goidstein, M. K., Atwood, J. E. 2005; 118 (9): 1034-1037

  View details for DOI 10.1016/j.amjmed.2004.12.028

  View details for Web of Science ID 000231807300018

  View details for PubMedID 16164891

• A cost-effectiveness analysis of combination antiplatelet therapy for high-risk acute coronary syndromes: Clopidogrel plus aspirin versus aspirin alone ANNALS OF INTERNAL MEDICINE Schleinitz, M. D., Heidenreich, P. A. 2005; 142 (4): 251-259

  Abstract

  Although clopidogrel plus aspirin is more effective than aspirin alone in preventing subsequent vascular events in patients with unstable angina, the cost-effectiveness of this combination has yet to be examined in this high-risk population.To determine the cost-effectiveness of clopidogrel plus aspirin compared with aspirin alone.Cost-utility analysis.Published literature.Patients with unstable angina and electrocardiographic changes or non-Q-wave myocardial infarction. time horizon: Lifetime.Societal.Combination therapy with clopidogrel, 75 mg/d, plus aspirin, 325 mg/d, for 1 year, followed by aspirin monotherapy, was compared with lifelong aspirin therapy, 325 mg/d.Lifetime costs, life expectancy in quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio.Patients treated with aspirin alone lived 9.51 QALYs after their initial event and incurred expenses of 127,700 dollars; the addition of clopidogrel increased life expectancy to 9.61 QALYs and costs to 129,300 dollars. The incremental cost-effectiveness ratio for clopidogrel plus aspirin compared with aspirin alone was 15,400 dollars per QALY. RESULTS OF SENSITIVITY ANALYSES: The analysis of 1 year of therapy was robust to all sensitivity analyses. In the probabilistic sensitivity analysis, fewer than 3% of simulations resulted in cost-effectiveness ratios over 50,000 dollars per QALY. The cost-effectiveness of longer combination therapy depends critically on the balance of thrombotic event rates, durable efficacy, and the increased bleeding rate in patients taking clopidogrel.This analysis may not apply to patients with severe heart failure, those undergoing long-term anticoagulant therapy, those recently managed with revascularization, or those undergoing short-term treatment with glycoprotein IIb/IIIa inhibitors.In patients with high-risk acute coronary syndromes, 1 year of therapy with clopidogrel plus aspirin results in greater life expectancy than aspirin alone, at a cost within the traditional limits of cost-effectiveness. The durable efficacy of clopidogrel relative to the risk for hemorrhage should be further explored before more protracted therapy can be recommended.

  View details for Web of Science ID 000227239500003

  View details for PubMedID 15710958

• Cost-effectiveness of screening with B-type natriuretic peptide to identify patients with reduced left ventricular ejection fraction JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Heidenreich, P. A., Gubens, M. A., Fonarow, G. C., Konstam, M. A., Stevenson, L. W., Shekelle, P. G. 2004; 43 (6): 1019-1026

  Abstract

  This study was designed to evaluate the cost-effectiveness of screening patients with a B-type natriuretic peptide (BNP) blood test to identify those with depressed left ventricular systolic function.Asymptomatic patients with depressed ejection fraction (EF) may have less progression to heart failure if they can be identified and treated.We used a decision model to estimate economic and health outcomes for different screening strategies using BNP and echocardiography to detect left ventricular EF <40% for men and women age 60 years. We used published data from community cohorts (gender-specific BNP test characteristics, prevalence of depressed EF) and randomized trials (benefit from treatment).Screening 1,000 asymptomatic patients with BNP followed by echocardiography in those with an abnormal test increased the lifetime cost of care (176,000 US dollars for men, 101,000 US dollars for women) and improved outcome (7.9 quality-adjusted life years [QALYs] for men, 1.3 QALYs for women), resulting in a cost per QALY of 22,300 US dollars for men and 77,700 US dollars for women. For populations with a prevalence of depressed EF of at least 1%, screening with BNP followed by echocardiography increased outcome at a cost < 50,000 US dollars per QALY gained. Screening would not be attractive if a diagnosis of left ventricular dysfunction led to significant decreases in quality of life or income.Screening populations with a 1% prevalence of reduced EF (men at age 60 years) with BNP followed by echocardiography should provide a health benefit at a cost that is comparable to or less than other accepted health interventions.

  View details for DOI 10.1016/j.jacc.2003.10.043

  View details for Web of Science ID 000220212400016

  View details for PubMedID 15028361

• Improving guideline adherence - A randomized trial evaluating strategies to increase beta-blocker use in heart failure CIRCULATION Ansari, M., Shlipak, M. G., Heidenreich, P. A., Van Ostaeyen, D., Pohl, E. C., Browner, W. S., Massie, B. M. 2003; 107 (22): 2799-2804

  Abstract

  The dissemination of clinical practice guidelines often has not been accompanied by desired improvements in guideline adherence. This study evaluated interventions for implementing a new practice guideline advocating the use of beta-blockers for heart failure patients.This was a randomized controlled trial involving heart failure patients (n=169) with an ejection fraction < or =45% and no contraindications to beta-blockers. Patients' primary providers were randomized in a stratified design to 1 of 3 interventions: (1) control: provider education; (2) provider and patient notification: computerized provider reminders and patient letters advocating beta-blockers; and (3) nurse facilitator: supervised nurse to initiate and titrate beta-blockers. The primary outcome, the proportion of patients who were initiated or uptitrated and maintained on beta-blockers, analyzed by intention to treat, was achieved in 67% (36 of 54) of patients in the nurse facilitator group compared with 16% (10 of 64) in the provider/patient notification and 27% (14 of 51) in the control groups (P<0.001 for the comparisons between the nurse facilitator group and both other groups). The proportion of patients on target beta-blocker doses at the study end (median follow-up, 12 months) was also highest in the nurse facilitator group (43%) compared with the control (10%) and provider/patient notification groups (2%) (P<0.001). There were no differences in adverse events among groups.The use of a nurse facilitator was a successful approach for implementing a beta-blocker guideline in heart failure patients. The use of provider education, clinical reminders, and patient education was of limited value in this setting.

  View details for DOI 10.1161/01.CIR.0000070952.08969.5B

  View details for Web of Science ID 000183400500008

  View details for PubMedID 12756157

• Biomedical research and then some: The causes of technological change in heart attack treatment Conference on the Economics of Medical Research Heidenreich, P., McClellan, M. UNIV CHICAGO PRESS. 2003: 163–205

  View details for Web of Science ID 000221685400006

• The relation between managed care market share and the treatment of elderly fee-for-service patients with myocardial infarction AMERICAN JOURNAL OF MEDICINE Heidenreich, P. A., McClellan, M., Frances, C., Baker, L. C. 2002; 112 (3): 176-182

  Abstract

  To determine if greater managed care market share is associated with greater use of recommended therapies for fee-for-service patients with acute myocardial infarction.We examined the care of 112,900 fee-for-service Medicare beneficiaries aged > or = 65 years who resided in one of 320 metropolitan statistical areas and who were admitted with an acute myocardial infarction between February 1994 through July 1995. Use of recommended medical treatments and 30-day survival were determined for areas with low (<10%), medium (10% to 30%), and high (>30%) managed care market share.After adjustment for severity of illness, teaching status of the admission hospital, and area characteristics, areas with high levels of managed care had greater use of beta-blockers (relative risk [RR] for greater use = 1.18; 95% confidence interval [CI]: 1.06 to 1.29) and aspirin at discharge (RR = 1.05; 95% CI: 1.02 to 1.07), but less appropriate coronary angiography (RR = 0.93; 95% CI: 0.86 to 1.01) and reperfusion (RR = 0.95; 95% CI: 0.85 to 1.03) when compared with areas with low levels of managed care.Medicare beneficiaries with fee-for-service insurance who resided in areas with high managed care activity were more likely to have received appropriate treatment with beta-blockers and aspirin, and less likely to have undergone coronary angiography following admission for myocardial infarction. Thus, the effects of managed care may not be limited to managed care enrollees.

  View details for Web of Science ID 000174602100002

  View details for PubMedID 11893343

• Trends in treatment and outcomes for acute myocardial infarction: 1975-1995 AMERICAN JOURNAL OF MEDICINE Heidenreich, P. A., McClellan, M. 2001; 110 (3): 165-174

  Abstract

  To review the trends in treatment and survival for patients with acute myocardial infarction over the last 20 years.Studies were identified through MEDLINE searches and review of study bibliographies. Additional data were obtained from the Health Care Financing Administration including data from Medicare claims files (part A). Thirty-day mortality rates were calculated using Medicare data and case fatality rates from the National Hospital Discharge Survey. Published meta-analyses were used to determine treatment effects. Published studies were included if they reported the use of therapies for acute myocardial infarction at a population level. Trends in the demographic characteristics of the patients as well as infarct characteristics, medication use, and revascularization were recorded.The use of acute treatments that are known to improve survival among patients with myocardial infarction has increased markedly during the last 20 years, leading to an estimated 9.6% reduction (from 27.0% to 17.4%) in 30-day mortality. After adjusting for potential interactions between therapies, the increase in use of aspirin, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and reperfusion can explain 71% of the decrease in the 30-day age- and sex-adjusted mortality rate from 1975 to 1995. The greatest effect of a given therapy was that of aspirin, which accounted for 34% of the decrease in 30-day mortality, followed by thrombolysis (17%), primary angioplasty (10%), beta-blockers (7%), and ACE inhibitors (3%). If other treatments (such as heparin or nonprimary angioplasty), whose effects on mortality are less certain, are included, up to 90% of the decrease in 30-day mortality can be explained by changes in treatment.The primary reason for the decrease in early mortality from myocardial infarction during the last 20 years appears to be increased use of effective treatments.

  View details for Web of Science ID 000166946600001

  View details for PubMedID 11182101

• Trends in heart attack treatment and outcomes, 1975-1995 - Literature review and synthesis Conference on Research in Income and Wealth Heidenreich, P., McClellan, M. UNIV CHICAGO PRESS. 2001: 363–409

  View details for Web of Science ID 000173314700010

• Meta-analysis of trials comparing beta-blockers, calcium antagonists, and nitrates for stable angina JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Heidenreich, P. A., McDonald, K. M., Hastie, T., Fadel, B., Hagan, V., Lee, B. K., Hlatky, M. A. 1999; 281 (20): 1927-1936

  Abstract

  Which drug is most effective as a first-line treatment for stable angina is not known.To compare the relative efficacy and tolerability of treatment with beta-blockers, calcium antagonists, and long-acting nitrates for patients who have stable angina.We identified English-language studies published between 1966 and 1997 by searching the MEDLINE and EMBASE databases and reviewing the bibliographies of identified articles to locate additional relevant studies.Randomized or crossover studies comparing antianginal drugs from 2 or 3 different classes (beta-blockers, calcium antagonists, and long-acting nitrates) lasting at least 1 week were reviewed. Studies were selected if they reported at least 1 of the following outcomes: cardiac death, myocardial infarction, study withdrawal due to adverse events, angina frequency, nitroglycerin use, or exercise duration. Ninety (63%) of 143 identified studies met the inclusion criteria.Two independent reviewers extracted data from selected articles, settling any differences by consensus. Outcome data were extracted a third time by 1 of the investigators. We combined results using odds ratios (ORs) for discrete data and mean differences for continuous data. Studies of calcium antagonists were grouped by duration and type of drug (nifedipine vs nonnifedipine).Rates of cardiac death and myocardial infarction were not significantly different for treatment with beta-blockers vs calcium antagonists (OR, 0.97; 95% confidence interval [CI], 0.67-1.38; P = .79). There were 0.31 (95% CI, 0.00-0.62; P = .05) fewer episodes of angina per week with beta-blockers than with calcium antagonists. beta-Blockers were discontinued because of adverse events less often than were calcium antagonists (OR, 0.72; 95% CI, 0.60-0.86; P<.001). The differences between beta-blockers and calcium antagonists were most striking for nifedipine (OR for adverse events with beta-blockers vs nifedipine, 0.60; 95% CI, 0.47-0.77). Too few trials compared nitrates with calcium antagonists or beta-blockers to draw firm conclusions about relative efficacy.beta-Blockers provide similar clinical outcomes and are associated with fewer adverse events than calcium antagonists in randomized trials of patients who have stable angina.

  View details for Web of Science ID 000080427300033

  View details for PubMedID 10349897

• Temporal trends in lipoprotein(a) testing among United States veterans from 2014 to 2023 AMERICAN JOURNAL OF PREVENTIVE CARDIOLOGY Gomez, S. E., Furst, A., Chen, T., Din, N., Maron, D. J., Heidenreich, P., Kalwani, N., Nallamshetty, S., Ward, J. H., Lozama, A., Sandhu, A., Rodriguez, F. 2024; 20

  View details for DOI 10.1016/j.ajpc.2024.100872

  View details for Web of Science ID 001331656700001

• Temporal trends in lipoprotein(a) testing among United States veterans from 2014 to 2023. American journal of preventive cardiology Gomez, S. E., Furst, A., Chen, T., Din, N., Maron, D. J., Heidenreich, P., Kalwani, N., Nallamshetty, S., Ward, J. H., Lozama, A., Sandhu, A., Rodriguez, F. 2024; 20: 100872

  Abstract

  Lipoprotein (a) [Lp(a)] is a causal, genetically-inherited risk amplifier for atherosclerotic cardiovascular disease (ASCVD). Practice guidelines increasingly recommend broad Lp(a) screening among various populations to optimize preventive care. Corresponding changes in testing rates and population-level detection of elevated Lp(a) in recent years has not been well described.Using Veterans Affairs electronic health record data, we performed a retrospective cohort study evaluating temporal trends in Lp(a) testing and detection of elevated Lp(a) levels (defined as greater than 50 mg/dL) from January 1, 2014 to December 31, 2023 among United States Veterans without prior Lp(a) testing. Testing rates were stratified based on demographic and clinical factors to investigate possible drivers for and disparities in testing: age, sex, race and ethnicity, history of ASCVD, and neighborhood social vulnerability.Lp(a) testing increased nationally from 1 test per 10,000 eligible Veterans (558 tests) in 2014 to 9 tests per 10,000 (4,440 tests) in 2023, while the proportion of elevated Lp(a) levels remained stable. Factors associated with higher likelihood of Lp(a) testing over time were a history of ASCVD, Asian race, and residing in neighborhoods with less social vulnerability.Despite a 9-fold increase in Lp(a) testing among US Veterans over the last decade, the overall testing rate remains extremely low. The steady proportion of Veterans with elevated Lp(a) over time supports the clinical utility of testing expansion. Efforts to increase testing, especially among Veterans living in neighborhoods with high social vulnerability, will be important to reduce emerging disparities as novel therapeutics to target Lp(a) become available.

  View details for DOI 10.1016/j.ajpc.2024.100872

  View details for PubMedID 39430431

  View details for PubMedCentralID PMC11489823

• Lower Risk of Death and Kidney Failure Associated with Higher Target (vs. Below-Target) Doses of RAS Inhibitors in Octogenarians with HFrEF. The American journal of medicine Sin, M. K., Allman, R. M., Faselis, C., Aronow, W. S., Brown, C. J., Lam, P. H., Wu, W. C., Zeng-Treitler, Q., Patel, S. S., Raman, V. K., Zhang, S., Sheriff, H. M., Morgan, C. J., Heidenreich, P. A., Fonarow, G. C., Ahmed, A. 2024

  Abstract

  Renin-angiotensin system inhibitors (RASIs) at higher target doses reduce the risk of death in patients with heart failure with reduced ejection fraction (HFrEF). Less is known about their effectiveness in octogenarians, the examination of which was the objective of this study.Of 32,964 Veterans ≥80 years with HFrEF (ejection fraction ≤40%) receiving RASIs, 6655 received target-dose. Using propensity scores for target-dose, calculated for each of 32,964 patients, we assembled a matched cohort of 13,284 patients balanced on 66 baseline characteristics. Hazard ratios (95% CI) for 5-year mortality and kidney failure associated with target (vs. below-target) dose RASI were estimated in the matched cohort. Kidney failure was defined as receipt of kidney replacement therapy or estimated glomerular filtration rate (eGFR) <15 mL/min/1.73m2 measured twice >30 days apart.Patients had mean(±SD) age 84.5(±3.4) years, EF 31.3(±8.2) %, and eGFR 58.5(±18.2) mL/min/1.73m2. All-cause mortality occurred in 71.2% and 69.5% of matched patients in below-target and target dose RASI groups, respectively (HR associated with target-dose RASI, 0.95; 95% CI, 0.91-0.99; p=0.009). Respective rates for kidney failure were 1.8% and 1.5%, with a trend toward a lower risk in the target-dose group (HR, 0.80; 95% CI, 0.61-1.04; p=0.094). Consequently, there was a lower risk of the composite endpoint of kidney failure or death (HR, 0.94; 95% CI, 0.91-0.98; p=0.004).These findings provide evidence that in octogenarians with HFrEF, the use of RASIs in higher target (vs. below-target) doses was associated with lower risks of death and kidney failure.

  View details for DOI 10.1016/j.amjmed.2024.10.019

  View details for PubMedID 39551174

• Racial and Ethnic Differences in Semaglutide Prescriptions for Veterans With Overweight or Obesity in the Veterans Affairs Healthcare System. Circulation. Cardiovascular quality and outcomes Tisdale, R. L., Beyene, T. J., Tang, W., Heidenreich, P., Asch, S. M., Yong, C. M. 2024: e011649

  View details for DOI 10.1161/CIRCOUTCOMES.124.011649

  View details for PubMedID 39524000

• Safety of sodium-glucose cotransporter-2 inhibitors for heart failure. BMJ (Clinical research ed.) Manja, V., Heidenreich, P. 2024; 387: q2424

  View details for DOI 10.1136/bmj.q2424

  View details for PubMedID 39505391

• Digoxin Discontinuation in Patients with HFrEF on Beta-Blockers: Implication for Future "Knock-Out Trials" in Heart Failure. The American journal of medicine Lam, P. H., Liu, K., Ahmed, A. A., Butler, J., Heidenreich, P. A., Anker, M. S., Faselis, C., Deedwania, P., Aronow, W. S., Kanonidis, I., Masson, R., Gill, G. S., Morgan, C. J., Arundel, C., Allman, R. M., Wu, W., Fonarow, G. C., Ahmed, A. 2024

  Abstract

  BACKGROUND: National heart failure guidelines recommend quadruple therapy with renin-angiotensin system inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter 2 inhibitors for patients with heart failure with reduced ejection fraction (HFrEF), most of whom also receive loop diuretics. However, the guidelines are less clear about the safe approaches to discontinuing older drugs whose decreasing or residual benefit is less well understood. The objective of this study was to examine whether digoxin can be safely discontinued in patients with HFrEF receiving beta-blockers.METHODS: In OPTIMIZE-HF, of 2,477 patients with HFrEF (EF ≤45%) receiving beta-blockers and digoxin, digoxin was discontinued in 450 patients. We assembled a propensity score-matched cohort of 433 pairs of patients in which digoxin continuation vs. discontinuation groups were balanced on 51 baseline characteristics. Using the same approach, from 992 patients not on beta-blockers, we assembled a matched cohort of 198 pairs of patients also balanced on 51 baseline characteristics. Hazard ratios (HRs) and 95% CIs for one-year outcomes were estimated.RESULTS: Among patients receiving beta-blockers, digoxin discontinuation had no association with the combined endpoint of heart failure readmission or death (HR, 1.01; 95% CI, 0.85-1.19), heart failure readmission (HR, 1.03; 95% CI, 0.85-1.25) or death (HR, 0.91; 95% CI, 0.72-1.14). Respective HRs (95% CIs) among patients not receiving beta-blockers were 1.60 (1.25-2.04), 1.62 (1.18-2.22) and 1.43 (1.08-1.89).CONCLUSIONS: Digoxin can be discontinued without increasing the risk of adverse outcomes in patients with HFrEF receiving beta-blockers. Future studies need to examine the residual benefit of older heart failure drugs to ensure their safe discontinuation in patients with HFrEF receiving newer guideline-directed medical therapy.

  View details for DOI 10.1016/j.amjmed.2024.10.015

  View details for PubMedID 39424217

• Racial and Ethnic Differences in Adoption of Mitral Valve Transcatheter Edge-to-Edge Repair Over a Decade in the National Veterans Affairs Healthcare System. Journal of the American Heart Association Pillai, B., Beyene, T. J., Kang, G., Amponsah, D., Heidenreich, P. A., Yong, C. M. 2024; 13 (19): e035767

  View details for DOI 10.1161/JAHA.124.035767

  View details for PubMedID 39344644

• Validating the Association Between Composite Metrics of Guideline-Directed Medical Therapy (GDMT) and Clinical Outcomes for Patients with Heart Failure with Reduced Ejection Fraction (HFrEF). Journal of cardiac failure Steverson, A., Calma, J., Hsiao, S., Sallam, K., Varshney, A. S., Golbus, J. R., Heidenreich, P. A., Sandhu, A. T. 2024

  View details for DOI 10.1016/j.cardfail.2024.08.054

  View details for PubMedID 39357668

• Hospital Heart Failure Medical Therapy Score and Associated Clinical Outcomes and Costs. JAMA cardiology Polsinelli, V. B., Sun, J. L., Greene, S. J., Chiswell, K., Grunwald, G. K., Allen, L. A., Peterson, P., Pandey, A., Fonarow, G. C., Heidenreich, P., Ho, P. M., Hess, P. L. 2024

  Abstract

  A composite score for guideline-directed medical therapy (GDMT) for patients with heart failure (HF) is associated with increased survival. Whether hospital performance according to a GDMT score is associated with a broader array of clinical outcomes at lower costs is unknown.To evaluate hospital variability in GDMT score at discharge, 90-day risk-standardized clinical outcomes and costs, and associations between hospital GDMT score and clinical outcomes and costs.This was a retrospective cohort study conducted from January 2015 to September 2019. Included for analysis were patients hospitalized for HF with reduced ejection fraction (HFrEF) in the Get With the Guidelines-Heart Failure Registry, a national hospital-based quality improvement registry. Study data were analyzed from July 2022 to April 2023.GDMT score at discharge.Hospital variability in GDMT score, a weighted index from 0 to 1 of GDMT prescribed divided by the number of medications eligible, at discharge was evaluated using a generalized linear mixed model using the hospital as a random effect and quantified with the adjusted median odds ratio (AMOR). Parallel analyses centering on 90-day mortality, HF rehospitalization, mortality or HF rehospitalization, home time, and costs were performed. Costs were assessed from the perspective of the Centers of Medicare & Medicaid Services. Associations between hospital GDMT score and clinical outcomes and costs were evaluated using Spearman coefficients.Among 41 161 patients (median [IQR] age, 78 [71-85] years; 25 546 male [62.1%]) across 360 hospitals, there was significant hospital variability in GDMT score at discharge (AMOR, 1.23; 95% CI, 1.21-1.26), clinical outcomes (mortality AMOR, 1.17; 95% CI, 1.14-1.24; HF rehospitalization AMOR, 1.22; 95% CI, 1.18-1.27; mortality or HF rehospitalization AMOR, 1.21; 95% CI, 1.18-1.26; home time AMOR, 1.07; 95% CI, 1.06-1.10) and costs (AMOR, 1.23; 95% CI, 1.21-1.26). Higher hospital GDMT score was associated with lower hospital mortality (Spearman ρ, -0.22; 95% CI, -0.32 to -0.12; P < .001), lower mortality or HF rehospitalization (Spearman ρ, -0.17; 95% CI, -0.26 to -0.06; P = .002), more home time (Spearman ρ, 0.14; 95% CI, 0.03-0.24; P = .01), and lower cost (Spearman ρ, -0.11; 95% CI, -0.21 to 0; P = .047) but not with HF rehospitalization (Spearman ρ, -0.10; 95% CI, -0.20 to 0; P = .06).Results of this cohort study reveal that hospital variability in GDMT score, clinical outcomes, and costs was significant. Higher GDMT score at discharge was associated with lower mortality, lower mortality or hospitalization, more home time, and lower cost. Efforts to increase health care value should include GDMT optimization.

  View details for DOI 10.1001/jamacardio.2024.2969

  View details for PubMedID 39320905

• Low-Density Lipoprotein Cholesterol Control as a Performance Measure: A National Analysis of the VHA. Journal of the American College of Cardiology Jain, S. S., Skye, M., Din, N., Furst, A., Maron, D. J., Heidenreich, P., Kalwani, N., Bhatt, A. S., Sandhu, A. T., Rodriguez, F. 2024; 84 (13): 1272-1275

  View details for DOI 10.1016/j.jacc.2024.07.025

  View details for PubMedID 39293887

• Equity in Heart Failure Care: A Get With the Guidelines Analysis of Between- and Within-Hospital Differences in Care by Sex, Race, Ethnicity, and Insurance. Circulation. Heart failure Sandhu, A. T., Grau-Sepulveda, M. V., Witting, C., Tisdale, R. L., Zheng, J., Rodriguez, F., Edward, J. A., Ambrosy, A. P., Greene, S. J., Alhanti, B., Fonarow, G. C., Joynt Maddox, K. E., Heidenreich, P. A. 2024: e011177

  Abstract

  BACKGROUND: Disparities in guideline-based quality measures likely contribute to differences in heart failure (HF) outcomes. We evaluated between- and within-hospital differences in the quality of care across sex, race, ethnicity, and insurance for patients hospitalized for HF.METHODS: This retrospective analysis included patients hospitalized for HF across 596 hospitals in the Get With the Guidelines-HF registry between 2016 and 2021. We evaluated performance across 7 measures stratified by patient sex, race, ethnicity, and insurance. We evaluated differences in performance with and without adjustment for the treating hospital. We also measured variation in hospital-specific disparities.RESULTS: Among 685 227 patients, the median patient age was 72 (interquartile range, 61-82) and 47.2% were women. Measure performance was significantly lower (worse) for women compared with men for all 7 measures before adjustment. For 4 of 7 measures, there were no significant sex-related differences after patient-level adjustment. For 20 of 25 other comparisons, racial and ethnic minorities and Medicaid/uninsured patients had similar or higher (better) adjusted measure performance compared with White and Medicare/privately insured patients, respectively. Angiotensin receptor neprilysin inhibitor measure performance was significantly lower for Asian, Hispanic, and Medicaid/uninsured patients, and cardiac resynchronization therapy implant/prescription was lower among women and Black patients after hospital adjustment, indicating within-hospital differences. There was hospital-level variation in these differences. For cardiac resynchronization therapy implantation/prescription, 278 hospitals (46.6%) had ≥2% lower implant/prescription for Black versus White patients compared with 109 hospitals (18.3%) with the same or higher cardiac resynchronization therapy implantation/prescription for Black patients.CONCLUSIONS: HF quality measure performance was equitable for most measures. There were within-hospital differences in angiotensin receptor neprilysin inhibitor and cardiac resynchronization therapy implant/prescription for historically marginalized groups. The magnitude of hospital-specific disparities varied across hospitals.

  View details for DOI 10.1161/CIRCHEARTFAILURE.123.011177

  View details for PubMedID 39291393

• Inpatient Use of Guideline-Directed Medical Therapy During Heart Failure Hospitalizations Among Community-Based Health Systems. JACC. Heart failure Zheng, J., Sandhu, A. T., Bhatt, A. S., Collins, S. P., Flint, K. M., Fonarow, G. C., Fudim, M., Greene, S. J., Heidenreich, P. A., Lala, A., Testani, J. M., Varshney, A. S., Wi, R. S., Ambrosy, A. P. 2024

  Abstract

  Guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) remains underused. Acute heart failure (HF) hospitalization represents a critical opportunity for rapid initiation of evidence-based medications. However, data on GDMT use at discharge are mostly derived from national quality improvement registries.This study aimed to describe contemporary GDMT use patterns across HF hospitalizations at community-based health systems.The authors identified HF hospitalizations from 2016 to 2022 in a U.S. database aggregating deidentified electronic health record data from more than 30 health systems. In-hospital and discharge rates of GDMT use were reported for eligible HFrEF patients. Factors associated with inpatient GDMT use and predischarge discontinuation were evaluated with the use of multivariable models.A total of 20,387 HF hospitalizations among 13,729 HFrEF patients were identified. Renin-angiotensin system inhibitors, beta-blockers, and mineralocorticoid receptor antagonists were administered during 70%, 86%, and 37% of eligible hospitalizations, respectively. Angiotensin receptor-neprilysin inhibitors and sodium-glucose cotransporter 2 inhibitors were used in 17% and 8% of eligible hospitalizations, respectively. Discharge GDMT rates were low. Triple/quadruple therapy was administered in 26% of hospitalizations, falling to 14% on discharge. Predischarge GDMT discontinuations were associated with inpatient hypotension, hyperkalemia, and worsening renal function, but 43%-57% had no medical contraindications. In adjusted analyses, use of 3 or more GDMT classes was associated with fewer 90-day all-cause deaths and HF readmissions compared with less comprehensive GDMT.Inpatient GDMT use in a national analysis of HF hospitalizations was lower than reported in quality improvement registries. High discontinuation rates emphasize an unmet need for inpatient and postdischarge strategies to optimize GDMT use.

  View details for DOI 10.1016/j.jchf.2024.08.004

  View details for PubMedID 39269395

• Novel Use of Z Codes to Identify Social Determinants of Cardiovascular Disease Outcomes. Circulation Song, N., Beyene, T. J., Amponsah, D. K., Asch, S. M., Heidenreich, P. A., Yong, C. M. 2024; 150 (3): 243-245

  View details for DOI 10.1161/CIRCULATIONAHA.124.069083

  View details for PubMedID 39008558

• Prevalence, Geographic Variation and Racial/Ethnic Disparities in Methamphetamine Associated Heart Failure Among Veterans Manja, V., Chen, C., Sandhu, A., Asch, S., Frayne, S., McGovern, M., Heidenreich, P. ELSEVIER IRELAND LTD. 2024

  View details for DOI 10.1016/j.drugalcdep.2023.110866

  View details for Web of Science ID 001280690400820

• Pharmacist heart failure management and quality of medical care Heidenreich, P., Godbout, R., Sahay, A., Lin, S., Gholami, P., Steverson, A., Cho, S., Sandhu, A. WILEY. 2024: 253

  View details for Web of Science ID 001290635502066

• Artificial intelligence approaches for phenotyping heart failure in U.S. Veterans Health Administration electronic health record. ESC heart failure Shao, Y., Zhang, S., Raman, V. K., Patel, S. S., Cheng, Y., Parulkar, A., Lam, P. H., Moore, H., Sheriff, H. M., Fonarow, G. C., Heidenreich, P. A., Wu, W. C., Ahmed, A., Zeng-Treitler, Q. 2024

  Abstract

  Heart failure (HF) is a clinical syndrome with no definitive diagnostic tests. HF registries are often based on manual reviews of medical records of hospitalized HF patients identified using International Classification of Diseases (ICD) codes. However, most HF patients are not hospitalized, and manual review of big electronic health record (EHR) data is not practical. The US Department of Veterans Affairs (VA) has the largest integrated healthcare system in the nation, and an estimated 1.5 million patients have ICD codes for HF (HF ICD-code universe) in their VA EHR. The objective of our study was to develop artificial intelligence (AI) models to phenotype HF in these patients.The model development cohort (n = 20 000: training, 16 000; validation 2000; testing, 2000) included 10 000 patients with HF and 10 000 without HF who were matched by age, sex, race, inpatient/outpatient status, hospital, and encounter date (within 60 days). HF status was ascertained by manual chart reviews in VA's External Peer Review Program for HF (EPRP-HF) and non-HF status was ascertained by the absence of ICD codes for HF in VA EHR. Two clinicians annotated 1000 random snippets with HF-related keywords and labelled 436 as HF, which was then used to train and test a natural language processing (NLP) model to classify HF (positive predictive value or PPV, 0.81; sensitivity, 0.77). A machine learning (ML) model using linear support vector machine architecture was trained and tested to classify HF using EPRP-HF as cases (PPV, 0.86; sensitivity, 0.86). From the 'HF ICD-code universe', we randomly selected 200 patients (gold standard cohort) and two clinicians manually adjudicated HF (gold standard HF) in 145 of those patients by chart reviews. We calculated NLP, ML, and NLP + ML scores and used weighted F scores to derive their optimal threshold values for HF classification, which resulted in PPVs of 0.83, 0.77, and 0.85 and sensitivities of 0.86, 0.88, and 0.83, respectively. HF patients classified by the NLP + ML model were characteristically and prognostically similar to those with gold standard HF. All three models performed better than ICD code approaches: one principal hospital discharge diagnosis code for HF (PPV, 0.97; sensitivity, 0.21) or two primary outpatient encounter diagnosis codes for HF (PPV, 0.88; sensitivity, 0.54).These findings suggest that NLP and ML models are efficient AI tools to phenotype HF in big EHR data to create contemporary HF registries for clinical studies of effectiveness, quality improvement, and hypothesis generation.

  View details for DOI 10.1002/ehf2.14787

  View details for PubMedID 38873749

• Comparative Effectiveness and Safety of Apixaban and Rivaroxaban in Older Patients with Atrial Fibrillation: A Population-Based Cohort Study. Heart rhythm Shurrab, M., Austin, P. C., Jackevicius, C. A., Tu, K., Qiu, F., Haldenby, O., Middleton, A., Turakhia, M. P., Lopes, R. D., Boden, W. E., Castellucci, L. A., Heidenreich, P. A., Healey, J. S., Ko, D. T. 2024

  Abstract

  There are no clinical trials with head-to-head comparison between the two most commonly used oral anticoagulants (apixaban and rivaroxaban) in patients with atrial fibrillation (AF). The comparative efficacy and safety between these drugs remain unclear, especially among older patients who are at the highest risk for stroke and bleeding.To compare the risk of major bleeding and thromboembolic events with apixaban versus rivaroxaban in older patients with AF.We conducted a population-based, retrospective cohort study of all adult patients (66 years or older) with AF in Ontario, Canada who were treated with apixaban or rivaroxaban between April 1, 2011 and March 31, 2020. The primary safety outcome was major bleeding and the primary efficacy outcome was thromboembolic events. Secondary outcomes included any bleeding. Rates and hazard ratios (HRs) were adjusted for baseline comorbidities with inverse probability of treatment weighting (IPTW).This study included 42,617 patients with AF treated with apixaban and 30,725 patients treated with rivaroxaban. After IPTW using the propensity score, patients in the apixaban and rivaroxaban groups were well balanced for baseline values of demographics, comorbidities and medications; both groups had similar mean age of 77.4 years and 49.9% were female. At one year, the apixaban group had reduced risk for both major bleeding with an absolute risk reduction at one year of 1.1% (2.1% vs 3.2%; HR 0.65 [95% CI, 0.59-0.71]) and any bleeding (8.1% vs 10.9%; HR 0.73 [95% CI, 0.69-0.77]) with no difference in the risk for thromboembolic events (2.2% vs 2.2%; HR 1.02 [95% CI, 0.92-1.13]).Among AF patients, 66 years or older, treatment with apixaban was associated with reduced risk for major bleeding with no difference in risk for thromboembolic events compared with rivaroxaban.

  View details for DOI 10.1016/j.hrthm.2024.06.010

  View details for PubMedID 38878942

• Equity in the Setting of Heart Failure Diagnosis: An Analysis of Differences Between and Within Clinician Practices. Circulation. Heart failure Gupta, A., Tisdale, R. L., Calma, J., Stafford, R. S., Maron, D. J., Hernandez-Boussard, T., Ambrosy, A. P., Heidenreich, P. A., Sandhu, A. T. 2024: e010718

  Abstract

  BACKGROUND: Timely heart failure (HF) diagnosis can lead to earlier intervention and reduced morbidity. Among historically marginalized patients, new-onset HF diagnosis is more likely to occur in acute care settings (emergency department or inpatient hospitalization) than outpatient settings. Whether inequity within outpatient clinician practices affects diagnosis settings is unknown.METHODS: We determined the setting of incident HF diagnosis among Medicare fee-for-service beneficiaries between 2013 and 2017. We identified sociodemographic and medical characteristics associated with HF diagnosis in the acute care setting. Within each outpatient clinician practice, we compared acute care diagnosis rates across sociodemographic characteristics: female versus male sex, non-Hispanic White versus other racial and ethnic groups, and dual Medicare-Medicaid eligible (a surrogate for low income) versus nondual-eligible patients. Based on within-practice differences in acute diagnosis rates, we stratified clinician practices by equity (high, intermediate, and low) and compared clinician practice characteristics.RESULTS: Among 315 439 Medicare patients with incident HF, 173 121 (54.9%) were first diagnosed in acute care settings. Higher adjusted acute care diagnosis rates were associated with female sex (6.4% [95% CI, 6.1%-6.8%]), American Indian (3.6% [95% CI, 1.1%-6.1%]) race, and dual eligibility (4.1% [95% CI, 3.7%-4.5%]). These differences persisted within clinician practices. With clinician practice adjustment, dual-eligible patients had a 4.9% (95% CI, 4.5%-5.4%) greater acute care diagnosis rate than nondual-eligible patients. Clinician practices with greater equity across dual eligibility also had greater equity across sex and race and ethnicity and were more likely to be composed of predominantly primary care clinicians.CONCLUSIONS: Differences in HF diagnosis rates in the acute care setting between and within clinician practices highlight an opportunity to improve equity in diagnosing historically marginalized patients.

  View details for DOI 10.1161/CIRCHEARTFAILURE.123.010718

  View details for PubMedID 38847082

• Kidney Outcomes Among Medicare Beneficiaries After Hospitalization for Heart Failure. JAMA cardiology Ostrominski, J. W., Greene, S. J., Patel, R. B., Solomon, N. C., Chiswell, K., DeVore, A. D., Butler, J., Heidenreich, P. A., Huang, J. C., Kittleson, M. M., Joynt Maddox, K. E., Linganathan, K. K., McDermott, J. J., Owens, A. T., Peterson, P. N., Solomon, S. D., Vardeny, O., Yancy, C. W., Fonarow, G. C., Vaduganathan, M. 2024

  Abstract

  Kidney health has received increasing focus as part of comprehensive heart failure (HF) treatment efforts. However, the occurrence of clinically relevant kidney outcomes in contemporary populations with HF has not been well studied.To examine rates of incident dialysis and acute kidney injury (AKI) among Medicare beneficiaries after HF hospitalization.This retrospective cohort study evaluated adults aged 65 years or older who were hospitalized for HF across 372 sites in the Get With The Guidelines-Heart Failure registry in the US between January 1, 2014, and December 31, 2018. Patients younger than 65 years or requiring dialysis either during or prior to hospitalization were excluded. Data were analyzed from May 4, 2021, to March 8, 2024.The primary outcome was inpatient dialysis initiation in the year after HF hospitalization and was ascertained via linkage with Medicare claims data. Other all-cause and cause-specific hospitalizations were also evaluated. The covariate-adjusted association between discharge estimated glomerular filtration rate (eGFR) and 1-year postdischarge outcomes was examined using Cox proportional hazards regression models.Overall, among 85 298 patients included in the analysis (mean [SD] age, 80 [9] years; 53% women) mean (SD) left ventricular ejection fraction was 47% (16%) and mean (SD) eGFR was 53 (29) mL/min per 1.73 m2; 54 010 (63%) had an eGFR less than 60 mL/min per 1.73 m2. By 1 year after HF hospitalization, 6% had progressed to dialysis, 7% had progressed to dialysis or end-stage kidney disease, and 7% had been readmitted for AKI. Incident dialysis increased steeply with lower discharge eGFR category: compared with patients with an eGFR of 60 mL/min per 1.73 m2 or more, individuals with an eGFR of 45 to less than 60 and of less than 30 mL/min per 1.73 m2 had higher rates of dialysis readmission (45 to <60: adjusted hazard ratio [AHR], 2.16 [95% CI, 1.86-2.51]; <30: AHR, 28.46 [95% CI, 25.25-32.08]). Lower discharge eGFR (per 10 mL/min per 1.73 m2 decrease) was independently associated with a higher rate of readmission for dialysis (AHR, 2.23; 95% CI, 2.14-2.32), dialysis or end-stage kidney disease (AHR, 2.34; 95% CI, 2.24-2.44), and AKI (AHR, 1.25; 95% CI, 1.23-1.27), with similar findings for all-cause mortality, all-cause readmission, and HF readmission. Baseline left ventricular ejection fraction did not modify the covariate-adjusted association between lower discharge eGFR and kidney outcomes.In this study, older adults with HF had substantial risk of kidney complications, with an estimated 6% progressing to dialysis in the year after HF hospitalization. These findings emphasize the need for health care approaches prioritizing kidney health in this high-risk population.

  View details for DOI 10.1001/jamacardio.2024.1108

  View details for PubMedID 38809567

• Identification and outcomes of KDIGO-defined chronic kidney disease in 1.4 million U.S. Veterans with heart failure. European journal of heart failure Patel, S. S., Raman, V. K., Zhang, S., Deedwania, P., Zeng-Treitler, Q., Wu, W. C., Lam, P. H., Bakris, G., Moore, H., Heidenreich, P. A., Rangaswami, J., Morgan, C. J., Cheng, Y., Sheriff, H. M., Faselis, C., Mehta, R. L., Anker, S. D., Fonarow, G. C., Ahmed, A. 2024

  Abstract

  According to the Kidney Disease: Improving Global Outcomes (KDIGO) guideline, the definition of chronic kidney disease (CKD) requires the presence of abnormal kidney structure or function for >3 months with implications for health. CKD in patients with heart failure (HF) has not been defined using this definition, and less is known about the true health implications of CKD in these patients. The objective of the current study was to identify patients with HF who met KDIGO criteria for CKD and examine their outcomes.Of the 1 419 729 Veterans with HF not receiving kidney replacement therapy, 828 744 had data on ≥2 ambulatory serum creatinine >90 days apart. CKD was defined as estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2 (n = 185 821) or urinary albumin-to-creatinine ratio (uACR) >30 mg/g (n = 32 730) present twice >3 months apart. Normal kidney function (NKF) was defined as eGFR ≥60 ml/min/1.73 m2, present for >3 months, without any uACR >30 mg/g (n = 365 963). Patients with eGFR <60 ml/min/1.73 m2 were categorized into four stages: 45-59 (n = 72 606), 30-44 (n = 74 812), 15-29 (n = 32 077), and <15 (n = 6326) ml/min/1.73 m2. Five-year all-cause mortality occurred in 40.4%, 57.8%, 65.6%, 73.3%, 69.7%, and 47.5% of patients with NKF, four eGFR stages, and uACR >30mg/g (albuminuria), respectively. Compared with NKF, hazard ratios (HR) (95% confidence intervals [CI]) for all-cause mortality associated with the four eGFR stages and albuminuria were 1.63 (1.62-1.65), 2.00 (1.98-2.02), 2.49 (2.45-2.52), 2.28 (2.21-2.35), and 1.22 (1.20-1.24), respectively. Respective age-adjusted HRs (95% CIs) were 1.13 (1.12-1.14), 1.36 (1.34-1.37), 1.87 (1.84-1.89), 2.24 (2.18-2.31) and 1.19 (1.17-1.21), and multivariable-adjusted HRs (95% CIs) were 1.11 (1.10-1.12), 1.24 (1.22-1.25), 1.46 (1.43-1.48), 1.42 (1.38-1.47), and 1.13 (1.11-1.16). Similar patterns were observed for associations with hospitalizations.Data needed to define CKD using KDIGO criteria were available in six out of ten patients, and CKD could be defined in seven out of ten patients with data. HF patients with KDIGO-defined CKD had higher risks for poor outcomes, most of which was not explained by abnormal kidney structure or function. Future studies need to examine whether CKD defined using a single eGFR is characteristically and prognostically different from CKD defined using KDIGO criteria.

  View details for DOI 10.1002/ejhf.3210

  View details for PubMedID 38700246

• Temporal Trends in Cardiovascular Disease Prevalence Among Asian American Subgroups. Journal of the American Heart Association Nguyen, K. T., Li, J., Peng, A. W., Azar, K., Heidenreich, P., Palaniappan, L., Yong, C. M. 2024: e031444

  Abstract

  Asian and multiracial individuals represent the 2 fastest growing racial and ethnic groups in the United States, yet most prior studies report Asian American and Native Hawaiian or Other Pacific Islander as a single racial group, with limited data on cardiovascular disease (CVD) prevalence among subgroups. We sought to evaluate temporal trends in CVD burden among disaggregated Asian subgroups.Patients with CVD based on International Classification of Diseases, Ninth Revision and Tenth Revision (ICD-9 and ICD-10) coding who received care from a mixed-payer health care organization in California between 2008 and 2018 were classified into self-identified racial and ethnic subgroups (non-Hispanic White [NHW], Asian Indian, Chinese, Filipino, Japanese, Korean, Native Hawaiian or Other Pacific Islander, and multiracial groups). Adjusted trends in CVD prevalence over time by subgroup were compared using logistic regression. Among 3 494 071 patient-years, prevalence of CVD increased faster among all subgroups except Japanese and Native Hawaiian or Other Pacific Islander patients (P<0.01 for each, reference: NHW). Filipino patients had the highest overall CVD prevalence, which increased from 34.3% to 45.1% over 11 years (increase from 17.3%-21.9%, P<0.0001, reference: NHW). Asian Indian patients had the fastest increase in CVD prevalence over time (16.9%-23.7%, P<0.0001, reference: NHW). Among subcategories of disease, hypertension increased faster among Asian Indian, Chinese, Filipino, Korean, and multiracial groups (P<0.01 for all, reference: NHW), and coronary artery disease increased faster among Asian Indian, Chinese, Filipino, and Japanese groups (P<0.05 for each, reference: NHW).The increasing prevalence of CVD among disaggregated Asian, Native Hawaiian or Other Pacific Islander, and multiracial subgroups over time highlights the importance of tailored approaches to addressing CVD in these diverse subpopulations.

  View details for DOI 10.1161/JAHA.123.031444

  View details for PubMedID 38606778

• Advances in management of heart failure BMJ-BRITISH MEDICAL JOURNAL Heidenreich, P., Sandhu, A. 2024; 385

  View details for DOI 10.1136/bmj-2023-077025

  View details for Web of Science ID 001206543900001

• Clinical Impact of Routine Assessment of Patient-Reported Health Status in Heart Failure Clinic. Circulation Sandhu, A. T., Calma, J., Skye, M., Kalwani, N. M., Zheng, J., Schirmer, J., Din, N., Brown Johnson, C., Gupta, A., Lan, R., Yu, B., Spertus, J. A., Heidenreich, P. A. 2024

  Abstract

  The impact of routine clinic use of patient-reported outcome (PRO) measures on clinical outcomes in patients with heart failure (HF) has not been well-characterized. We tested if clinic-based use of a disease-specific PRO improves patient-reported quality of life at 1 year.PRO-HF was an open-label, parallel, patient-level randomized clinical trial of routine PRO assessment or usual care at an academic HF clinic between August 30, 2021, and June 30, 2022, with 1 year of follow-up. In the PRO assessment arm, participants completed the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) at each HF clinic visit and results were shared with their treating clinician. The usual care arm completed the KCCQ-12 at randomization and 1 year later, which was not shared with the treating clinician. The primary outcome was the KCCQ-12 Overall Summary Score (OSS) between 12-15 months post-randomization. Secondary outcomes included domains of the KCCQ-12, hospitalization and emergency department visit rates, HF medication therapy, clinic visit frequency, and testing rates.Across 17 clinicians, 1,248 participants were enrolled and randomized to PRO assessment (n=624) or usual care (n=624). The median age was 63.9 (interquartile range [IQR] 51.8-72.8), 38.9% were women, and the median baseline KCCQ-12 OSS was 82.3 (IQR 58.3-94.8). Final KCCQ-12 (available in 87.9% of the PRO arm and 85.1% in usual care [p=0.16]) median OSS scores were 87.5 (IQR 68.8-96.9) in the PRO arm and 87.6 (IQR 69.7-96.9) in the usual care arm with a baseline-adjusted mean difference of 0.2 (95% CI: -1.7 to 2.0; p=0.85). The results were consistent across pre-specified subgroups. A post hoc analysis demonstrated a significant interaction with greater benefit among participants with baseline KCCQ-12 OSS scores of 60-80 but not in less or more symptomatic participants. No significant differences were found in 1-year mortality, hospitalizations, ED visits, medication therapy, clinic follow-up, or testing rates between arms.Routine PRO assessment in HF clinic visits did not impact patient-reported quality of life or other clinical outcomes. Alternate strategies and settings for embedding PROs into routine clinical care should be tested.

  View details for DOI 10.1161/CIRCULATIONAHA.124.069624

  View details for PubMedID 38583147

• Cause-Specific Health Care Costs Following Hospitalization for HeartFailure and Cost Offset WithSGLT2i Therapy. JACC. Heart failure Kittipibul, V., Vaduganathan, M., Ikeaba, U., Chiswell, K., Butler, J., DeVore, A. D., Heidenreich, P. A., Huang, J. C., Kittleson, M. M., Joynt Maddox, K. E., Linganathan, K. K., McDermott, J. J., Owens, A. T., Peterson, P. N., Solomon, S. D., Vardeny, O., Yancy, C. W., Fonarow, G. C., Greene, S. J. 2024

  Abstract

  BACKGROUND: Little is known regarding differences in cause-specific costs between heart failure (HF) with ejection fraction (EF)≤40% vs >40%, and potential cost implications of sodium glucose co-transporter 2 inhibitor (SGLT2i) therapy.OBJECTIVES: This study sought to compare cause-specific health care costs following hospitalization for HF with EF≤40% vs >40% and estimate the cost offset with implementation of SGLT2i therapy.METHODS: This study examined Medicare beneficiaries hospitalized for HF in the Get With The Guidelines-Heart Failure registry from 2016 to 2020. Mean per-patient total (excluding drug costs) and cause-specific costs from discharge through 1-year follow-up were calculated and compared between EF≤40% vs >40%. Next, risk reductions on total all-cause and HF hospitalizations were estimated in a trial-level meta-analysis of 5 pivotal trials of SGLT2is in HF. Finally, these relative treatment effects were applied to Medicare beneficiaries eligible for SGLT2i therapy to estimate the projected cost offset with implementation of SGLT2i, excluding drug costs.RESULTS: Among 146,003 patients, 50,598 (34.7%) had EF≤40% and 95,405 (65.3%) had EF >40%. Mean total cost through 1 year was $40,557. Total costs were similar between EF groups overall but were higher for EF≤40% among patients surviving the 1-year follow-up period. Patients with EF >40% had higher costs caused by non-HF and noncardiovascular hospitalizations, and skilled nursing facilities (all P< 0.001). Trial-level meta-analysis of the 5 SGLT2i clinical trials estimated 11% (rate ratio: 0.89; 95%CI: 0.84-0.93; P< 0.001) and 29% (rate ratio: 0.71; 95%CI: 0.66-0.76; P< 0.001) relative reductions in rates of total all-cause and HF hospitalizations, respectively, regardless of EF. Reductions in all-cause and HF hospitalizations were projected to reduce annual costs of readmission by $2,451 to $2,668 per patient with EF≤40% and $1,439 to $2,410 per patient with EF >40%.CONCLUSIONS: In this large cohort of older U.S. adults hospitalized for HF, cause-specific costs of care differed among patients with EF≤40% vs >40%. SGLT2i significantly reduced the rate of HF and all-cause hospitalizations irrespective of EF in clinical trials, and implementation of SGLT2i therapy in clinical practice is projected to reduce costs by $1,439 to $2,668 per patient over the 1 year post-discharge, excluding drug costs.

  View details for DOI 10.1016/j.jchf.2024.04.003

  View details for PubMedID 38727651

• PRICE VARIABILITY OF HEART TRANSPLANT AND VENTRICULAR ASSIST PROCEDURES ACROSS THE UNITED STATES Paranjpe, I., Wei, C., Sharma, P., Juthani, P., Lan, R., Sahu, M., Heidenreich, P. A., Dieleman, J., Schulman, K., Sandhu, A. ELSEVIER SCIENCE INC. 2024: 282

  View details for Web of Science ID 001324901500283

• INPATIENT HEART FAILURE PRICING IN THE US Wei, C., Paranjpe, I., Song, N., Sharma, P., Schulman, K., Heidenreich, P. A., Sandhu, A. ELSEVIER SCIENCE INC. 2024: 719

  View details for Web of Science ID 001324901500720

• LOW-DENSITY LIPOPROTEIN CHOLESTEROL TESTING AND CONTROL AS PERFORMANCE METRICS: A NATIONAL ANALYSIS OF VETERANS AFFAIRS HEALTH CARE SYSTEMS Jain, S. S., Skye, M., Din, N., Maron, D., Heidenreich, P. A., Kalwani, N., Bhatt, A., Sandhu, A., Rodriguez, F. ELSEVIER SCIENCE INC. 2024: 2014

  View details for Web of Science ID 001324901502048

• CARDIOLOGY FOLLOWUP CARE FOR VETERANS WITH HEART FAILURE Cao, F., Tisdale, R., Heidenreich, P. A., Sandhu, A. ELSEVIER SCIENCE INC. 2024: 402

  View details for Web of Science ID 001324901500403

• SOCIAL FACTORS IMPACTING MORTALITY AMONG CARDIOVASCULAR DISEASE PATIENTS: INSIGHTS FROM THE VETERANS AFFAIRS HEALTHCARE SYSTEM Song, N., Beyene, T., Amponsah, D., Asch, S., Heidenreich, P. A., Yong, C. M. ELSEVIER SCIENCE INC. 2024: 2047

  View details for Web of Science ID 001324901502081

• PRICE VARIABILITY OF HEART TRANSPLANT AND VENTRICULAR ASSIST PROCEDURES ACROSS THE UNITED STATES Paranjpe, I., Wei, C., Sharma, P., Juthani, P., Lan, R., Sahu, M., Heidenreich, P. A., Dieleman, J., Schulman, K., Sandhu, A. ELSEVIER SCIENCE INC. 2024: 282

  View details for Web of Science ID 001291434300283

• CARDIOLOGY FOLLOWUP CARE FOR VETERANS WITH HEART FAILURE Cao, F., Tisdale, R., Heidenreich, P. A., Sandhu, A. ELSEVIER SCIENCE INC. 2024: 402

  View details for Web of Science ID 001291434300403

• INPATIENT HEART FAILURE PRICING IN THE US Wei, C., Paranjpe, I., Song, N., Sharma, P., Schulman, K., Heidenreich, P. A., Sandhu, A. ELSEVIER SCIENCE INC. 2024: 719

  View details for Web of Science ID 001291434300720

• Healthcare utilization and left ventricular ejection fraction distribution in methamphetamine use associated heart failure hospitalizations. American heart journal Manja, V., Sandhu, A. T., Asch, S., Frayne, S., McGovern, M., Chen, C., Heidenreich, P. 2024; 270: 156-160

  Abstract

  Although methamphetamine use associated heart failure (MU-HF) is increasing, data on its clinical course are limited due to a preponderance of single center studies and significant heterogeneity in the definition of MU-HF in the published literature. Our objective was to evaluate left ventricular ejection fraction (LVEF) distribution, methamphetamine use treatment engagement and postdischarge healthcare utilization among Veterans with heart failure hospitalization in the department of Veterans Affairs (VA) medical centers for MU-HF versus HF not associated with methamphetamine use (other-HF).Observational study including a cohort of Veterans with a first heart failure hospitalization during 2007 - 2020 using data in the VA Corporate Data Warehouse. MU-HF was identified based on the presence of an ICD-code for methamphetmaine use or positive toxicology results within 1-year of heart failure hospitalization. LVEF values entered in the medical record were identified using a validated natural language processing algorithm. Healthcare utilization data was obtained using clinic stop-codes and hosptilaization records.Of 203,005 first-time heart failure hospitlaizations, 4080 were categorized as MU-HF. Median (interquartile range) of LVEF was 30 (20-45) % for MU-HF versus 40 (25-55)% for other-HF (P < .0001). Eighteen percent of MU-HF had LVEF ≥ 50% compared to 28% in other-HF. Discharge against medical advice was higher in MU-HF (8% vs 2%). Among Veterans with MU-HF, post hospital discharge methamphetamine use treatment engagement was low (18% at 30 days post discharge), with higher follow-up in primary care (76% at 30 days). Post discharge emergency department visits (33% versus 22% at 30 days) and rehospitalizations (24% versus 18% at 30 days) were higher in MU-HF compared to other-HF.While the majority of MU-HF hospitalizations are HFrEF, a sizeable minority have HFpEF. This finding has implications for accurate MU-HF classification, treatment, and prognosis. Patients with MU-HF have low addiction treatment receipt and high postdischarge unplanned healthcare utilization. Increasing substance use disorder treatment in this population must be a priority to improve health outcomes. Care-coordination and linkage interventions are urgently needed to increase post-hospitalization addiction treatment and follow-up in an effort to increase evidence-base care and mitigate unplanned healthcare utilization.

  View details for DOI 10.1016/j.ahj.2023.12.014

  View details for PubMedID 38492945

• National Trends in Hospital Performance in Guideline-Recommended Pharmacologic Treatment for Heart Failure at Discharge. JACC. Heart failure Hess, P. L., Langner, P., Heidenreich, P. A., Essien, U., Leonard, C., Swat, S. A., Polsinelli, V., Orlando, S. T., Grunwald, G. K., Ho, P. M. 2024

  Abstract

  The use of recommended heart failure (HF) medications has improved over time, but opportunities for improvement persist among women and at rural hospitals.This study aims to characterize national trends in performance in the use of guideline-recommended pharmacologic treatment for HF at U.S. Department of Veterans Affairs (VA) hospitals, at which medication copayments are modest.Among patients discharged from VA hospitals with HF between January 1, 2013, and December 31, 2019, receipt of all guideline-recommended HF pharmacotherapy among eligible patients was assessed, consisting of evidence-based beta-blockers; angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or angiotensin receptor neprilysin inhibitors; mineralocorticoid receptor antagonists; and oral anticoagulation.Of 55,560 patients at 122 hospitals, 32,304 (58.1%) received all guideline-recommended HF medications for which they were eligible. The proportion of patients receiving all recommended medications was higher in 2019 relative to 2013 (OR: 1.54; 95% CI: 1.44-1.65). The median of hospital performance was 59.1% (Q1-Q3: 53.2%-66.2%), improving with substantial variation across sites from 2013 (median 56.4%; Q1-Q3: 50.0%-62.0%) to 2019 (median 65.7%; Q1-Q3: 56.3%-73.5%). Women were less likely to receive recommended therapies than men (adjusted OR [aOR]: 0.84; 95% CI: 0.74-0.96). Compared with non-Hispanic White patients, non-Hispanic Black patients were less likely to receive recommended therapies (aOR: 0.83; 95% CI: 0.79-0.87). Urban hospital location was associated with lower likelihood of medication receipt (aOR: 0.73; 95% CI: 0.59-0.92).Forty-two percent of patients did not receive all recommended HF medications at discharge, particularly women, minority patients, and those receiving care at urban hospitals. Rates of use increased over time, with variation in performance across hospitals.

  View details for DOI 10.1016/j.jchf.2024.02.014

  View details for PubMedID 38573268

• Assessment of Price Variation in Coronary Artery Bypass Surgery at US Hospitals. Journal of the American Heart Association Wei, C., Paranjpe, I., Sharma, P., Milligan, M., Lam, M., Heidenreich, P. A., Kalwani, N., Schulman, K., Sandhu, A. 2024: e031982

  Abstract

  Little is known about hospital pricing for coronary artery bypass grafting (CABG). Using new price transparency data, we assessed variation in CABG prices across US hospitals and the association between higher prices and hospital characteristics, including quality of care.Prices for diagnosis related group code 236 were obtained from the Turquoise database and linked by Medicare Facility ID to publicly available hospital characteristics. Univariate and multivariable analyses were performed to assess factors predictive of higher prices. Across 544 hospitals, median commercial and self-pay rates were 2.01 and 2.64 times the Medicare rate ($57 240 and $75 047, respectively, versus $28 398). Within hospitals, the 90th percentile insurer-negotiated price was 1.83 times the 10th percentile price. Across hospitals, the 90th percentile commercial rate was 2.91 times the 10th percentile hospital rate. Regional median hospital prices ranged from $35 624 in the East South Central to $84 080 in the Pacific. In univariate analysis, higher inpatient revenue, greater annual discharges, and major teaching status were significantly associated with higher prices. In multivariable analysis, major teaching and investor-owned status were associated with significantly higher prices (+$8653 and +$12 200, respectively). CABG prices were not related to death, readmissions, patient ratings, or overall Centers for Medicare and Medicaid Services hospital rating.There is significant variation in CABG pricing, with certain characteristics associated with higher rates, including major teaching status and investor ownership. Notably, higher CABG prices were not associated with better-quality care, suggesting a need for further investigation into drivers of pricing variation and the implications for health care spending and access.

  View details for DOI 10.1161/JAHA.123.031982

  View details for PubMedID 38362880

• Uptake of sodium-glucose cotransporter-2 inhibitors in hospitalized patients with heart failure: insights from the veterans affairs healthcare system. Journal of cardiac failure Varshney, A. S., Calma, J., Kalwani, N. M., Hsiao, S., Sallam, K., Cao, F., Din, N., Schirmer, J., Bhatt, A. S., Ambrosy, A. P., Heidenreich, P., Sandhu, A. T. 2024

  Abstract

  The use of sodium-glucose cotransporter-2 inhibitor (SGLT2i) in Veteran Affairs (VA) patients hospitalized with heart failure (HF) has not been previously reported.VA electronic health record data were used to identify patients hospitalized for HF (primary or secondary diagnosis) from 01/2019-11/2022. Patients with SGLT2i allergy, advanced/end-stage chronic kidney disease (CKD), or advanced HF therapies were excluded. We identified factors associated with discharge SGLT2i prescription among hospitalizations in 2022. We also compared SGLT2i and angiotensin receptor-neprilysin inhibitor (ARNI) prescription rates. Hospital-level variation in SGLT2i prescription was assessed via the median odds ratio.A total of 69,680 patients were hospitalized for HF; 10.3% were prescribed SGLT2i at discharge (4.4% newly prescribed, 5.9% continued pre-admission therapy). SGLT2i prescription increased over time and was higher in patients with HFrEF and primary HF. Among 15,762 patients hospitalized in 2022, SGLT2i prescription was more likely in patients with diabetes (adjusted odds ratio [aOR] 2.27; 95% confidence interval [CI]: 2.09-2.47) and ischemic heart disease (aOR 1.14; 95% CI: 1.03-1.26). Patients with increased age (aOR 0.77 per 10 years; 95% CI: 0.73-0.80) and lower systolic blood pressure (aOR 0.94 per 10mmHg; 95% CI: 0.92-0.96) were less likely to be prescribed SGLT2i, and SGLT2i prescription was not more likely in patients with CKD (aOR 1.07; 95% CI 0.98-1.16). The adjusted median odds ratio suggested a 1.8-fold variation in the likelihood that similar patients at 2 random VA sites were prescribed SGLT2i (range 0%-21.0%). In patients with EF ≤40%, 30.9% were prescribed SGLT2i while 26.9% were prescribed ARNI (p<0.01).One-tenth of VA patients hospitalized for HF were prescribed SGLT2i at discharge. Opportunities exist to reduce variation in SGLT2i prescription across hospitals and promote use in patients with CKD and older age.

  View details for DOI 10.1016/j.cardfail.2023.12.018

  View details for PubMedID 38281540

• The economics of heart failure care. Progress in cardiovascular diseases Wei, C., Heidenreich, P. A., Sandhu, A. T. 2024

  Abstract

  Heart failure (HF) poses a significant economic burden in the US, with costs projected to reach $70 billion by 2030. Cost-effectiveness analyses play a pivotal role in assessing the economic value of HF therapies. In this review, we overview the cost-effectiveness of HF therapies and discuss ways to improve patient access. Based on current costs, guideline directed medical therapies for HF with reduced ejection fraction provide high economic value except for sodium-glucose cotransporter-2 inhibitors, which provide intermediate economic value. Combining therapy with the four pillars of medical therapy also has intermediate economic value, with incremental cost-effectiveness ratios ranging from $73,000 to $98,500/ quality adjusted life-years. High economic value procedures include cardiac resynchronization devices, implantable cardioverter-defibrillators, and coronary artery bypass surgery. In contrast, advanced HF therapies have previously demonstrated intermediate to low economic value, but newer data appear more favorable. Given the affordability challenges of HF therapies, additional efforts are needed to ensure optimal care for patients. The recent Inflation Reduction Act contains provisions to reform policy pertaining to drug price negotiation and out-of-pocket spending, as well as measures to increase access to existing programs, including the Medicare low-income subsidy. On a patient level, it is also important to encourage patient and physician awareness and discussions surrounding medical costs. Overall, a broad approach to improving available therapies and access to care is needed to reduce the growing clinical and economic morbidity of HF.

  View details for DOI 10.1016/j.pcad.2024.01.010

  View details for PubMedID 38244828

• Patient Representativeness With Virtual Enrollment in the PRO-HF Trial. Journal of the American Heart Association Gupta, A., Skye, M., Calma, J., Din, N., Azizi, Z., Hernandez, M. F., Zheng, J., Kalwani, N. M., Malunjkar, S., Schirmer, J., Wang, P., Rodriguez, F., Heidenreich, P., Sandhu, A. T. 2024; 13 (2): e030903

  View details for DOI 10.1161/JAHA.123.030903

  View details for PubMedID 38226522

• Bundled Payments for Care Improvement and Quality of Care and Outcomes in Heart Failure. JAMA cardiology Oddleifson, D. A., Holmes, D. N., Alhanti, B., Xu, X., Heidenreich, P. A., Wadhera, R. K., Allen, L. A., Greene, S. J., Fonarow, G. C., Spatz, E. S., Desai, N. R. 2024

  Abstract

  The Centers for Medicare & Medicaid Services (CMS) Bundled Payments for Care Improvement (BPCI) program was launched in 2013 with a goal to improve care quality while lowering costs to Medicare.To compare changes in the quality and outcomes of care for patients hospitalized with heart failure according to hospital participation in the BPCI program.This cross-sectional study used a difference-in-difference approach to evaluate the BPCI program in 18 BPCI hospitals vs 211 same-state non-BPCI hospitals for various process-of-care measures and outcomes using American Heart Association Get With The Guidelines-Heart Failure registry and CMS Medicare claims data from November 1, 2008, to August 31, 2018. Data were analyzed from May 2022 to May 2023.Hospital participation in CMS BPCI Model 2 Heart Failure, which paid hospitals in a fee-for-service process and then shared savings or required reimbursement depending on how the total cost of an episode of care compared with a target price.Primary end points included 7 quality-of-care measures. Secondary end points included 9 outcome measures, including in-hospital mortality and hospital-level risk-adjusted 30-day and 90-day all-cause readmission rate and mortality rate.During the study period, 8721 patients were hospitalized in the 23 BPCI hospitals and 94 530 patients were hospitalized in the 224 same-state non-BPCI hospitals. Less than a third of patients (30 723 patients, 29.8%) were 75 years or younger; 54 629 (52.9%) were female, and 48 622 (47.1%) were male. Hospital participation in BPCI Model 2 was not associated with significant differential changes in the odds of various process-of-care measures, except for a decreased odds of evidence-based β-blocker at discharge (adjusted odds ratio [aOR], 0.63; 95% CI, 0.41-0.98; P = .04). Participation in the BPCI was not associated with a significant differential change in the odds of receiving angiotensin-converting enzyme inhibitors/angiotensin receptor blockers or angiotensin receptor-neprilysin inhibitors at discharge, receiving an aldosterone antagonist at discharge, having a cardiac resynchronization therapy (CRT)-defibrillator or CRT pacemaker placed or prescribed at discharge, having implantable cardioverter-defibrillator (ICD) counseling or an ICD placed or prescribed at discharge, heart failure education being provided among eligible patients, or having a follow-up visit within 7 days or less. Participation in the BPCI was associated with a significant decrease in odds of in-hospital mortality (aOR, 0.67; 95% CI, 0.51-0.86; P = .002). Participation was not associated with a significant differential change in hospital-level risk-adjusted 30-day or 90-day all-cause readmission rate and 30-day or 90-day all-cause mortality rate.In this study, hospital participation in the BPCI Model 2 Heart Failure program was not associated with improvement in process-of-care quality measures or 30-day or 90-day risk-adjusted all-cause mortality and readmission rates.

  View details for DOI 10.1001/jamacardio.2023.5009

  View details for PubMedID 38170516

  View details for PubMedCentralID PMC10765313

• Impact of Virtual Interviewing on Cardiovascular Fellowship Applicant Diversity: Insights From 2 Academic Programs. Journal of the American Heart Association Witting, C., Knowles, J. W., DeFaria Yeh, D., Beyene, T. J., Gummipundi, S. E., Heidenreich, P. A., Yong, C. M. 2023: e030255

  View details for DOI 10.1161/JAHA.123.030255

  View details for PubMedID 38156448

• Heart failure management guidelines: New recommendations and implementation. Journal of cardiology Heidenreich, P. 2023

  Abstract

  The prevalence of heart failure has increased in many developed countries including Japan and the USA, due in large part to the aging of their populations. The lifetime risk of heart failure is now 20-30 % in the USA. Fortunately, there have been important advances in therapy that increase quality and length of life for those with heart failure. This review discusses the important advances in care including treatment and diagnosis and the new recommendations for this care from the recent American College of Cardiology (ACC)/ American Heart Association (AHA)/ Heart Failure Society of America (HFSA) Guideline. Relevant studies that have been published since the guideline was released are also included. Of the many recommendations in the ACC/AHA/HFSA Guideline, this review focuses on the definition of heart failure, the medical treatments specific to left ventricular ejection fraction, use of devices for treatment and diagnosis, diagnosis and treatment of amyloidosis, treatment of iron deficiency, screening for asymptomatic left ventricular dysfunction, use of patient reported outcomes, and tools for implementation.

  View details for DOI 10.1016/j.jjcc.2023.10.009

  View details for PubMedID 37949313

• Validating the association between a composite metric of guideline-directed medical therapy (GDMT) and clinical outcomes for patients with heart failure with reduced ejection fraction (HFrEF) Calma, J., Hsiao, S., Varshney, A. S., Azizi, Z., Golbus, J. R., Heidenreich, P. A., Sandhu, A. T. OXFORD UNIV PRESS. 2023

  View details for Web of Science ID 001115619401553

• Uptake of SGLT2i therapyamongpatients hospitalized with heart failure: Insights from the veterans affairs healthcare system Calma, J., Varshney, A. S., Hernandez, M., Hsiao, S., Sallam, K., Heidenreich, P. A., Sandhu, A. T. OXFORD UNIV PRESS. 2023

  View details for Web of Science ID 001115619401408

• Changes in medical therapy after cardiac resynchronization in patients with heart failure: insights from the US Veterans Affairs healthcare system Varshney, A., Skye, M., Azizi, Z., Heidenreich, P. A., Sandhu, A. T. OXFORD UNIV PRESS. 2023

  View details for Web of Science ID 001115619401446

• Sex differences in long-term outcomes among hospitalized heart failure patients across the spectrum of ejection fraction: findings from the Get with the guidelines - heart failure registry Keshvani, N., Shah, S., Ayodele, I., Chiswell, K., Alhanti, B., Allen, L., Sharma, K., Greene, S., Yancy, C., Van Spall, H., Fonarow, G., Heidenreich, P., Pandey, A. OXFORD UNIV PRESS. 2023

  View details for Web of Science ID 001115619401296

• Deep Learning of Electrocardiograms in Sinus Rhythm From US Veterans to Predict Atrial Fibrillation. JAMA cardiology Yuan, N., Duffy, G., Dhruva, S. S., Oesterle, A., Pellegrini, C. N., Theurer, J., Vali, M., Heidenreich, P. A., Keyhani, S., Ouyang, D. 2023

  Abstract

  Early detection of atrial fibrillation (AF) may help prevent adverse cardiovascular events such as stroke. Deep learning applied to electrocardiograms (ECGs) has been successfully used for early identification of several cardiovascular diseases.To determine whether deep learning models applied to outpatient ECGs in sinus rhythm can predict AF in a large and diverse patient population.This prognostic study was performed on ECGs acquired from January 1, 1987, to December 31, 2022, at 6 US Veterans Affairs (VA) hospital networks and 1 large non-VA academic medical center. Participants included all outpatients with 12-lead ECGs in sinus rhythm.A convolutional neural network using 12-lead ECGs from 2 US VA hospital networks was trained to predict the presence of AF within 31 days of sinus rhythm ECGs. The model was tested on ECGs held out from training at the 2 VA networks as well as 4 additional VA networks and 1 large non-VA academic medical center.A total of 907 858 ECGs from patients across 6 VA sites were included in the analysis. These patients had a mean (SD) age of 62.4 (13.5) years, 6.4% were female, and 93.6% were male, with a mean (SD) CHA2DS2-VASc (congestive heart failure, hypertension, age, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age, sex category) score of 1.9 (1.6). A total of 0.2% were American Indian or Alaska Native, 2.7% were Asian, 10.7% were Black, 4.6% were Latinx, 0.7% were Native Hawaiian or Other Pacific Islander, 62.4% were White, 0.4% were of other race or ethnicity (which is not broken down into subcategories in the VA data set), and 18.4% were of unknown race or ethnicity. At the non-VA academic medical center (72 483 ECGs), the mean (SD) age was 59.5 (15.4) years and 52.5% were female, with a mean (SD) CHA2DS2-VASc score of 1.6 (1.4). A total of 0.1% were American Indian or Alaska Native, 7.9% were Asian, 9.4% were Black, 2.9% were Latinx, 0.03% were Native Hawaiian or Other Pacific Islander, 74.8% were White, 0.1% were of other race or ethnicity, and 4.7% were of unknown race or ethnicity. A deep learning model predicted the presence of AF within 31 days of a sinus rhythm ECG on held-out test ECGs at VA sites with an area under the receiver operating characteristic curve (AUROC) of 0.86 (95% CI, 0.85-0.86), accuracy of 0.78 (95% CI, 0.77-0.78), and F1 score of 0.30 (95% CI, 0.30-0.31). At the non-VA site, AUROC was 0.93 (95% CI, 0.93-0.94); accuracy, 0.87 (95% CI, 0.86-0.88); and F1 score, 0.46 (95% CI, 0.44-0.48). The model was well calibrated, with a Brier score of 0.02 across all sites. Among individuals deemed high risk by deep learning, the number needed to screen to detect a positive case of AF was 2.47 individuals for a testing sensitivity of 25% and 11.48 for 75%. Model performance was similar in patients who were Black, female, or younger than 65 years or who had CHA2DS2-VASc scores of 2 or greater.Deep learning of outpatient sinus rhythm ECGs predicted AF within 31 days in populations with diverse demographics and comorbidities. Similar models could be used in future AF screening efforts to reduce adverse complications associated with this disease.

  View details for DOI 10.1001/jamacardio.2023.3701

  View details for PubMedID 37851434

  View details for PubMedCentralID PMC10585587

• Developing Clinical Risk Prediction Models for Worsening Heart Failure Events and Death by Left Ventricular Ejection Fraction. Journal of the American Heart Association Parikh, R. V., Go, A. S., Bhatt, A. S., Tan, T. C., Allen, A. R., Feng, K. Y., Hamilton, S. A., Tai, A. S., Fitzpatrick, J. K., Lee, K. K., Adatya, S., Avula, H. R., Sax, D. R., Shen, X., Cristino, J., Sandhu, A. T., Heidenreich, P. A., Ambrosy, A. P. 2023: e029736

  Abstract

  Background There is a need to develop electronic health record-based predictive models for worsening heart failure (WHF) events across clinical settings and across the spectrum of left ventricular ejection fraction (LVEF). Methods and Results We studied adults with heart failure (HF) from 2011 to 2019 within an integrated health care delivery system. WHF encounters were ascertained using natural language processing and structured data. We conducted boosted decision tree ensemble models to predict 1-year hospitalizations, emergency department visits/observation stays, and outpatient encounters for WHF and all-cause death within each LVEF category: HF with reduced ejection fraction (EF) (LVEF <40%), HF with mildly reduced EF (LVEF 40%-49%), and HF with preserved EF (LVEF ≥50%). Model discrimination was evaluated using area under the curve and calibration using mean squared error. We identified 338 426 adults with HF: 61 045 (18.0%) had HF with reduced EF, 49 618 (14.7%) had HF with mildly reduced EF, and 227 763 (67.3%) had HF with preserved EF. The 1-year risks of any WHF event and death were, respectively, 22.3% and 13.0% for HF with reduced EF, 17.0% and 10.1% for HF with mildly reduced EF, and 16.3% and 10.3% for HF with preserved EF. The WHF model displayed an area under the curve of 0.76 and mean squared error of 0.13, whereas the model for death displayed an area under the curve of 0.83 and mean squared error of 0.076. Performance and predictors were similar across WHF encounter types and LVEF categories. Conclusions We developed risk prediction models for 1-year WHF events and death across the LVEF spectrum using structured and unstructured electronic health record data and observed no substantial differences in model performance or predictors except for death, despite differences in underlying HF cause.

  View details for DOI 10.1161/JAHA.122.029736

  View details for PubMedID 37776209

• TEMPORARY REMOVAL: Heart Failure Epidemiology and Outcomes Statistics: A Report of the Heart Failure Society of America. Journal of cardiac failure Bozkurt, B., Ahmad, T., Alexander, K., Baker, W. L., Bosak, K., Breathett, K., Fonarow, G. C., Heidenreich, P., Ho, J. E., Hsich, E., Ibrahim, N. E., Jones, L. M., Khan, S. S., Khazanie, P., Koelling, T., Krumholz, H. M., Khush, K. K., Lee, C., Morris, A. A., Page, R. 3., Pandey, A., Piano, M., Stehlik, J., Stevenson, L., Teerlink, J., Vaduganathan, M., Ziaeian, B. 2023

  Abstract

  The publisher regrets that this article has been temporarily removed. A replacement will appear as soon as possible in which the reason for the removal of the article will be specified, or the article will be reinstated. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/policies/article-withdrawal.

  View details for DOI 10.1016/j.cardfail.2023.07.006

  View details for PubMedID 37797885

• Medical Therapy Before, During, and After Hospitalization in Medicare Beneficiaries with Heart Failure and Diabetes: The Get With The Guidelines - Heart Failure Registry. Journal of cardiac failure Bhatt, A. S., Fonarow, G. C., Greene, S. J., Holmes, D. N., Alhanti, B., DeVore, A. D., Butler, J., Heidenreich, P. A., Huang, J. C., Kittleson, M. M., Linganathan, K., Joynt Maddox, K. E., McDermott, J. J., Owens, A. T., Peterson, P. N., Solomon, S. D., Vardeny, O., Yancy, C. W., Vaduganathan, M. 2023

  Abstract

  Patients hospitalized with heart failure (HF) and diabetes mellitus (DM) are at risk for worsening clinical status. Little is known about the frequency of therapeutic changes during hospitalization. We characterized use of medical therapies before, during, and after hospitalization in patients with HF and DM.We identified Medicare beneficiaries in Get With The Guidelines®-Heart Failure (GWTG-HF) hospitalized between July 2014-September 2019 with Part D prescription coverage. We evaluated trends in the use of 7 classes of antihyperglycemic therapies (metformin, sulfonylureas, GLP-1RA, SGLT2-inhibitors, DPP-4 inhibitors, thiazolidinediones, and insulins) and 4 classes of HF therapies (evidence-based β-blockers, ACEi or ARB, MRA, and ARNI). Medication fills were assessed at 6 and 3 months before hospitalization, at hospital discharge, and 3 months post-discharge.Among 35,165 Medicare beneficiaries, median age was 77 years, 54% were women, and 76% were White, 11,660 (33%) had HFrEF (LVEF≤40%), 3,700 (11%) had HFmrEF(LVEF 41-49%), and 19,805 (56%) had HFpEF (LVEF≥50%). Overall, insulin was the most prescribed antihyperglycemic after HF hospitalization (n=12,919, 37%), followed by metformin (n=7,460, 21%) and sulfonylureas (n= 7,030, 20%). GLP-1RA (n= 700, 2.0%) and SGLT2i (n=287, 1.0%) use was low and did not improve over time. In patients with HFrEF, evidence-based β-blocker, RASi, MRA, and ARNI fills 6 months preceding HF hospitalization were 63%, 62%, 19%, and 4%, respectively. Fills initially declined prior to hospitalization, but then rose from 3 months before hospitalization to discharge (β-blockers:56% to 82%, RASi: 51% to 57%, MRA: 15% to 28%, ARNI: 3% to 6%, triple therapy: 8% to 20%; P<0.01 for all). Prescription rates 3 months after hospitalization were similar to those at hospital discharge.In-hospital optimization of medical therapy in patients with HF and DM is common among participating hospitals.

  View details for DOI 10.1016/j.cardfail.2023.09.005

  View details for PubMedID 37757995

• What Is a Normal Left Ventricular Ejection Fraction? Circulation Heidenreich, P. 2023; 148 (9): 750-752

  View details for DOI 10.1161/CIRCULATIONAHA.123.065791

  View details for PubMedID 37639509

• Sex Differences in long-term outcomes following acute heart failure hospitalization: Findings from the Get with The Guidelines - Heart Failure Registry. European journal of heart failure Keshvani, N., Shah, S., Ayodele, I., Chiswell, K., Alhanti, B., Allen, L., Greene, S. J., Yancy, C., Alonso, W., Van Spall, H., Fonarow, G. C., Heidenreich, P. A., Pandey, A. 2023

  Abstract

  BACKGROUND AND AIMS: Sex differences in long-term outcomes following hospitalization for heart failure (HF) across ejection fraction (EF) subtypes are not well described. In this study, we evaluated the risk of mortality and re-hospitalization among males and females across the spectrum of EF over 5years of follow-up following an index HF hospitalization event.METHODS: Patients hospitalized with HF between 1/1/2006-12/31/2014 from the AHA's GWTG-HF registry with available 5-year follow-up using Medicare Part A claims data were included. The association between sex and risk of mortality and readmission over a 5-year follow-up period for each HF subtype (HFrEF [EF≤40%], HFmrEF [EF 41% to 49%], and HFpEF[EF>50%]) was assessed using adjusted Cox models. The effect modification by the HF subtype for the association between sex and outcomes was assessed by including multiplicative interaction terms in the models.RESULTS: 155670 patients (81y, 53.4% females) were included. Over 5-years follow-up, males and females had comparably poor survival post-discharge; however, females (vs. males) had greater years of survival lost to HF compared with the median age- and sex-matched U.S. population (HFpEF: 17.0y vs. 14.6y; HFmrEF: 17.3y vs. 15.1y; HFrEF: 17.7y vs. 14.6y). In adjusted analysis, females (vs. males) had a lower risk of 5-year mortality (aHR 0.89, 95% CI 0.87-0.90, p<0.001), and the risk difference was most pronounced among patients with HFrEF (aHR 0.87, 95% CI 0.85-0.90; Pinteraction [sex*HF subtype]=0.04). Females (vs. males) had a higher adjusted risk of HF readmission over 5-year follow-up (aHR 1.06, 95% CI 1.04-1.08, p<0.001, with the risk difference most pronounced among patients with HFpEF (aHR 1.11, 95% CI 1.07-1.14; Pinteraction [sex*HF subtype]<0.01).CONCLUSION: While females (vs. males) had lower adjusted mortality, females experienced a significantly greater loss in survival time than the median age- and sex-matched U.S. population and had a greater risk of rehospitalization over 5years following HF hospitalization. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1002/ejhf.3003

  View details for PubMedID 37632339

• Variation in Methamphetamine-Associated Heart Failure Hospitalizations Across the United States. Journal of cardiac failure Manja, V., Sandhu, A. T., Frayne, S., Asch, S., McGovern, M., Chen, C., Heidenreich, P. 2023

  View details for DOI 10.1016/j.cardfail.2023.07.015

  View details for PubMedID 37611844

• A Precision Approach to Family Screening in ARVC. Journal of the American College of Cardiology Heidenreich, P. A., Haddad, F., Parikh, V. N. 2023; 82 (3): 226-227

  View details for DOI 10.1016/j.jacc.2023.05.020

  View details for PubMedID 37438008

• Should Beta-Blockers Be Used in Heart Failure If the LVEF Is Not Reduced? JACC. Heart failure Heidenreich, P. A., McMurray, J. J. 2023

  View details for DOI 10.1016/j.jchf.2023.05.023

  View details for PubMedID 37452802

• Contemporary Use of Sodium-Glucose Cotransporter-2 Inhibitor Therapy Among Patients Hospitalized for Heart Failure With Reduced Ejection Fraction in the US: The Get With The Guidelines-Heart Failure Registry. JAMA cardiology Pierce, J. B., Vaduganathan, M., Fonarow, G. C., Ikeaba, U., Chiswell, K., Butler, J., DeVore, A. D., Heidenreich, P. A., Huang, J. C., Kittleson, M. M., Joynt Maddox, K. E., Linganathan, K. K., McDermott, J. J., Owens, A. T., Peterson, P. N., Solomon, S. D., Vardeny, O., Yancy, C. W., Greene, S. J. 2023

  Abstract

  Importance: Clinical guidelines for patients with heart failure with reduced ejection fraction (HFrEF) strongly recommend treatment with a sodium-glucose cotransporter-2 inhibitor (SGLT2i) to reduce cardiovascular mortality or HF hospitalization. Nationwide adoption of SGLT2i for HFrEF in the US is unknown.Objective: To characterize patterns of SGLT2i use among eligible US patients hospitalized for HFrEF.Design, Setting, and Participants: This retrospective cohort study analyzed 49 399 patients hospitalized for HFrEF across 489 sites in the Get With The Guidelines-Heart Failure (GWTG-HF) registry between July 1, 2021, and June 30, 2022. Patients with an estimated glomerular filtration rate less than 20 mL/min/1.73 m2, type 1 diabetes, and previous intolerance to SGLT2i were excluded.Main Outcomes and Measures: Patient-level and hospital-level prescription of SGLT2i at hospital discharge.Results: Of 49 399 included patients, 16 548 (33.5%) were female, and the median (IQR) age was 67 (56-78) years. Overall, 9988 patients (20.2%) were prescribed an SGLT2i. SGLT2i prescription was less likely among patients with chronic kidney disease (CKD; 4550 of 24 437 [18.6%] vs 5438 of 24 962 [21.8%]; P<.001) but more likely among patients with type 2 diabetes (T2D; 5721 of 21 830 [26.2%] vs 4262 of 27 545 [15.5%]; P<.001) and those with both T2D and CKD (2905 of 12 236 [23.7%] vs 7078 vs 37 139 [19.1%]; P<.001). Patients prescribed SGLT2i therapy were more likely to be prescribed background triple therapy with an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor, beta-blocker, and mineralocorticoid receptor antagonist (4624 of 9988 [46.3%] vs 10 880 of 39 411 [27.6%]; P<.001), and 4624 of 49 399 total study patients (9.4%) were discharged with prescriptions for quadruple medical therapy including SGLT2i. Among 461 hospitals with 10 or more eligible discharges, 19 hospitals (4.1%) discharged 50% or more of patients with prescriptions for SGLT2i, whereas 344 hospitals (74.6%) discharged less than 25% of patients with prescriptions for SGLT2i (including 29 [6.3%] that discharged zero patients with SGLT2i prescriptions). There was high between-hospital variance in the rate of SGLT2i prescription in unadjusted models (median odds ratio, 2.53; 95% CI, 2.36-2.74) and after adjustment for patient and hospital characteristics (median odds ratio, 2.51; 95% CI, 2.34-2.71).Conclusions and Relevance: In this study, prescription of SGLT2i at hospital discharge among eligible patients with HFrEF was low, including among patients with comorbid CKD and T2D who have multiple indications for therapy, with substantial variation among US hospitals. Further efforts are needed to overcome implementation barriers and improve use of SGLT2i among patients with HFrEF.

  View details for DOI 10.1001/jamacardio.2023.1266

  View details for PubMedID 37212192

• Long-Term Outcomes of Early Coronary Artery Disease Testing After New-Onset Heart Failure. Circulation. Heart failure Zheng, J., Heidenreich, P. A., Kohsaka, S., Fearon, W. F., Sandhu, A. T. 2023: e010426

  Abstract

  BACKGROUND: Coronary artery disease (CAD) testing remains underutilized in patients with newly diagnosed heart failure (HF). The longitudinal clinical impact of early CAD testing has not been well-characterized. We investigated changes in clinical management and long-term outcomes after early CAD evaluation in patients with incident HF.METHODS: We identified Medicare patients with incident HF from 2006 to 2018. The exposure variable was early CAD testing within 1 month of initial HF diagnosis. Covariate-adjusted rates of cardiovascular interventions after testing, including CAD-related management, were modeled using mixed-effects regression with clinician as a random intercept. We assessed mortality and hospitalization outcomes using landmark analyses with inverse probability-weighted Cox proportional hazards models. Falsification end points and mediation analysis were employed for bias assessment.RESULTS: Among 309 559 patients with new-onset HF without prior CAD, 15.7% underwent early CAD testing. Patients who underwent prompt CAD evaluation had higher adjusted rates of subsequent antiplatelet/statin prescriptions and revascularization, guideline-directed therapy for HF, and stroke prophylaxis for atrial fibrillation/flutter than controls. In weighted Cox models, 1-month CAD testing was associated with significantly reduced all-cause mortality (hazard ratio, 0.93 [95% CI, 0.91-0.96]). Mediation analyses indicated that 70% of this association was explained by CAD management, largely from new statin prescriptions. Falsification end points (outpatient diagnoses of urinary tract infection and hospitalizations for hip/vertebral fracture) were nonsignificant.CONCLUSIONS: Early CAD testing after incident HF was associated with a modest mortality benefit, driven mostly by subsequent statin therapy. Further investigation on clinician barriers to testing and treating high-risk patients may improve adherence to guideline-recommended cardiovascular interventions.

  View details for DOI 10.1161/CIRCHEARTFAILURE.122.010426

  View details for PubMedID 37212148

• Evaluating the Implementation of Patient-Reported Outcomes in Heart Failure Clinic: A Qualitative Assessment. Circulation. Cardiovascular quality and outcomes Brown-Johnson, C., Calma, J., Amano, A., Winget, M., Harris, S. R., Vilendrer, S., Asch, S. M., Heidenreich, P., Sandhu, A. T., Kalwani, N. M. 2023: e009677

  Abstract

  Patient-reported outcomes (PROs) may improve care for patients with heart failure. The Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) is a patient survey that captures symptom frequency, symptom burden, physical limitations, social limitations, and quality of life. Despite the utility of PROs and the KCCQ-12, the implementation and routine use of these measures can be difficult. We conducted an evaluation of clinician perceptions of the KCCQ-12 to identify barriers and facilitators to implementation into clinical practice.We conducted interviews with cardiologists from 4 institutions across the United States and Canada (n=16) and observed clinic visits at 1 institution in Northern California (n=5). Qualitative analysis was conducted in 2 rounds: (1) rapid analysis constructed around major themes related to the aims of the study and (2) content analysis with codes derived from the rapid analysis and implementation science.Most heart failure physicians and advanced practice clinicians reported that the KCCQ-12 was acceptable, appropriate, and useful in clinical care. Clinician engagement efforts, trialability, and the straightforward design of the KCCQ-12 facilitated its use in clinical care. Further opportunities identified to facilitate implementation include more streamlined integration into the electronic health record and comprehensive staff education on PROs. Participants highlighted that the KCCQ-12 was useful in clinic visits to improve the consistency of patient history taking, focus patient-clinician conversations, collect a more accurate account of patient quality of life, track trends in patient well-being over time, and refine clinical decision-making.In this qualitative study, clinicians reported that the KCCQ-12 enhanced several aspects of heart failure patient care. Use of the KCCQ-12 was facilitated by a robust clinician engagement campaign and the design of the KCCQ-12 itself. Future implementation of PROs in heart failure clinic should focus on streamlining electronic health record integration and providing additional staff education on the value of PROs.URL: https://clinicaltrials.gov; Unique identifier: NCT04164004.

  View details for DOI 10.1161/CIRCOUTCOMES.122.009677

  View details for PubMedID 37114990

• Clinical and echocardiographic diversity associated with physical fitness in the Project Baseline Health Study: implications for heart failure staging. Journal of cardiac failure Cauwenberghs, N., Haddad, F., Daubert, M. A., Chatterjee, R., Salerno, M., Mega, J. L., Heidenreich, P., Hernandez, A., Amsallem, M., Kobayashi, Y., Mahaffey, K. W., Shah, S. H., Bloomfield, G. S., Kuznetsova, T., Douglas, P. S. 2023

  Abstract

  Clinical and echocardiographic features may carry diverse information on the development of heart failure (HF). Therefore, we determined heterogeneity in clinical and echocardiographic phenotypes and its association with exercise capacity.In 2036 community-dwelling individuals, we defined echocardiographic profiles of left and right heart remodeling and dysfunction. We subdivided the cohort based on presence (+) or absence (-) of HF risk factors and echocardiographic abnormalities (RF-/Echo-, RF-/Echo+, RF+/Echo-, RF+/Echo+). Multivariable-adjusted associations between RF/Echo subgroups and physical performance metrics from 6-minute walk and treadmill exercise testing were assessed.Prevalence was: 35.3% for RF-/Echo-, 4.7% for RF-/Echo+, 39.3% for RF+/Echo- and 20.6% for RF+/Echo+. We observed large diversity in echocardiographic profiles in the Echo+ group. Participants with RF-/Echo+ (18.6% of Echo+) predominantly had echocardiographic abnormalities other than left ventricular (LV) diastolic dysfunction, hypertrophy and reduced ejection fraction, while their physical performance was similar to RF-/Echo-. In contrast, participants with RF+/Echo+ mostly presented LV hypertrophy or dysfunction, features that related to lower 6-minute walking distance and lower exercise capacity.Subclinical echocardiographic abnormalities suggest HF pathogenesis, but the presence of HF risk factors and type of echo abnormality should be considered to distinguish adverse from benign adaptation and stratify HF risk.

  View details for DOI 10.1016/j.cardfail.2023.04.008

  View details for PubMedID 37116641

• Administrative Coding Versus Laboratory Diagnosis of Inpatient Hypoglycemia. Diabetes care Gallo, R. J., Fang, D. Z., Heidenreich, P. A. 2023

  View details for DOI 10.2337/dc23-0053

  View details for PubMedID 37068271

• Association of CHA2DS2-VASc and HAS-BLED to Frailty and Frail Outcomes: From the TREAT-AF Study. American heart journal Pundi, K., Perino, A. C., Fan, J., Din, N., Szummer, K., Heidenreich, P., Turakhia, M. P. 2023

  Abstract

  BACKGROUND: Morbidity and mortality associated with high CHA2DS2-VASc and HAS-BLED scores is not specific to atrial fibrillation (AF). Frailty could be an important contributor to this morbidity and mortality while being mechanistically independent from AF. We sought to evaluate the association of stroke and bleeding risk to non-cardiovascular frail events and the association of stroke prevention therapy to outcomes in frail patients with atrial fibrillation.METHODS: Using the TREAT-AF (The Retrospective Evaluation and Assessment of Therapies in AF) study from the Veterans Health Administration, we identified patients with newly diagnosed AF from 2004-2014. Baseline frailty was identified using a previously validated claims-based index requiring ≥2 of 12 ICD-9 diagnoses. Logistic regressions modeled the association between CHA2DS2-VASc and modified HAS-BLED and frailty. Cox proportional hazard regressions were used to evaluate the association between CHA2DS2-VASc and modified HAS-BLED and a composite of non-cardiovascular frail events (fractures, urinary tract infections, bacterial pneumonia, or dehydration). We also evaluated the association of oral anticoagulant (OAC) use with stroke, bleeding, and 1-year mortality in frail patients and non-frail patients.RESULTS: In 213,435 patients (age 70 ± 11; 98% male; CHA2DS2-VASc 2.4±1.7) with AF, 8498 (4%) were frail. CHA2DS2-VASc > 0 and HAS-BLED > 0 were strongly associated with frailty (Odds Ratio [OR] 13.3 (95% CI: 11.6-15.2) for CHA2DS2-VASc 4+ and OR 13.4 (10.2 - 17.5) for HAS-BLED 3+). After adjusting for covariates, CHA2DS2-VASc and HAS-BLED > 0 were associated with higher risk of non-cardiovascular frail events (Hazard Ratio [HR] 2.1 (95% CI: 2.0-2.2) for CHA2DS2-VASc 4+ and HR 1.4 (95% CI: 1.3-1.5) for HAS-BLED 3+). In frail patients, OAC use was associated with significantly lower risk of 1-year mortality (HR 0.82; 95% CI 0.72 - 0.94, p = 0.0031) but did not reach significance for risk of stroke (HR 0.80; 95% CI 0.55 - 1.18, p = 0.26) or major bleeding (HR 1.08; 95% CI 0.93 - 1.25, p = 0.34).CONCLUSION: High CHA2DS2-VASc and HAS-BLED scores are strongly associated with frailty. However, in frail patients, OAC use was associated with reduction in 1-year mortality. For this challenging clinical population with competing risks of frailty and frail events, focused prospective studies are needed to support clinical decision-making. Until then, careful evaluation of frailty should inform shared decision-making.

  View details for DOI 10.1016/j.ahj.2023.03.015

  View details for PubMedID 37024025

• Pharmacist- and Nurse-Led Medical Optimization in Heart Failure: A Systematic Review and Meta-Analysis. Journal of cardiac failure Zheng, J., Mednick, T., Heidenreich, P. A., Sandhu, A. T. 2023

  Abstract

  Traditional approaches to guideline-directed medical therapy (GDMT) management often lead to delayed initiation and titration of therapies in heart failure. This study sought to characterize alternative models of care involving non-physician provider-led GDMT interventions and their associations with therapy utilization and clinical outcomes.We performed a systematic review and meta-analysis of randomized controlled trials (RCT) and observational studies comparing non-physician provider-led GDMT initiation and/or uptitration interventions versus usual physician care (PROSPERO ID: CRD42022334661). We queried PubMed, Embase, the Cochrane Library, and the World Health Organization International Clinical Trial Registry Platform for peer-reviewed studies from database inception to July 31, 2022. In the meta-analysis, we used RCT data only and leveraged random-effects models to estimate pooled outcomes. Primary outcomes were GDMT initiation and titration to target doses by therapeutic class. Secondary outcomes included all-cause mortality and HF hospitalizations.33 studies were reviewed, of which 17 (52%) were randomized controlled trials with median follow-up of 6 months. 14 (82%) trials evaluated nurse interventions, while the remainder assessed pharmacist interventions. The primary analysis pooled data from 16 RCTs, which enrolled 5,268 patients. Pooled risk ratios (RR) for RASI and BB initiation were 2.09 (95% CI 1.05-4.16; I2=68%) and 1.91 (95% CI 1.35-2.70; I2=37%), respectively. Outcomes were similar for uptitration of RASI (RR 1.99, 95% CI 1.24-3.20; I2=77%) and BB (RR 2.22, 95% CI 1.29-3.83; I2=66%). No association was found with MRA initiation (RR 1.01, 95% CI 0.47-2.19). There were lower rates of mortality (RR 0.82, 95% CI 0.67-1.04; I2=12%) and HF hospitalization (RR 0.80, 95% CI 0.63-1.01; I2=25%) across intervention arms, but these differences were small and not statistically significant. Prediction intervals were wide due to moderate-to-high heterogeneity across trial populations and interventions. Subgroup analyses by provider type did not show significant effect modification.Pharmacist- and nurse-led interventions for GDMT initiation and/or uptitration improved guideline concordance. Further research evaluating newer therapies and titration strategies integrated with pharmacist- and/or nurse-based care may be valuable.

  View details for DOI 10.1016/j.cardfail.2023.03.012

  View details for PubMedID 37004867

• Opportunities for Change in Home Health Care in HeartFailure. JACC. Heart failure Verma, A., Heidenreich, P. A., Ziaeian, B. 2023

  View details for DOI 10.1016/j.jchf.2023.02.018

  View details for PubMedID 37115138

• The Value of Comprehensive Guideline-Directed Therapy for HeartFailure With Reduced EjectionFraction. JACC. Heart failure Kazi, D. S., Heidenreich, P. 2023

  View details for DOI 10.1016/j.jchf.2023.02.014

  View details for PubMedID 37052552

• Updating the Accuracy of Administrative Claims for Identifying Left Ventricular Ejection Fraction Among Patients With Heart Failure. Circulation. Cardiovascular quality and outcomes Sandhu, A. T., Zheng, J., Skye, M., Heidenreich, P. A. 2023: e008919

  View details for DOI 10.1161/CIRCOUTCOMES.122.008919

  View details for PubMedID 36924223

• METHAMPHETAMINE ASSOCIATED HEART FAILURE HOSPITALIZATIONS AMONG VETERANS IN THE UNITED STATES Manja, V., Sandhu, A., Chen, C., Asch, S., Frayne, S., Heidenreich, P. A. ELSEVIER SCIENCE INC. 2023: 492

  View details for Web of Science ID 000990866100493

• PREVALENCE AND PROGNOSTIC VALUE OF VENTRICULAR TACHYCARDIA ON AMBULATORY ECG MONITORING Pundi, K., Fan, J., Din, N., Sandhu, A., Heidenreich, P. A., Turakhia, M. ELSEVIER SCIENCE INC. 2023: 125

  View details for Web of Science ID 000990866100126

• The importance of low-density lipoprotein cholesterol measurement and control as performance measures: A joint clinical perspective from the National Lipid Association and the American Society for Preventive Cardiology. American journal of preventive cardiology Virani, S. S., Aspry, K., Dixon, D. L., Ferdinand, K. C., Heidenreich, P. A., Jackson, E. J., Jacobson, T. A., McAlister, J. L., Neff, D. R., Gulati, M., Ballantyne, C. M. 2023; 13: 100472

  Abstract

  Despite the established role of low-density lipoprotein cholesterol (LDL-C) as a major risk factor for cardiovascular disease (CVD), and the persistence of CVD as the leading cause of morbidity and mortality in the United States, national quality assurance metrics no longer include LDL-C measurement as a required performance metric. This clinical perspective reviews the history of LDL-C as a quality and performance metric and the events that led to its replacement. It also presents patient, healthcare provider, and health system rationales for re-establishing LDL-C measurement as a performance measure to improve cholesterol control in high-risk groups and to stem the rising tide of CVD morbidity and mortality, cardiovascular care disparities, and related healthcare costs.

  View details for DOI 10.1016/j.ajpc.2023.100472

  View details for PubMedID 36970638

  View details for PubMedCentralID PMC10037190

• The importance of low-density lipoprotein cholesterol measurement and control as performance measures: A joint Clinical Perspective from the National Lipid Association and the American Society for Preventive Cardiology. Journal of clinical lipidology Virani, S. S., Aspry, K., Dixon, D. L., Ferdinand, K. C., Heidenreich, P. A., Jackson, E. J., Jacobson, T. A., McAlister, J. L., Neff, D. R., Gulati, M., Ballantyne, C. M. 2023; 17 (2): 208-218

  Abstract

  Despite the established role of low-density lipoprotein cholesterol (LDL-C) as a major risk factor for cardiovascular disease (CVD), and the persistence of CVD as the leading cause of morbidity and mortality in the United States, national quality assurance metrics no longer include LDL-C measurement as a required performance metric. This clinical perspective reviews the history of LDL-C as a quality and performance metric and the events that led to its replacement. It also presents patient, healthcare provider, and health system rationales for re-establishing LDL-C measurement as a performance measure to improve cholesterol control in high-risk groups and to stem the rising tide of CVD morbidity and mortality, cardiovascular care disparities, and related healthcare costs.

  View details for DOI 10.1016/j.jacl.2023.02.003

  View details for PubMedID 36965958

• Care to Share? Patients in Private Rooms Are More Likely to Recommend a Hospital to Others. Journal of patient experience Atsavapranee, E., Heidenreich, P., Smith-Bentley, M., Vyas, A., Shieh, L. 2023; 10: 23743735231158250

  Abstract

  A patient's likelihood to recommend a hospital is used to assess the quality of their experience. This study investigated whether room type influences patients' likelihood to recommend Stanford Health Care using Hospital Consumer Assessment of Healthcare Providers and Systems survey data from November 2018 to February 2021 (n = 10,703). The percentage of patients who gave the top response was calculated as a top box score, and the effects of room type, service line, and the COVID-19 pandemic were represented as odds ratios (ORs). Patients in private rooms were more likely to recommend than patients in semi-private rooms (aOR: 1.32; 95% CI: 1.16-1.51; 86% vs 79%, p < .001), and service lines with only private rooms had the greatest increases in odds of a top response. The new hospital had significantly higher top box scores than the original hospital (87% vs 84%, p < .001), indicating that room type and hospital environment impact patients' likelihood to recommend.

  View details for DOI 10.1177/23743735231158250

  View details for PubMedID 36865380

  View details for PubMedCentralID PMC9972040

• Late to Palliate? Inpatient Palliative Care Consultation at an Academic Veterans Affairs Hospital MILITARY MEDICINE Allaudeen, N., Millhouse, C. F., Huberman, D. B., Wang, H., Heidenreich, P. A. 2023

  Abstract

  Despite robust evidence describing the benefits of palliative care consultation (PCC), this service is underutilized. Hospital admission provides an important opportunity to obtain PCC.We evaluated all inpatients who received PCC at a Veterans Affairs academic hospital from January 1, 2019 to December 31, 2019. Logistic regression was used to determine factors associated with early versus late PCC, with early defined as >30 days from consult to death and late defined as ≤30 days.The median time from PCC to death was 37 days. The majority of PCCs were early (58.4%). Of all patients receiving inpatient PCC, 13.2% died that admission. Cardiac (odds ratio = 0.3, 95% CI = 0.11-0.73) and neurological (odds ratio = 0.21, 95% CI = 0.05-0.70) diagnoses were more likely to receive early PCC compared to malignancy. Of the late PCCs receiving first-time consults, 58.9% had at least one admission during the last year.Many patients are introduced to palliative care services within a month of death. These patients were often admitted during the prior year, presenting a missed opportunity to involve inpatient PCC earlier.

  View details for DOI 10.1093/milmed/usad038

  View details for Web of Science ID 000937320700001

  View details for PubMedID 36794805

• Aiming at harmony. Comparing and contrasting International HFrEF Guidelines (vol 24, pg L20, 2022) EUROPEAN HEART JOURNAL SUPPLEMENTS Tomasoni, D., Adamo, M., Bozkurt, B., Heidenreich, P., McDonagh, T., Rosano, G. C., Virani, S. A., Zieroth, S., Metra, M. 2023

  View details for DOI 10.1093/eurheartjsupp/suad032

  View details for Web of Science ID 000935617300001

• Temporal Trends in Gender of Principal Investigators and Patients in Cardiovascular Clinical Trials. Journal of the American College of Cardiology Yong, C., Suvarna, A., Harrington, R., Gummidipundi, S., Krumholz, H. M., Mehran, R., Heidenreich, P. 2023; 81 (4): 428-430

  View details for DOI 10.1016/j.jacc.2022.10.038

  View details for PubMedID 36697143

• Can We Attribute Outcome Improvements to Improved Cardiac Imaging? JACC. Cardiovascular imaging Heidenreich, P. A. 2023

  View details for DOI 10.1016/j.jcmg.2022.12.025

  View details for PubMedID 36881427

• Variation in Cost of Echocardiography Within and Across US Hospitals. Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography Wei, C., Milligan, M., Lam, M., Heidenreich, P. A., Sandhu, A. 2023

  Abstract

  BACKGROUND: While transthoracic echocardiography (TTE) is responsible for more Medicare spending than any other cardiovascular imaging procedure, little is known about its commercial cost footprint. The 2021 Hospital Price Transparency Final Rule mandated US hospitals publish their insurer-negotiated and self-pay prices for services. This study sought to characterize and assess factors contributing to variation in TTE prices.METHODS: We used a commercial database containing hospital-disclosed prices to characterize variation in TTE prices within and across hospitals. We linked this price data to hospital and regional characteristics using Medicare Facility IDs.RESULTS: 1949 hospitals reported commercial prices. Among reporting hospitals, median commercial and self-pay prices were 2.93- and 3.06-times greater than the median Medicare price ($1313 and $1422, respectively, versus $464). Within hospitals, the 90th percentile payer-negotiated rate was 2.78 (IQR 1.80-5.09) times the 10th percentile rate (within-center ratio). Across hospitals within the same hospital referral region (HRR), the median price at the 90th percentile hospital was 2.47 (IQR 1.69-3.75) times that at the 10th percentile hospital (across-center ratio). On univariate analysis, for-profit (p=0.04), teaching (p<0.01), investor-owned (P<0.01), and higher-rated hospitals (p<0.01) charged higher prices, whereas rural referral centers (p=0.01) and disproportionate share hospitals (DSH) (p<0.01) charged less. On multivariate analysis, the association between these characteristics and TTE prices persisted, except investor ownership and rural referral centers.CONCLUSIONS: Self-pay and commercial TTE prices were higher than Medicare prices and varied significantly within and across hospitals. For-profit, teaching, and higher-rated hospitals had higher prices, in contrast to DSH hospitals. Better understanding the relationship between this cost variation and quality of care is critical given the impact of cost on healthcare access and affordability.

  View details for DOI 10.1016/j.echo.2023.01.002

  View details for PubMedID 36638930

• Predictors of Incident HeartFailure Diagnosis Setting: Insights From the Veterans Affairs Healthcare System. JACC. Heart failure Tisdale, R. L., Fan, J., Calma, J., Cyr, K., Podchiyska, T., Stafford, R. S., Maron, D. J., Hernandez-Boussard, T., Ambrosy, A., Heidenreich, P. A., Sandhu, A. T. 2022

  Abstract

  BACKGROUND: Early recognition of heart failure (HF) can reduce morbidity, yet HF is often diagnosed only after symptoms require urgent treatment.OBJECTIVES: The authors sought to describe predictors of HF diagnosis in the acute care vs outpatient setting within the Veterans Health Administration (VHA).METHODS: The authors estimated whether incident HF diagnoses occurred in acute care (inpatient hospital or emergency department) vs outpatient settings within the VHA between 2014 and 2019. After excluding new-onset HF potentially caused by acute concurrent conditions, they identified sociodemographic and clinical variables associated with diagnosis setting and assessed variation across 130 VHA facilities using multivariable regression analysis.RESULTS: The authors identified 303,632 patients with new HF, with 160,454 (52.8%) diagnosed in acute care settings. In the prior year, 44% had HF symptoms and 11% had a natriuretic peptide tested, 88% of which were elevated. Patients with housing insecurity and high neighborhood social vulnerability had higher odds of acute care diagnosis (adjusted odds ratio: 1.22 [95%CI: 1.17-1.27] and 1.17 [95%CI: 1.14-1.21], respectively) adjusting for medical comorbidities. Better outpatient quality of care (blood pressure control and cholesterol and diabetes monitoring within the prior 2 years) predicted a lower odds of acute care diagnosis. Likelihood of acute care HF diagnosis varied from 41% to 68% across facilities after adjusting for patient-level risk factors.CONCLUSIONS: Many first HF diagnoses occur in the acute care setting, especially among socioeconomically vulnerable populations. Better outpatient care was associated with lower rates of an acute care diagnosis. These findings highlight opportunities for timelier HF diagnosis that may improve patient outcomes.

  View details for DOI 10.1016/j.jchf.2022.11.013

  View details for PubMedID 36881392

• Clinical Trial to Evaluate an Atrial Fibrillation Stroke Prevention Shared DecisionMaking Pathway Wang, P. J., Lu, Y., Mahaffey, K. W., Lin, A., Morin, D. P., Sears, S. F., Chung, M. K., Russo, A. M., Lin, B., Piccini, J. P., Hills, M. T., Berube, C., Pundi, K., Baykaner, T., Garay, G., Lhamo, K., Rice, E., Shah, R., Newswanger, P., DeSutter, K., Nunes, J., Albert, M. A., Schulman, K., Heidenreich, P. A., Bunch, T. J., Sanders, L., Turakhia, M., Stafford, R. S. LIPPINCOTT WILLIAMS & WILKINS. 2022: E582-E583

  View details for Web of Science ID 000928164500042

• Early Results of the Patient-Reported Outcome Measurement in Heart Failure Clinic (PRO-HF) Trial Sandhu, A. T., Zheng, J., Kalwani, N. M., Gupta, A., Calma, J., Amano, A., Johnson, C., Winget, M., Heidenreich, P. A. LIPPINCOTT WILLIAMS & WILKINS. 2022: E572

  View details for Web of Science ID 000928164500017

• Use of lipid-lowering therapy preceding first hospitalization for acute myocardial infarction or stroke. American journal of preventive cardiology Sandhu, A. T., Rodriguez, F., Maron, D. J., Heidenreich, P. A. 2022; 12: 100426

  View details for DOI 10.1016/j.ajpc.2022.100426

  View details for PubMedID 36304918

• Aiming at harmony. Comparing and contrasting International HFrEF Guidelines. European heart journal supplements : journal of the European Society of Cardiology Tomasoni, D., Adamo, M., Bozkurt, B., Heidenreich, P., McDonagh, T., Rosano, G. M., Virani, S. A., Zieroth, S., Metra, M. 2022; 24 (Suppl L): L20-L28

  Abstract

  Large randomized controlled trials (RCTs) have led to major changes in the treatment of patients with heart failure and reduced left ventricular ejection fraction (HFrEF) and these advances are included in the recent European Society of Cardiology (ESC) and the American College of Cardiology/American Heart Association/Heart Failure Society of America (ACC/AHA/HFSA) guidelines issued in 2021 and 2022, respectively. According to both guidelines, treatment of patients with HFrEF is based on the administration of four classes of drugs that reduce the primary endpoint of cardiovascular death and HF hospitalizations in RCTs: angiotensin-converting enzyme or angiotensin receptor neprilysin inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose co-transporter 2 inhibitors. Specific sequences of treatment are not recommended but emphasis is given to reaching treatment with all four drugs as early as possible. Further treatments are considered in selected patients including ivabradine, hydralazine nitrates, digoxin, and the new agent vericiguat. Specific treatments, mostly new, for cardiovascular and non-cardiovascular comorbidities are also given. The aim of this article is to compare the two recent guidelines issued by the ESC and ACC/AHA/HFSA and show the few differences and the many consistent recommendations, now more numerous given the evidence available for many new treatments.

  View details for DOI 10.1093/eurheartjsupp/suac124

  View details for PubMedID 36545230

• Disparities in virtual cardiology visits among Veterans Health Administration patients during the COVID-19 pandemic. JAMIA open Tisdale, R. L., Ferguson, J., Van Campen, J., Greene, L., Sandhu, A. T., Heidenreich, P. A., Zulman, D. M. 2022; 5 (4): ooac103

  Abstract

  Objective: In response to the coronavirus disease 2019 (COVID-19) pandemic, the Veterans Health Administration (VA) rapidly expanded virtual care (defined as care delivered by video and phone), raising concerns about technology access disparities (ie, the digital divide). Virtual care was somewhat established in primary care and mental health care prepandemic, but video telehealth implementation was new for most subspecialties, including cardiology. We sought to identify patient characteristics of virtual and video-based care users in VA cardiology clinics nationally during the first year of the COVID-19 pandemic.Materials and Methods: Cohort study of Veteran patients across all VA facilities with a cardiology visit January 1, 2019-March 10, 2020, with follow-up January 1, 2019-March 10, 2021. Main measures included cardiology visits by visit type and likelihood of receiving cardiology-related virtual care, calculated with a repeated event survival model.Results: 416587 Veterans with 1689595 total cardiology visits were analyzed; average patient age was 69.6 years and 4.3% were female. Virtual cardiology care expanded dramatically early in the COVID-19 pandemic from 5% to 70% of encounters. Older, lower-income, and rural-dwelling Veterans and those experiencing homelessness were less likely to use video care (adjusted hazard ratio for ages 75 and older 0.80, 95% confidence interval (CI) 0.75-0.86; for highly rural residents 0.77, 95% CI 0.68-0.87; for low-income status 0.94, 95% CI 0.89-0.98; for homeless Veterans 0.85, 95% CI 0.80-0.92).Conclusion: The pandemic worsened the digital divide for cardiology care for many vulnerable patients to the extent that video visits represent added value over phone visits. Targeted interventions may be necessary for equity in COVID-19-era access to virtual cardiology care.

  View details for DOI 10.1093/jamiaopen/ooac103

  View details for PubMedID 36531138

• Methamphetamine-associated heart failure: a systematic review of observational studies. Heart (British Cardiac Society) Manja, V., Nrusimha, A., Gao, Y., Sheikh, A., McGovern, M., Heidenreich, P. A., Sandhu, A. T., Asch, S. 2022

  Abstract

  To conduct a systematic review of observational studies on methamphetamine-associated heart failure (MethHF) .Six databases were searched for original publications on the topic. Title/abstract and included full-text publications were reviewed in duplicate. Data extraction and critical appraisal for risk of bias were performed in duplicate.Twenty-one studies are included in the final analysis. Results could not be combined because of heterogeneity in study design, population, comparator, and outcome assessment. Overall risk of bias is moderate due to the presence of confounders, selection bias and poor matching; overall certainty in the evidence is very low. MethHF is increasing in prevalence, affects diverse racial/ethnic/sociodemographic groups with a male predominance; up to 44% have preserved left-ventricular ejection fraction. MethHF is associated with significant morbidity including worse heart failure symptoms compared with non-methamphetamine related heart failure. Female sex, methamphetamine abstinence and guideline-directed heart failure therapy are associated with improved outcomes. Chamber dimensions on echocardiography and fibrosis on biopsy predict the extent of recovery after abstinence.The increasing prevalence of MethHF with associated morbidity underscores the urgent need for well designed prospective studies of people who use methamphetamine to accurately assess the epidemiology, clinical features, disease trajectory and outcomes of MethHF. Methamphetamine abstinence is an integral part of MethHF treatment; increased availability of effective non-pharmacological interventions for treatment of methamphetamine addiction is an essential first step. Availability of effective pharmacological treatment for methamphetamine addiction will further support MethHF treatment. Using harm reduction principles in an integrated addiction/HF treatment programme will bolster efforts to stem the increasing tide of MethHF.

  View details for DOI 10.1136/heartjnl-2022-321610

  View details for PubMedID 36456204

• Cardiovascular vs. non-cardiovascular deaths after heart failure hospitalization in young, older, and very old patients. ESC heart failure Nakamaru, R., Shiraishi, Y., Sandhu, A. T., Heidenreich, P. A., Shoji, S., Kohno, T., Takei, M., Nagatomo, Y., Nakano, S., Kohsaka, S., Yoshikawa, T. 2022

  Abstract

  AIMS: The long-term outcome in patients with heart failure (HF) after hospitalization may vary substantially depending on their age and left ventricular ejection fraction (LVEF). We aimed to assess the relative rates of cardiovascular death (CVD) and non-CVD based on the age and how the rates differ under the updated LVEF classification system.METHODS AND RESULTS: Consecutively registered hospitalized patients with HF (N=3558; 39.7% women with a mean age of 73.9±13.3years) were followed for a median of 2 (interquartile range, 0.8-3.1) years. The CVDs and non-CVDs were evaluated based on age [young (<65years), older (65-84years), and very old (≥85years)] and LVEF classification [HF with preserved EF (HFpEF; LVEF ≥50%) and non-HFpEF (LVEF <50%)]. The adverse clinical events were adjudicated independently by a central committee. Overall, 1505 (42.3%) had HFpEF [young: n=182 (12.1%), older: n=894 (59.4%), very old: n=429 (28.5%)], and 2053 (57.7%) had non-HFpEF [young: n=575 (28.0%), older: n=1159 (56.5%), very old: n=319 (15.5%)]. During the follow-up, the crude incidence of all-cause death was higher in non-HFpEF than in HFpEF across all age groups (non-HFpEF vs. HFpEF, young: 10.4% vs. 5.5%, log-rank P=0.10; older: 26.6% vs. 20.9%, log-rank P=0.002; very old: 36.7% vs. 31.7%, log-rank P=0.043). CVDs accounted for more than half of all deaths in non-HFpEF (young 65.0%, older 64.2%, and very old 55.6%), whereas the proportion of CVDs remained less than half in HFpEF (young 50.0%, older 41.2%, very old 38.2%). HF readmission was associated with subsequent all-cause death in non-HFpEF [hazard ratio (HR): 1.72, 95% confidence interval (CI): 1.41-2.09, P<0.001], but not in HFpEF (HR: 1.12, 95% CI: 0.87-1.43, P=0.39).CONCLUSIONS: The probability of a non-CVD increases in both LVEF categories with advancing age, but that it is greater in the HFpEF category. The findings indicate that mitigating CV-related outcomes alone may be insufficient for treating HF in older population, particularly in the HFpEF category.

  View details for DOI 10.1002/ehf2.14245

  View details for PubMedID 36436825

• Reference change value of global longitudinal strain in clinical practice: A test-rest quality implementation project. Echocardiography (Mount Kisco, N.Y.) Tuzovic, M., Tang, X., Francisco, N., Sell, A., Drew, R., Paloma, A., Chow, J., Liang, D., Heidenreich, P., Salerno, M., Schnittger, I., Haddad, F. 2022

  Abstract

  BACKGROUND: Reference change value (RCV) is used to assess the significance of the difference between two measurements after accounting for pre-analytic, analytic, and within-subject variability. The objective of the current study was to define the RCV for global longitudinal strain (GLS) using different semi-automated software in standard clinical practice.METHODS: Using a test-retest study design, we quantified the median coefficient of variation (CV) for GLS using AutoStrain and Automated Cardiac Motion Quantification (aCMQ) by Philips. Triplane left-ventricular ejection fraction (LVEF) was measured for comparison. Multivariable regression analysis was performed to determine factors influencing test-retest CV including image quality and the presence of segmental wall motion abnormalities (WMA). RCV was reported using a standard formula assuming two standard deviations for repeated measurements; results were also translated into Bayesian probability. Total measurement variation was described in terms of its three different components: pre-analytic (acquisition), analytic (measuring variation), and within-subject (biological) variation.RESULT: Of the 44 individuals who were screened, 41 had adequate quality for strain quantification. The mean age of the cohort was 56.4±16.8 years, 41% female, LVEF was 55.8±9.8% and the median and interquartile range for LV GLS was -17.2 [-19.3 to -14.8]%. Autostrain was more time efficient (80% less analysis time) and had a lower total median CV than aCMQ (CV=7.4%vs. 17.6%, p <.001). The total CV was higher in patients with WMA (6.4%vs. 13.2%, p=.035). In non-segmental disease, the CV translates to a RCV of 15% (corresponding to a probability of real change of 80%). Assuming a within-subject variability of 4.0%, the component analysis identified that inter-reader variability accounts for 3.7% of the CV, while acquisition variability accounts for 4.0%.CONCLUSION: Using test-retest analysis and CVs, we find that an RCV of 15% for GLS represents an optimistic estimate in routine clinical practice. Based on our results, a higher RCV of 17%-21% is needed in order to provide a high probability of clinically meaningful change in GLS in all comers. The methodology presented here for determining measurement reproducibility and RCVs is easily translatable into clinical practice for any imaging parameter.

  View details for DOI 10.1111/echo.15482

  View details for PubMedID 36376263

• Temporal Trends in Cardiovascular Disease Among Asian American Subgroups Nguyen, K. T., Li, J., Peng, A., Heidenreich, P. A., Palaniappan, L., Yong, C. M. LIPPINCOTT WILLIAMS & WILKINS. 2022

  View details for Web of Science ID 000890856902057

• Diversity of Cardiology Fellowship Candidates in the Era of Virtual Interviews Witting, C., Gummidipundi, S. E., Heidenreich, P. A., Knowles, J., Yong, C. M. LIPPINCOTT WILLIAMS & WILKINS. 2022

  View details for Web of Science ID 000890856907107

• Geographic Variation in Prescription of Heart Failure Guideline Directed Medical Therapies for United States Veterans is Prevalent Nationwide Kosaraju, R., Fonarow, G. C., Ong, M. K., Heidenreich, P. A., Washington, D. L., Wang, X., Ziaeian, B. LIPPINCOTT WILLIAMS & WILKINS. 2022

  View details for Web of Science ID 000890856901026

• A Randomized Clinical Trial to Evaluate an Atrial Fibrillation Stroke Prevention Shared Decision-Making Pathway. Journal of the American Heart Association Wang, P. J., Lu, Y., Mahaffey, K. W., Lin, A., Morin, D. P., Sears, S. F., Chung, M. K., Russo, A. M., Lin, B., Piccini, J., Hills, M. T., Berube, C., Pundi, K., Baykaner, T., Garay, G., Lhamo, K., Rice, E., Pourshams, I. A., Shah, R., Newswanger, P., DeSutter, K., Nunes, J. C., Albert, M. A., Schulman, K. A., Heidenreich, P. A., Bunch, T. J., Sanders, L. M., Turakhia, M., Verghese, A., Stafford, R. S. 2022: e8009

  Abstract

  Background Oral anticoagulation (OAC) reduces stroke and disability in atrial fibrillation (AF) but is underutilized. We evaluated the effects of a novel patient-clinician shared decision-making (SDM) tool in reducing OAC patient's decisional conflict as compared to usual care. Methods and Results We designed and evaluated a new digital decision aid in a multicenter, randomized, comparative effectiveness trial, ENHANCE-AF (Engaging Patients to Help Achieve Increased Patient Choice and Engagement for AF Stroke Prevention). The digital AF SDM Toolkit was developed using patient-centered design with clear health communication principles (e.g. meaningful images, limited text). Available in English and Spanish, the toolkit included the following: 1) a brief animated video; 2) interactive questions with answers; 3) a quiz to check on understanding; 4) a worksheet to be used by the patient during the encounter; and 5) an online guide for clinicians. The study population included English or Spanish speakers with non-valvular AF and a CHA2DS2-VASc stroke score ≥1 for men or ≥2 for women. Participants were randomized in a 1:1 ratio to either Usual Care (UC) or the SDM Toolkit. The primary endpoint was the validated 16-item Decisional Conflict Scale (DCS) at 1 month. Secondary outcomes included DCS at 6 months and the 10-item Decision Regret Scale (DRS) at 1 and 6 months as well as a weighted average of Mann-Whitney U-statistics for both DCS and DRS. A total of 1001 participants were enrolled and followed at 5 different sites in the United States between 12/18/19 and 8/17/22. The mean patient age was 69 ±10years (40% females, 16.9% Black, 4.5% Hispanic, 3.6% Asian), and 50% of participants had CHA2DS2-VASc scores ≥3 (M) or ≥4 (F). The primary endpoint at 1 month showed a clinically meaningful reduction in decisional conflict: a 7-point difference in median scores between the two arms (16.4 v 9.4; Mann-Whitney U-statistics=0.550; p-value=0.007). For the secondary endpoint of 1-month DRS, the difference in median scores between arms was 5 points in the direction of less decisional regret (p-value of 0.078). The treatment effects lessened over time: at 6 months the difference in medians was 4.7 points for DCS (p-value=0.060) and 0 points for DRS (p-value=0.35). Conclusions Implementation of a novel, Shared Decision-Making Toolkit (afibguide.com; afibguide.com/clinician) achieved significantly lower decisional conflict compared to usual care in patients with AF.

  View details for DOI 10.1161/JAHA.122.028562

  View details for PubMedID 36342828

• Cost-effectiveness of Empagliflozin in Patients With Heart Failure With Preserved Ejection Fraction. JAMA internal medicine Zheng, J., Parizo, J. T., Spertus, J. A., Heidenreich, P. A., Sandhu, A. T. 2022

  Abstract

  Importance: In the Empagliflozin Outcome Trial in Patients With Chronic Heart Failure With Preserved Ejection Fraction (EMPEROR-Preserved), empagliflozin significantly reduced hospitalizations for heart failure while improving patient-reported health status compared with placebo. The long-term cost-effectiveness of empagliflozin among patients who have heart failure with preserved ejection fraction (HFpEF) remains unclear.Objective: To estimate the cost-effectiveness of empagliflozin in patients with HFpEF.Design, Setting, and Participants: This cost-effectiveness analysis performed from October 2021 to April 2022 included a Markov model using estimates of treatment efficacy, event probabilities, and utilities from EMPEROR-Preserved and published literature. Costs were derived from national surveys and pricing data sets. Quality of life was imputed from a heart failure-specific quality-of-life measure. Two analyses were performed, with and without a treatment effect on cardiovascular mortality. Subgroup analyses were based on diabetes status, ejection fraction, and health status impairment due to heart failure. The model reproduced the event rates and risk reduction with empagliflozin observed in EMPEROR-Preserved over 26 months of follow-up; future projections extended across the lifetime of patients.Exposures: Empagliflozin or standard of care.Main Outcomes and Measures: Hospitalizations for heart failure, life-years, quality-adjusted life-years (QALYs), lifetime costs, and lifetime incremental cost-effectiveness ratio.Results: A total of 5988 patients were included in the analysis, with a mean age of 72 years, New York Heart Association class II to IV heart failure, and left ventricular ejection fraction greater than 40%. At the Federal Supply Schedule price of $327 per month, empagliflozin yielded 0.06 additional QALYs and $26 257 incremental costs compared with standard of care, producing a cost per QALY gained of $437 442. Incremental costs consisted of total drug costs of $29 586 and savings of $3329 from reduced hospitalizations for heart failure. Cost-effectiveness was similar across subgroups. The results were most sensitive to the monthly cost, quality-of-life benefit, and mortality effect of empagliflozin. A price reduction to $153 per month, incremental utility of 0.02, or 8% reduction in cardiovascular mortality would bring empagliflozin to $180 000 per QALY gained, the threshold for intermediate value. Using Medicare Part D monthly pricing of $375 after rebates and $511 before rebates, empagliflozin would remain low value at $509 636 and $710 825 per QALY gained, respectively. Cost-effectiveness estimates were robust to variation in the frequency and disutility of heart failure hospitalizations.Conclusions and Relevance: In this economic evaluation, based on current cost-effectiveness benchmarks, empagliflozin provides low economic value compared with standard of care for HFpEF, largely due to its lack of efficacy on mortality and small benefit on quality of life.

  View details for DOI 10.1001/jamainternmed.2022.5010

  View details for PubMedID 36342696

• Disparities in Hospital Length of Stay Across Race and Ethnicity Among Patients With Heart Failure. Circulation. Heart failure Zheng, J., Tisdale, R. L., Heidenreich, P. A., Sandhu, A. T. 2022; 15 (11): e009362

  Abstract

  Reducing hospital length of stay (LOS) has been identified as an important lever for minimizing the burden of heart failure hospitalization, yet the impact of social and structural determinants of health on LOS has received little attention. We investigated disparities in LOS across race/ethnicity and their possible drivers.We analyzed patients hospitalized for heart failure from 2017 to 2020 using the Get With The Guidelines-Heart Failure registry. We characterized LOS differences across race/ethnicity by insurance and disposition, adjusting for demographics, comorbidities, and clinical severity. Effects of hospital-level clustering on LOS across race/ethnicity were assessed using hierarchical mixed-effects models. We evaluated the association between LOS and discharge rates of guideline-directed medical therapy.Three thousand three seven hundred thirty patients hospitalized for heart failure were identified. After excluding inpatient deaths, the adjusted LOS for Black (5.72 days [95% CI, 5.62-5.82]), Hispanic (5.94 days [95% CI, 5.79-6.08]), and Indigenous American/Pacific Islander (6.06 days [95% CI, 5.85-6.27]) patients remained significantly longer compared with non-Hispanic White patients (5.32 days [95% CI, 5.25-5.39]). This pattern was driven by LOS differences among patients discharged to hospice or nursing facilities. After accounting for variability between hospitals, associations of race/ethnicity with LOS either were attenuated or reversed in direction. Guideline-directed medical therapy rates on discharge did not differ significantly across race/ethnicity despite longer LOS for Black, Hispanic, and Indigenous American/Pacific Islander patients.Differences between hospitals drive LOS disparities across race/ethnicity. Longer LOS among Black, Hispanic, and Indigenous American/Pacific Islander patients was not associated with improved quality of care.

  View details for DOI 10.1161/CIRCHEARTFAILURE.121.009362

  View details for PubMedID 36378760

• Assessing the Impact of the American Heart Association's Research Portfolio: A Scientific Statement From the American Heart Association CIRCULATION Creager, M. A., Hernandez, A. F., Bender, J. R., Foster, M. H., Heidenreich, P. A., Houser, S. R., Lloyd-Jones, D. M., Roach, W. H., Roger, V. L., Amer Heart Assoc Res Comm 2022; 146 (18): E246-E256

  Abstract

  A task force composed of American Heart Association (AHA) Research Committee members established processes to measure the performance of the AHA's research portfolio and evaluated key outcomes that are fundamental to the overall success of the program. This report reviews progress that the AHA research program has had in achieving its goals relevant to the research programs in the AHA's research portfolio from 2008 to 2017. Comprehensive performance metrics were identified to assess the impact of AHA funding on researchers' career progress and research outcomes. Metrics included bibliometric analysis (ie, tracking of publications and their impact) and career development measures (ie, subsequent grant funding, intellectual property, faculty appointment/promotion, or industry position). Publication rates ranged from ≈0.5 to 4 publications per year, with a strong correlation between number of publications per year and later career stage. The Field-Weighted Citation Index, a metric of bibliometric impact, was between 1.5 and 3.0 for all programs, indicating that AHA awardee publications had a higher citation impact compared with similar publications. To gain insight into the career progression of AHA awardees, a 2-year postaward survey was distributed. Of the Postdoctoral Fellowship recipient respondents, 72% obtained academic research positions, with the remaining working in industry or government research settings; 72% of those in academic positions obtained additional funding. Among respondents who were Beginning Grant-in-Aid and Scientist Development Grant awardees, 45% received academic promotions and 83% obtained additional funding. Measuring performance of the AHA's research portfolio is critical to ensure that its strategic goals are met and to show the AHA's commitment to high-quality, impactful research.

  View details for DOI 10.1161/CIR.0000000000001094

  View details for Web of Science ID 000877143300003

  View details for PubMedID 36134568

• The Patient-Reported Outcome Measurement in Heart Failure Clinic Trial: Rationale and Methods of The PRO-HF Trial. American heart journal Kalwani, N. M., Calma, J., Varghese, G. M., Gupta, A., Zheng, J., Brown-Johnson, C., Amano, A., Vilendrer, S., Winget, M., Asch, S. M., Heidenreich, P., Sandhu, A. 2022

  Abstract

  BACKGROUND: Among patients with heart failure (HF), patient-reported health status provides information beyond standard clinician assessment. Although HF management guidelines recommend collecting patient-reported health status as part of routine care, there is minimal data on the impact of this intervention.STUDY DESIGN: The Patient-Reported Outcomes in Heart Failure Clinic (PRO-HF) trial is a pragmatic, randomized, implementation-effectiveness trial testing the hypothesis that routine health status assessment via the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) leads to an improvement in patient-reported health status among patients treated in a tertiary health system HF clinic. PRO-HF has completed randomization of 1,248 participants to routine KCCQ-12 assessment or usual care. Patients randomized to the KCCQ-12 arm complete KCCQ-12 assessments before each HF clinic visit with the results shared with their treating clinician. Clinicians received education regarding the interpretation and potential utility of the KCCQ-12. The primary endpoint is the change in KCCQ-12 over 1 year. Secondary outcomes are HF therapy patterns and healthcare utilization, including clinic visits, testing, hospitalizations, and emergency department (ED) visits. As a sub-study, PRO-HF also evaluated the impact of routine KCCQ-12 assessment on patient experience and the accuracy of clinician-assessed health status. In addition, clinicians completed semi-structured interviews to capture their perceptions on the trial's implementation of routine KCCQ-12 assessment in clinical practice.CONCLUSIONS: PRO-HF is a pragmatic, randomized trial based in a real-world HF clinic to determine the feasibility of routinely assessing patient-reported health status and the impact of this intervention on health status, care delivery, patient experience, and the accuracy of clinician health status assessment.

  View details for DOI 10.1016/j.ahj.2022.10.081

  View details for PubMedID 36309127

• Treatment Differences in Medical Therapy for Heart Failure With Reduced Ejection Fraction Between Sociodemographic Groups. JACC. Heart failure Witting, C., Zheng, J., Tisdale, R. L., Shannon, E., Kohsaka, S., Lewis, E. F., Heidenreich, P., Sandhu, A. 2022

  Abstract

  There are sociodemographic disparities in outcomes of heart failure with reduced ejection fraction (HFrEF), but disparities in guideline-directed medical therapy (GDMT) remain poorly characterized.This study aimed to analyze GDMT treatment rates in eligible patients with recently diagnosed HFrEF, and to determine how rates vary by sociodemographic characteristics.This retrospective cohort study included patients diagnosed with HFrEF at Veterans Affairs (VA) hospitals from 2013 to 2019. The authors analyzed GDMT treatment rates and doses, excluding patients with contraindications. Therapies of interest were evidence-based beta-blockers (BBs), renin-angiotensin system inhibitors (RASIs), angiotensin receptor-neprilysin inhibitors (ARNIs), and mineralocorticoid antagonists (MRAs). The authors compared adjusted treatment rates by race and ethnicity, neighborhood social vulnerability, rurality, distance to medical care, and sex.The cohort comprised 126,670 VA patients with recently diagnosed HFrEF. The study found that racial and ethnic minorities had similar or higher treatment rates than White patients. Patients residing in socially vulnerable neighborhoods had 3.4% lower ARNI (95% CI: 1.9%-5.0%) treatment rates. Patients residing farther from specialty care had similar rates of GDMT therapy overall, but were less likely to be taking at least 50% of the target doses of either BBs (4.0% less likely; 95% CI: 3.1%-5.0%) or RASIs (5.0% less likely; 95% CI: 4.1%-6.0%) compared with those closer to care.Among VA patients with recently diagnosed HFrEF, the authors did not find that racial and ethnic minority patients were less likely to receive GDMT. However, appropriate dose up-titration may occur less frequently in more remote patients.

  View details for DOI 10.1016/j.jchf.2022.08.023

  View details for PubMedID 36647925

• Weight Loss and Cardiac Reverse Remodeling. Journal of the American College of Cardiology Heidenreich, P. 2022; 80 (16): 1513-1515

  View details for DOI 10.1016/j.jacc.2022.08.752

  View details for PubMedID 36229086

• Medical therapy for patients with recent-onset heart failure with reduced ejection fraction during the COVID-19 pandemic: Insights from the Veteran's affairs healthcare system. American heart journal plus : cardiology research and practice Sandhu, A., Zheng, J., Tisdale, R., Kohsaka, S., Turakhia, M. P., Heidenreich, P. 2022: 100210

  Abstract

  This study aims to evaluate trends in guideline-directed medical therapy (GDMT) for patients with recent-onset heart failure with reduced ejection fraction (HFrEF) following the onset of the COVID-19 pandemic using an interrupted time series analysis in the Veteran's Affairs Healthcare System. Among 71,428 patients with recent-onset HFrEF between 1/1/2018 and 2/28/2021, we found the pandemic was not associated with differences in treatment rates for beta-blockers, renin-angiotensin-aldosterone system inhibitors, or mineralocorticoid receptor antagonists; there was a 2.6 % absolute decrease (95 % CI: 0.5 %-4.7 %) in ARNI rates in April 2020; which decreased over the pandemic. Despite the changes to healthcare delivery, the COVID-19 pandemic was associated with minimal changes in GDMT rates among patients with recent-onset HFrEF.

  View details for DOI 10.1016/j.ahjo.2022.100210

  View details for PubMedID 36156887

• Interruptive Electronic Alerts for Choosing Wisely Recommendations: A Cluster Randomized Controlled Trial. Journal of the American Medical Informatics Association : JAMIA Ho, V. T., Aikens, R. C., Tso, G., Heidenreich, P. A., Sharp, C., Asch, S. M., Chen, J. H., Shah, N. K. 2022

  Abstract

  OBJECTIVE: To assess the efficacy of interruptive electronic alerts in improving adherence to the American Board of Internal Medicine's Choosing Wisely recommendations to reduce unnecessary laboratory testing.MATERIALS AND METHODS: We administered 5 cluster randomized controlled trials simultaneously, using electronic medical record alerts regarding prostate-specific antigen (PSA) testing, acute sinusitis treatment, vitamin D testing, carotid artery ultrasound screening, and human papillomavirus testing. For each alert, we assigned 5 outpatient clinics to an interruptive alert and 5 were observed as a control. Primary and secondary outcomes were the number of postalert orders per 100 patients at each clinic and number of triggered alerts divided by orders, respectively. Post hoc analysis evaluated whether physicians experiencing interruptive alerts reduced their alert-triggering behaviors.RESULTS: Median postalert orders per 100 patients did not differ significantly between treatment and control groups; absolute median differences ranging from 0.04 to 0.40 for PSA testing. Median alerts per 100 orders did not differ significantly between treatment and control groups; absolute median differences ranged from 0.004 to 0.03. In post hoc analysis, providers receiving alerts regarding PSA testing in men were significantly less likely to trigger additional PSA alerts than those in the control sites (Incidence Rate Ratio 0.12, 95% CI [0.03-0.52]).DISCUSSION: Interruptive point-of-care alerts did not yield detectable changes in the overall rate of undesired orders or the order-to-alert ratio between active and silent sites. Complementary behavioral or educational interventions are likely needed to improve efforts to curb medical overuse.CONCLUSION: Implementation of interruptive alerts at the time of ordering was not associated with improved adherence to 5 Choosing Wisely guidelines.TRIAL REGISTRATION: NCT02709772.

  View details for DOI 10.1093/jamia/ocac139

  View details for PubMedID 36018731

• Atrial fibrillation bleeding risk and prediction while treated with direct oral anticoagulants in warfarin-naive or warfarin-experienced patients. Clinical cardiology Perino, A. C., Fan, J., Pundi, K., Schmitt, S., Kothari, M., Din, N., Heidenreich, P. A., Turakhia, M. P. 2022

  Abstract

  BACKGROUND: In patients with atrial fibrillation (AF) treated with direct oral anticoagulants (DOAC), bleeding risk scores provide only modest discrimination for major or intracranial bleeding. However, warfarin experience may impact HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (>65 years), Drugs/alcohol concomitantly) score performance in patients evaluated for DOACs, as HAS-BLED was derived and validated in warfarin cohorts.METHODS: We performed a retrospective cohort study of patients prescribed DOAC for AF in the Veterans Health Administration between 2010 and 2017. We determined modified HAS-BLED score discrimination and calibration for bleeding, for patients treated with DOAC, stratified by prior warfarin exposure. We also determined the association betweenDOAC-warfarin-naive status to bleeding (nonintracranial and intracranial) with DOAC-warfarin-experienced patients as reference.RESULTS: The DOAC analysis cohort included 100,492 patients with AF (age [mean±SD]: 72.9±9.6 years; 1.7% female; 90.1% White), of which 26,760 patients (26.6%) and 73,732 patients (73.4%) were warfarin experienced or naive, respectively. HAS-BLED discrimination for bleeds was modest for patients treated with DOAC, regardless of prior warfarin experience (concordancestatistics: 0.53-0.59). For DOAC-warfarin-naive patients, as compared to DOAC-warfarin-experienced patients, adjusted risk of intracranial bleeding was lower, while risk of nonintracranial bleeding was higher (intracranial bleeding propensity adjusted with inverse probability of treatment weights [IPTWs]: hazard ratio [HR]: 0.86, 95% confidence interval [CI]: 0.78-0.95, p=.0040) (nonintracranial bleeding propensity adjusted with IPTW: HR: 1.15, 95% CI: 1.11-1.19, p<.0001).CONCLUSION: Patients' modified HAS-BLED score at the time of DOAC initiation, regardless of prior warfarin use, provided only modest discrimination for intracranial and nonintracranial bleeds. These data argue against maintaining DOAC eligible patients on warfarin therapy regardless of modified HAS-BLED score.

  View details for DOI 10.1002/clc.23887

  View details for PubMedID 35946047

• Expenditure on Heart Failure in the United States: The Medical Expenditure Panel Survey 2009-2018. JACC. Heart failure Bhatnagar, R., Fonarow, G. C., Heidenreich, P. A., Ziaeian, B. 2022; 10 (8): 571-580

  Abstract

  With rising United States health care expenditure, estimating current spending for patients with heart failure (HF) informs the value of preventative health interventions.The purpose of this study was to estimate current health care expenditure growth for patients with HF in the United States.The authors pooled MEPS (Medical Expenditure Panel Survey) data from 2009-2018 to calculate total HF-related expenditure across clinical settings in the United States. A 2-part model adjusted for demographics, comorbidities, and year was used to estimate annual mean and incremental expenditures associated with HF.In the United States, an average of $28,950 (2018 inflation-adjusted dollars) is spent per year for health care-related expenditure for individuals with HF compared with $5,727 for individuals without HF. After adjusting for demographics and comorbidities, a diagnosis of HF was associated with $3,594 in annual incremental expenditure compared with those without HF. HF-related expenditure increased from $26,864 annual per person in 2009-2010 to $32,955 in 2017-2018, representing a 23% rise over 10 years. In comparison, expenditure on myocardial infarction, type 2 diabetes mellitus, and cancer grew by 16%, 28%, and 16%, respectively. Most of the cost was related to hospitalization: $12,569 per year. Outpatient office-based care and prescription medications saw the greatest growth in cost over the period, 41% and 24%, respectively. Estimated incremental national expenditure for HF per year was $22.3 billion; total annual expenditure for adults with HF was $179.5 billion.HF is a costly condition for which expenditure is growing faster than that of other chronic conditions.

  View details for DOI 10.1016/j.jchf.2022.05.006

  View details for PubMedID 35902161

• How successful was the use of a community of practice for the implementation of evidence-based practices for heart failure within the United States Department of Veterans Affairs: Insights from a formative evaluation. Health research policy and systems Sahay, A., Mittman, B. S., Gholami, P., Lin, S., Heidenreich, P. A. 2022; 20 (1): 79

  Abstract

  BACKGROUND: Communities of Practice (CoPs) are a promising approach to facilitate the implementation of evidence-based practices (EBPs) to improve care for chronic conditions like heart failure (HF). CoPs involve a complex process of acquiring and converting both explicit and tacit knowledge into clinical activities. This study describes the conceptualization, creation, capacity-building and dissemination of a CoP sustainedover 9 years, and evaluates its value and impact on EBP.METHODS: In July 2006, a CoP called the Heart Failure Provider Network (HF Network) was established within the United States Department of Veterans Affairs (VA) with the overarching goal of improving the quality of care for HF patients. We assessed (formative) the HF Network in terms of its various activities (inputs) and proximal impacts (mediators) at the individual level, and its distal impacts (outcomes) at the site level including implementation of new/improved EBPs at the systemwide level.RESULTS: The HF Network membership grew steadily over the 9 years. The CoP has involved a total of 1341 multidisciplinary and multilevel members at all 144 VA HealthCare Systems (sites). Most members were practising clinicians (n=891, 66.4%), followed by administrators (n=342, 25.5%), researchers (n=70, 5.2%) and others (n=38, 2.8%). Participation wasassessed to be "active" for 70.6% versus "passive" for 29.4% of members. The distribution of active members (clinicians 64.7%, administrators 21.6%) was similar to the distribution of overall membership.CONCLUSIONS: Survey respondents perceived the HF Network as useful in terms of its varied activities and resources relevant for patient care. Strong evidence shows that these members, particularly those who considered themselves influential in improving quality of care, noted multiple benefits of membership, which included confirmation of their own clinical practices, evidence-based changes to their practice and help in understanding facilitators and barriers in setting up or running HF clinics and other programmes. Such CoPs have strong impacts on the quality of care being delivered for both mandated and non-mandated initiatives.

  View details for DOI 10.1186/s12961-022-00880-9

  View details for PubMedID 35804413

• Clinical predictors of improvement in left ventricular ejection fraction in U.S. veterans with heart failure. American heart journal plus : cardiology research and practice Nallamshetty, S., Castillo, A., Nguyen, A., Haddad, F., Heidenreich, P. 2022; 19: 100183

  Abstract

  Our understanding of the factors associated with improvement of LVEF and a heart failure with improved EF (HFimpEF) phenotype remains incomplete.We conducted a retrospective study using a national database of patients followed in the Veterans Affairs (VA) health system with serial assessment of left ventricular ejection fraction (LVEF) by echocardiography. We identified US veterans with a new diagnosis of heart failure with: (i) LVEF of <40 % in the 12 months prior to diagnosis, and (ii) follow-up LVEF assessment at least 6 months after their diagnosis. We defined HFimpEF as a final LVEF of ≥40 %.Among the 106,414 US veterans with an initial LVEF of <40 % in this analysis, 39,994 (37.6 %) had a final EF of >40 % after a median follow up of 5 years. Multivariate regression analysis identified several factors that were independently associated with LVEF improvement including female sex, younger age, higher BMI, and a history of specific comorbid conditions such as hypertension, valve disease, atrial fibrillation, connective tissue disease, liver disease, and malignancy (p < 0.001). Conversely, a history of ischemic heart disease and peripheral arterial disease, as well as specific racial backgrounds (Black and Hispanic) were associated with lower rates of LVEF improvement. The model c-statistic for predicting LVEF improvement was 0.70.This large, detailed dataset facilitated an analysis of a large number of variables that significantly associated with HFimpEF; however, their combined discriminatory value for LVEF improvement remained modest, underscoring the complexity of the gene-environment-treatment interactions that govern LV function.

  View details for DOI 10.1016/j.ahjo.2022.100183

  View details for PubMedID 38558863

  View details for PubMedCentralID PMC10978352

• 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure JOURNAL OF CARDIAC FAILURE Heidenreich, P. A., Bozkurt, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., Deswal, A., Drazner, M. H., Dunlay, S. M., Evers, L. R., Fang, J. C., Fedson, S. E., Fonarow, G. C., Hayek, S. S., Hernandez, A. F., Khazanie, P., Kittleson, M. M., Lee, C. S., Link, M. S., Milano, C. A., Nnacheta, L. C., Sandhu, A. T., Stevenson, L., Vardeny, O., Vest, A. R., Yancy, C. W., Beckman, J. A., O'Gara, P. T., Al-Khatib, S. M., Armbruster, A. L., Birtcher, K. K., Cigarroa, J. E., de las Fuentes, L., Dixon, D. L., Fleisher, L. A., Gentile, F., Goldberger, Z. D., Gorenek, B., Haynes, N., Hlatky, M. A., Joglar, J. A., Jones, W., Marine, J. E., Mark, D. B., Mukherjee, D., Palaniappan, L. P., Piano, M. R., Rab, T., Spatz, E. S., Tamis-Holland, J. E., Wijeysundera, D. N., Woo, Y., WRITING COMM MEMBERS, ACC AHA Joint Comm Members 2022; 28 (5): E1-E167

  Abstract

  The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

  View details for DOI 10.1016/j.cardfail.2022.02.010

  View details for Web of Science ID 000830777400001

  View details for PubMedID 35378257

• Regional variations in the process of care for patients undergoing percutaneous coronary intervention in Japan. The Lancet regional health. Western Pacific Shoji, S., Yamaji, K., Sandhu, A. T., Ikemura, N., Shiraishi, Y., Inohara, T., Heidenreich, P. A., Amano, T., Ikari, Y., Kohsaka, S. 2022; 22: 100425

  Abstract

  Background: Measuring the quality of care has been central for improving the outcomes of patients undergoing percutaneous coronary intervention (PCI). This study described the performance rates and regional variations in quality metrics for PCI using a representative national Japanese registry.Methods: Overall, 760,854 patients across 714 institutions (2016-2018) were analysed. Quality metrics included preprocedural antiplatelet therapy use, door-to-balloon time ≤90min for ST-elevation myocardial infarction, transradial approach, and preprocedural noninvasive stress testing for elective cases in 47 Japanese prefectures. Coronary computed tomography angiography (CCTA) and fractional flow reserve (FFR) were also evaluated. Factors associated with preprocedural testing rates were evaluated using multivariable linear regression.Findings: Rates of preprocedural antiplatelet therapy use were high with low variations (96·4% [94·7-97·2%]), but there was still substantial room for improvement in the rates of door-to-balloon time (74·7% [71·2-78·9%]) and transradial approach use (70·9% [65·1-73·4%]). Rates of preprocedural noninvasive stress testing were low with substantial variation (36·6% [27·1-49·7%]). Additionally, we found substantial variations in CCTA (50·0% [39·5-55·1%]) and FFR measurement (15·7% [113·-18·3%]) rates. The number of scintigraphy scanners/ prefecture was associated with the performance of noninvasive stress testing (13·4% [95% CI, 2·45-24·4%] increase for every 1/100,000 population increase in scanners).Interpretations: We observed substantial regional variation in the use of preprocedural testing, and its performance was directly related to nuclear-scanner availability. These findings suggest the need for targeted efforts in improving testing rates, whether by optimising resource allocation or additional education or feedback mechanisms.Funding: This study was funded by the Japan Society for the Promotion of Science (Grant Nos. 20H03915, 16H05215, 16KK0186, and 20K22883) and by the Ministry of Health, Labor and Welfare Grants-in-Aid for Scientific Research Program (Grant No. 21FA1015).The J-PCI registry is led and supported by the Japanese Association of Cardiovascular Intervention and Therapeutics.

  View details for DOI 10.1016/j.lanwpc.2022.100425

  View details for PubMedID 35308578

• Health System-Level Performance in Prescribing Guideline-Directed Medical Therapy for Patients with HFrEF: Results from the CONNECT-HF Trial. Journal of cardiac failure Granger, B. B., Kaltenbach, L. A., Fonarow, G. C., Allen, L. A., Lanfear, D. E., Albert, N. M., Al-Khalidi, H. R., Butler, J., Cooper, L. B., DeWald, T., Felker, G. M., Heidenreich, P., Kottam, A., Lewis, E. F., Pina, I. L., Yancy, C. W., Granger, C. B., Hernandez, A. F., DeVore, A. D. 2022

  Abstract

  BACKGROUND: Health system-level interventions to improve use of guideline-directed medical therapy (GDMT) often fail in the acute care setting. We sought to identify factors associated with high performance in adoption of GDMT among health systems in CONNECT-HF.METHODS AND RESULTS: Site-level composite quality scores were calculated at discharge and last follow-up. Site performance was defined as the average change in score from baseline to last follow-up and analyzed by performance tertile using a mixed-effects model with baseline performance as a fixed effect and site as a random effect. Among 150 randomized sites, mean 12-month improvement in GDMT was 1.8% (-26.4% to 60.0%). Achievement of ≥50% target dose for angiotensin-converting enzymes/angiotensin receptor blockers/angiotensin receptor-neprilysin inhibitors and beta blockers at 12 months was modest, even at the highest performing sites (median 29.6% [23%, 41%] and 41.2% [29%, 50%]). Sites achieving higher GDMT scores had care teams that included social workers and pharmacists and patients able to afford medications and access medication lists in the electronic health record.CONCLUSIONS: Substantial gaps in site-level use of GDMT were found even among highest performing sites. Failure of hospital-level interventions to improve quality metrics suggests that a team-based approach to care and improved patient access to medications are needed for post-discharge success.

  View details for DOI 10.1016/j.cardfail.2022.03.356

  View details for PubMedID 35462033

• Temporal trends in transcatheter aortic valve replacement use and outcomes by race, ethnicity, and sex. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions Yong, C. M., Jaluba, K., Batchelor, W., Gummipundi, S., Asch, S. M., Heidenreich, P. 2022

  Abstract

  To identify trends in transcatheter aortic valve replacement (TAVR) use and outcomes by race (non-Hispanic White, Black), ethnicity (Hispanic), and sex over time.Despite rapid growth in TAVR use over time, our understanding of its use and outcomes among males and females of underrepresented racial/ethnic groups remains limited.A retrospective analysis of hospitalizations from 2013 to 2017 from the Healthcare Cost and Utilization Project database was performed.White patients comprised 65% (n = 2.16 × 107 ) of all hospitalizations, yet they comprised 83% (n = 176,887) of the admissions for aortic stenosis (p < 0.0001). Among 91,693 hospitalizations for aortic valve replacement, 64,069 were surgical (34.0% female, 7.0% Hispanic, and 5.9% Black) and 27,624 were transcatheter (46.6% female, 4.5% Hispanic, and 4.4% Black). Growth in TAVR volumes was the slowest among minorities and females. Hispanic males, Hispanic females, and White females had the highest in-hospital mortality (2.7%-3.3%; compared to White males, adjusted odds ratio: Hispanic males 1.9 [1.2-3.0], Hispanic females 1.9 [1.2-3.1], and White females 1.4 [1.2-1.7]). Despite less baseline vascular disease, females of all races/ethnicities had more vascular complications than men (female 5% vs. male 3.5%, p ≤ 0.001). Further adjustment for vascular complications only partially attenuated mortality differences. Black and Hispanic patients had a longer mean length of hospital stay than White patients, which was most pronounced among females. Pacemaker requirements were consistently low among all groups.Differences in TAVR growth and outcomes by race, ethnicity, and sex over time highlight areas for focused efforts to close gaps in minimally invasive structural heart disease care.

  View details for DOI 10.1002/ccd.30182

  View details for PubMedID 35395131

• Performance On Guideline Directed Medical Therapy Remains Low In A Cluster-randomized Trial: Results From CONNECT-HF GRANGER, B. I., DEVORE, A. M., KALTENBACH, L. A., FONAROW, G. G., AL-KHALIDI, H. N., ALBERT, N. Y., LEWIS, E. N., BUTLER, J. D., PINA, I. A., HEIDENREICH, P. L., ALLEN, L. Y., YANCY, C. E., COOPER, L. N., FELKER, M. L., MCRAE, A. W., LANFEAR, D. D., HARRISON, R. T., DISCH, M. E., ARIELY, D. N., MILLER, J. E., GRANGER, C. R., HERNANDEZ, A. N. CHURCHILL LIVINGSTONE INC MEDICAL PUBLISHERS. 2022: S43

  View details for Web of Science ID 000788638800109

• Temporal shift and predictive performance of machine learning for heart transplant outcomes. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation Miller, R. J., Sabovcik, F., Cauwenberghs, N., Vens, C., Khush, K. K., Heidenreich, P. A., Haddad, F., Kuznetsova, T. 2022

  Abstract

  BACKGROUND: Outcome prediction following heart transplant is critical to explaining risks and benefits to patients and decision-making when considering potential organ offers. Given the large number of potential variables to be considered, this task may be most efficiently performed using machine learning (ML). We trained and tested ML and statistical algorithms to predict outcomes following cardiac transplant using the United Network of Organ Sharing (UNOS) database.METHODS: We included 59,590 adult and 8,349 pediatric patients enrolled in the UNOS database between January 1994 and December 2016 who underwent cardiac transplantation. We evaluated 3 classification and 3 survival methods. Algorithms were evaluated using shuffled 10-fold cross-validation (CV) and rolling CV. Predictive performance for 1 year and 90 days all-cause mortality was characterized using the area under the receiver-operating characteristic curve (AUC) with 95% confidence interval.RESULTS: In total, 8,394 (12.4%) patients died within 1 year of transplant. For predicting 1-year survival, using the shuffled 10-fold CV, Random Forest achieved the highest AUC (0.893; 0.889-0.897) followed by XGBoost and logistic regression. In the rolling CV, prediction performance was more modest and comparable among the models with XGBoost and Logistic regression achieving the highest AUC 0.657 (0.647-0.667) and 0.641(0.631-0.651), respectively. There was a trend toward higher prediction performance in pediatric patients.CONCLUSIONS: Our study suggests that ML and statistical models can be used to predict mortality post-transplant, but based on the results from rolling CV, the overall prediction performance will be limited by temporal shifts inpatient and donor selection.

  View details for DOI 10.1016/j.healun.2022.03.019

  View details for PubMedID 35568604

• 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology Heidenreich, P. A., Bozkurt, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., Deswal, A., Drazner, M. H., Dunlay, S. M., Evers, L. R., Fang, J. C., Fedson, S. E., Fonarow, G. C., Hayek, S. S., Hernandez, A. F., Khazanie, P., Kittleson, M. M., Lee, C. S., Link, M. S., Milano, C. A., Nnacheta, L. C., Sandhu, A. T., Stevenson, L. W., Vardeny, O., Vest, A. R., Yancy, C. W. 2022

  Abstract

  The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

  View details for DOI 10.1016/j.jacc.2021.12.011

  View details for PubMedID 35379504

• 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of cardiac failure Heidenreich, P. A., BozkurtChair, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., Deswal, A., Drazner, M. H., Dunlay, S. M., Evers, L. R., Fang, J. C., Fedson, S. E., Fonarow, G. C., Hayek, S. S., Hernandez, A. F., Khazanie, P., Kittleson, M. M., Lee, C. S., Link, M. S., Milano, C. A., Nnacheta, L. C., Sandhu, A. T., Stevenson, L. W., Vardeny, O., Vest, A. R., Yancy, C. W. 2022

  Abstract

  The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

  View details for DOI 10.1016/j.cardfail.2022.02.009

  View details for PubMedID 35378259

• Assessment of coding-based frailty algorithms for long-term outcome prediction among older people in community settings: a cohort study from the Shizuoka Kokuho Database. Age and ageing Nishimura, S., Kumamaru, H., Shoji, S., Nakatani, E., Yamamoto, H., Ichihara, N., Miyachi, Y., Sandhu, A. T., Heidenreich, P. A., Yamauchi, K., Watanabe, M., Miyata, H., Kohsaka, S. 2022; 51 (3)

  Abstract

  OBJECTIVES: To assess the applicability of Electronic Frailty Index (eFI) and Hospital Frailty Risk Score (HFRS) algorithms to Japanese administrative claims data and to evaluate their association with long-term outcomes.STUDY DESIGN AND SETTING: A cohort study using a regional government administrative healthcare and long-term care (LTC) claims database in Japan 2014-18.PARTICIPANTS: Plan enrollees aged ≥50years.METHODS: We applied the two algorithms to the cohort and assessed the scores' distributions alongside enrollees' 4-year mortality and initiation of government-supported LTC. Using Cox regression and Fine-Gray models, we evaluated the association between frailty scores and outcomes as well as the models' discriminatory ability.RESULTS: Among 827,744 enrollees, 42.8% were categorised by eFI as fit, 31.2% mild, 17.5% moderate and 8.5% severe. For HFRS, 73.0% were low, 24.3% intermediate and 2.7% high risk; 35 of 36 predictors for eFI, and 92 of 109 codes originally used for HFRS were available in the Japanese system. Relative to the lowest frailty group, the highest frailty group had hazard ratios [95% confidence interval (CI)] of 2.09 (1.98-2.21) for mortality and 2.45 (2.28-2.63) for LTC for eFI; those for HFRS were 3.79 (3.56-4.03) and 3.31 (2.87-3.82), respectively. The area under the receiver operating characteristics curves for the unadjusted model at 48months was 0.68 for death and 0.68 for LTC for eFI, and 0.73 and 0.70, respectively, for HFRS.CONCLUSIONS: The frailty algorithms were applicable to the Japanese system and could contribute to the identifications of enrollees at risk of long-term mortality or LTC use.

  View details for DOI 10.1093/ageing/afac009

  View details for PubMedID 35231096

• Clinical Outcomes With Metformin and Sulfonylurea Therapies Among Patients With Heart Failure and Diabetes JACC-HEART FAILURE Khan, M., Solomo, N., DeVore, A. D., Sharma, A., Felke, G., Hernandez, A. F., Heidenreich, P. A., Matsouaka, R. A., Green, J. B., Butler, J., Yancy, C. W., Peterson, P. N., Fonarow, G. C., Greene, S. J. 2022; 10 (3): 198-210

  Abstract

  The authors sought to characterize associations between initiation of metformin and sulfonylurea therapy and clinical outcomes among patients with comorbid heart failure (HF) and diabetes (overall and by ejection fraction [EF] phenotype).Metformin and sulfonylureas are frequently prescribed to patients with diabetes for glycemic control. The impact of these therapies on clinical outcomes among patients with comorbid HF and diabetes is unclear.The authors evaluated Medicare beneficiaries hospitalized for HF in the Get With The Guidelines-Heart Failure Registry between 2006 and 2014 with diabetes and not prescribed metformin or sulfonylurea before admission. In parallel separate analyses for metformin and sulfonylurea, patients with newly prescribed therapy within 90 days of discharge were compared with patients not prescribed therapy. Multivariable models landmarked at 90 days evaluated associations between prescription of therapy, and mortality and hospitalization for HF (HHF) at 12 months. Negative control (falsification) endpoints included hospitalization for urinary tract infection, hospitalization for gastrointestinal bleed, and influenza vaccination. Prespecified subgroup analyses were stratified by EF ≤40% versus >40%.Of 5,852 patients, 454 (7.8%) were newly prescribed metformin and 504 (8.6%) were newly prescribed sulfonylurea. After adjustment, metformin prescription was independently associated with reduced risk of composite mortality/HHF (HR: 0.81; 95% CI: 0.67-0.98; P = 0.03), but individual components were not statistically significant. Findings among patients with EF >40% accounted for associations with mortality/HHF (HR: 0.68; 95% CI: 0.52-0.90) and HHF (HR: 0.58; 95% CI: 0.40-0.85) endpoints (all P for interaction ≤0.04). After adjustment, sulfonylurea initiation was associated with increased risk of mortality (HR: 1.24; 95% CI: 1.00-1.52; P = 0.045) and HHF (HR: 1.22; 95% CI: 1.00-1.48; P = 0.050) with nominal statistical significance. Associations between sulfonylurea initiation and endpoints were consistent regardless of EF (all P for interaction >0.11). Neither metformin initiation nor sulfonylurea initiation were associated with negative control endpoints.In this population of older U.S. adults hospitalized for HF with comorbid diabetes, metformin initiation was independently associated with substantial improvements in 12-month clinical outcomes, driven by findings among patients with EF >40%. By contrast, sulfonylurea initiation was associated with excess risk of death and HF hospitalization, regardless of EF.

  View details for DOI 10.1016/j.jchf.2021.11.001

  View details for Web of Science ID 000785068800007

  View details for PubMedID 34895861

• Changes in telemedicine use and ambulatory visit volumes at a multispecialty cardiovascular center during the COVID-19 pandemic. Journal of telemedicine and telecare Kalwani, N. M., Osmanlliu, E., Parameswaran, V., Qureshi, L., Dash, R., Heidenreich, P. A., Scheinker, D., Rodriguez, F. 1800: 1357633X211073428

  Abstract

  Early in the COVID-19 pandemic, cardiology clinics rapidly implemented telemedicine to maintain access to care. Little is known about subsequent trends in telemedicine use and visit volumes across cardiology subspecialties. We conducted a retrospective cohort study including all patients with ambulatory visits at a multispecialty cardiovascular center in Northern California from March 2019 to February 2020 (pre-COVID) and March 2020 to February 2021 (COVID). Telemedicine use increased from 3.5% of visits (1200/33,976) during the pre-COVID period to 63.0% (21,251/33,706) during the COVID period. Visit volumes were below pre-COVID levels from March to May 2020 but exceeded pre-COVID levels after June 2020, including when local COVID-19 cases peaked. Telemedicine use was above 75% of visits in all cardiology subspecialties in April 2020 and stabilized at rates ranging from over 95% in electrophysiology to under 25% in heart transplant and vascular medicine. From June 2020 to February 2021, subspecialties delivering a greater percentage of visits through telemedicine experienced larger increases in new patient visits (r=0.81, p=0.029). Telemedicine can be used to deliver a significant proportion of outpatient cardiovascular care though utilization varies across subspecialties. Higher rates of telemedicine adoption may increase access to care in cardiology clinics.

  View details for DOI 10.1177/1357633X211073428

  View details for PubMedID 35108126

• Association of Neighborhood Income with Clinical Outcomes Among Pregnant Patients with Cardiac Disease Reproductive Sciences Carland, C., Panelli, D. M., Leonard, S. A., Bryant, E., Sherwin , E. B., Lee, C. J., Levin, E., Jimenez , S., Tremmel, J. A., Tsai , S., Heidenreich , P. A., Bianco , K., Khandelwal , A. 2022

  View details for DOI 10.1007/s43032-022-00978-z

• Structural Patterns in Chronic Disease Clinical Practice Guidelines Formalized for Clinical Decision Support. AMIA ... Annual Symposium proceedings. AMIA Symposium Tu, S. W., Podchiyska, T., Oshiro, C., Martins, S., Ashcraft, M., Chambers, J., Robinson, A., Heidenreich, P., Goldstein, M. K. 2022; 2022: 1081-1090

  Abstract

  Making recommendations from clinical practice guidelines (CPGs) computable for clinical decision support (CDS) has typically been a laborious and costly process. Identifying domain-specific regularities helps clinicians and knowledge engineers conceptualize, extract, and encode evidence-based recommendations. Based on our work to provide complex CDS in the management of multiple chronic diseases, we propose nine chronic disease CPG structural patterns, discuss considerations in representing the necessary knowledge, and illustrate them with the solutions that our CDS system provides.

  View details for PubMedID 37128390

• Variability in Coronary Artery Disease Testing for Patients With New-Onset Heart Failure. Journal of the American College of Cardiology Zheng, J., Heidenreich, P. A., Kohsaka, S., Fearon, W. F., Sandhu, A. T. 2022; 79 (9): 849-860

  Abstract

  Coronary artery disease (CAD) is the most common cause of new-onset heart failure (HF). Although guidelines recommend ischemic evaluation in this population, testing has historically been underutilized.This study aimed to identify contemporary trends in CAD testing for patients with new-onset HF, particularly after publication of the STICHES (Surgical Treatment for Ischemic Heart Failure Extension Study), and to characterize geographic and clinician-level variability in testing patterns.We determined the proportion of patients with incident HF who received CAD testing from 2004 to 2019 using an administrative claims database covering commercial insurance and Medicare. We identified demographic and clinical predictors of CAD testing during the 90 days before and after initial diagnosis. Patients were grouped by their county of residence to assess national variation. Patients were then linked to their primary care physician and/or cardiologist to evaluate variation across clinicians.Among 558,322 patients with new-onset HF, 34.8% underwent CAD testing and 9.3% underwent revascularization. After multivariable adjustment, patients who underwent CAD testing were more likely to be younger, male, diagnosed in an acute care setting, and have systolic dysfunction or recent cardiogenic shock. Incidence of CAD testing remained flat without significant change post-STICHES. Covariate-adjusted testing rates varied from 20% to 45% across counties. The likelihood of testing was higher among patients co-managed by a cardiologist (adjusted OR: 5.12; 95% CI: 4.98-5.27) but varied substantially across cardiologists (IQR: 50.9%-62.4%).Most patients with new-onset HF across inpatient and outpatient settings did not receive timely testing for CAD. Substantial variability in testing persists across regions and clinicians.

  View details for DOI 10.1016/j.jacc.2021.11.061

  View details for PubMedID 35241218

• Harnessing the Potential of Primary Care Pharmacists to Improve Heart Failure Management JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY Slade, J., Lee, M., Park, J., Liu, A., Heidenreich, P., Allaudeen, N. 2022; 48 (1): 25-32

  Abstract

  Improved utilization of guideline-directed medical therapy (GDMT) in the management of heart failure with reduced ejection fraction (HFrEF) can reduce mortality, reduce heart failure hospitalizations, and improve quality of life. Despite well-established clinical guidelines, these therapies remain significantly underprescribed. The goal of this intervention was to increase prescribing of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB), angiotensin receptor neprilysin inhibitor (ARNI), and beta-blockers at ≥ 50% target doses.The study team identified key drivers to adequate dosing of GDMT: (1) frequent and reliable follow-up visits for titration opportunities, (2) identification of actionable patients for therapy initiation and titration, and (3) reduction in prescribing practice variability. The interventions were implemented at an outpatient clinical site and consisted of three main components: (1) establishing a pharmacist-led heart failure medication titration clinic, (2) creation of a standardized titration protocol, and (3) utilization of a patient dashboard to identify eligible patients.For patients seen in the titration clinic, in 14 months, the mean dose per patient increased from 31.3% to 70.5% of target dose for ACEI/ARB/ARNI, and from 45.8% to 85.4% for beta-blockers. At this clinical site, the percentage of HFrEF patients receiving > 50% of targeted dose increased from 39.7% to 46.7% for ACEI/ARB/ARNI, and from 39.5% to 42.9% for beta-blockers. For ACEI/ARB/ARNI, use of target doses was 5.9% higher (95% confidence interval [CI] = 3.6%-8.3%, p < 0.0001) for the intervention site, 0.2% higher (95% CI = -2.2%-2.5%, p = 0.89) during the intervention period, and 10.4% higher (95% CI = 6.9%-13.9%, p < 0.0001) for the interaction (intervention site during the intervention time period). For beta-blockers, use of target doses was 1.0% higher (95% CI = -0.6%-2.6%, p = 0.20) for the intervention site, 0.8% lower (95% CI = -2.4%-0.8%, p = 0.29) for the intervention period, and 5.8% higher (95% CI = 3.5%-8.1%, p < 0.0001) for the interaction (intervention site during the intervention time period).Through this project's interventions, the prescribing of ACEI/ARB/ARNI and beta-blocker therapy at ≥ 50% target doses for patients with HFrEF was increased. This study demonstrates the value of a multifaceted, team-based approach that integrates population-level interventions such as clinical dashboard management with a pharmacist-led heart failure medication titration clinic.

  View details for DOI 10.1016/j.jcjq.2021.10.004

  View details for Web of Science ID 000740813000005

  View details for PubMedID 34848159

• Perks and Pitfalls of Performance-Linked Reimbursement for Novel Drugs: The Case of Sacubitril-Valsartan. Circulation. Cardiovascular quality and outcomes Sandhu, A. T., Heidenreich, P. A., Lin, J., Parizo, J., Bhattacharya, J., Goldhaber-Fiebert, J. D. 1800; 15 (1): e007993

  Abstract

  BACKGROUND: Rising drug costs have increased interest in performance-linked reimbursement (PLR) contracts that tie payment to patient outcomes. PLR is theoretically attractive to payers interested in reducing the risk of overpaying for expensive drugs, to manufacturers working to improve early drug adoption, and to patients seeking improved access. Multiple PLR contracts were developed for sacubitril-valsartan. We evaluated how the characteristics of a PLR contract influence its performance.METHODS: We used a published cost-effectiveness model of sacubitril-valsartan. We evaluated hypothetical PLR contracts that adjusted drug payment based on observed therapy effectiveness. Ideally, these contracts reduce the uncertainty around the value obtained with purchasing sacubitril-valsartan. By reducing the financial risk in covering an ineffective therapy, PLR incentivizes insurers to increase patient access. We measured the uncertainty in value as the SD of the incremental net monetary benefit (INMB), an estimate of therapy value incorporating costs and clinical benefits. We evaluated the change in INMB SD under a variety of different assumptions regarding contract design, therapy effectiveness, and population characteristics.RESULTS: Over 2 years, sacubitril-valsartan led to 0.042 additional quality-adjusted life-years at an incremental cost of $4916. Using a willingness-to-pay of $150000 per quality-adjusted life-year, this led to a mean INMB across simulations of $1416 (SD, $1720). A PLR contract that adjusted payment based on cardiovascular mortality reduced the INMB SD moderately by 20.7% while a contract based on all-cause mortality was more effective (INMB SD reduction of 27.3%). A contract based on heart failure hospitalization reduction was ineffective. PLR effectiveness increased with greater uncertainty regarding therapy effectiveness or in sicker cohorts (eg, New York Heart Association Class III/IV heart failure). Contracts required precise estimates of treatment effect in addition to trust or verifiability between manufacturers and payers concerning patient selection.CONCLUSIONS: The development of accurate prospective estimates of treatment effectiveness using actual enrollee characteristics will be critical for successful PLR. If able to meet these requirements, PLRs could incentivize insurers to expand access to expensive treatments by reducing financial risk.

  View details for DOI 10.1161/CIRCOUTCOMES.121.007993

  View details for PubMedID 35041480

• Cost and Value in Contemporary Heart Failure Clinical Guidance Documents. JACC. Heart failure Ostrominski, J. W., Hirji, S., Bhatt, A. S., Butler, J., Fiuzat, M., Fonarow, G. C., Heidenreich, P. A., Januzzi, J. L., Lam, C. S., Maddox, T. M., O'Connor, C. M., Vaduganathan, M. 1800; 10 (1): 1-11

  Abstract

  OBJECTIVES: This study sought to evaluate the frequency and nature of cost/value statements in contemporary heart failure (HF) clinical guidance documents (CGDs).BACKGROUND: In an era of rising health care costs and expanding therapeutic options, there is an increasing need for formal consideration of cost and value in the development of HF CGDs.METHODS: HF CGDs published by major professional cardiovascular organizations between January 2010 and February 2021 were reviewed for the inclusion of cost/value statements.RESULTS: Overall, 33 documents were identified, including 5 (15%) appropriate use criteria, 7 (21%) clinical practice guidelines, and 21 (64%) expert consensus documents. Most CGDs (27 of 33; 82%) included at least 1 cost/value statement, and 20 (61%) CGDs included at least 1 cost/value-related citation. Most of these statements were found in expert consensus documents (77.7%). Three (9%) documents reported estimated costs of recommended interventions, but only 1 estimated out-of-pocket cost. Of 179 cost/value-related statements observed, 116 (64.8%) highlighted the economic impact of HF or HF-related care, 6 (3.4%) advocated for cost/value issues, 15 (8.4%) reported gaps in cost/value evidence, and 42 (23.5%) supported clinical guidance recommendations. Over time, patterns of inclusion of statements and citations of cost/value have been largely stable.CONCLUSIONS: Although most contemporary HF CGDs contain at least 1 cost/value statement, most CGDs focus on the high economic impact of HF and its related care; explicit inclusion of cost/value to support clinical guidance recommendations remains infrequent. These results highlight key opportunities for the integration of formalized cost/value considerations infuture HF-focused CGDs.

  View details for DOI 10.1016/j.jchf.2021.08.002

  View details for PubMedID 34969491

• Achievement and Quality Measure Attainment in Patients Hospitalized with Atrial Fibrillation: Results from the Get With The Guidelines - Atrial Fibrillation (GWTG-AFIB) Registry. American heart journal Ullal, A. J., Holmes, D. N., Lytle, B. L., Matsouaka, R. A., Sheng, S., Desai, N. R., Curtis, A. B., Fang, M. C., McCabe, P. J., Fonarow, G. C., Russo, A. M., Lewis, W. R., Heidenreich, P. A., Piccini, J. P., Turakhia, M. P., Perino, A. C., On Behalf Of The Gwtg-Afib Working Group 1800

  Abstract

  BACKGROUND: The Get With The Guidelines - Atrial Fibrillation (GWTG-AFIB) Registry uses achievement and quality measures to improve the care of patients with atrial fibrillation (AF). We sought to evaluate overall and site-level variation in attainment of these measures among sites participating in the GWTG-AFIB Registry.METHODS: From the GWTG-AFIB registry, we included patients with AF admitted between 1/3/2013 and 6/30/2019. We described patient-level attainment and variation in attainment across sites of 6 achievement measures with 1) defect-free scores (percent of patients with all eligible measures attained), and 2) composite opportunity scores (percent of all eligible patient measures attained). We also described attainment of 11 quality measures at the patient-level.RESULTS: Among 80,951 patients hospitalized for AF (age 70±13 years, 47.0% female; CHA2DS2-VASc 3.6±1.8) at 132 sites. Site-level defect-free scores ranged from 4.7% to 85.8% (25th, 50th, 75th percentile: 32.7%, 52.1%, 64.4%). Composite opportunity scores ranged from 39.4% to 97.5% (25th, 50th, 75th: 68.1%, 80.3%, 87.1%). Attainment was notably low for the following quality measures: 1) aldosterone antagonist prescription when ejection fraction ≤35% (29% of those eligible); and 2) avoidance of antiplatelet therapy with OAC in patients without coronary/peripheral artery disease (81% of those eligible).CONCLUSION: Despite high overall attainment of care measures across GWTG-AFIB registry sites, large site variation was present with meaningful opportunities to improve AF care beyond OAC prescription, including but not limited to prescription of aldosterone antagonists in those with AF and systolic dysfunction and avoidance of non-indicated adjunctive antiplatelet therapy.

  View details for DOI 10.1016/j.ahj.2021.12.002

  View details for PubMedID 34932998

• Utilization of Generic Cardiovascular Drugs in Medicare's Part D Program. Circulation. Cardiovascular quality and outcomes Ma, I., Tisdale, R. L., Vail, D., Heidenreich, P. A., Sandhu, A. T. 2021: CIRCOUTCOMES120007559

  Abstract

  BACKGROUND: Generic medications cost less than brand-name medications and are similarly effective, but brand-name medications are still prescribed. We evaluated patterns in generic cardiovascular medication fills and estimated the potential cost savings with increased substitution of generic for brand-name medications.METHODS: This was a cross-sectional study of cardiovascular therapies using the Medicare Part D database of prescription medications in 2017. We evaluated drug fill patterns for therapies with available brand-name and generic options. We determined the generic substitution ratio and estimated the potential savings with increased generic substitution at the national, state, and clinician level. We compared states with laws related to mandatory pharmacist generic substitution and patient consent for substitution.RESULTS: Of $22.9 billion spent on cardiovascular drugs in Medicare Part D prescription programs in 2017, $11.0 billion was spent on medications with both brand-name and generic options. Although only 2.4% of medication fills were for the brand-name choice, they made up 21.2% of total spending. Accounting for estimated brand-name rebates, generic substitution for these medications would save $641 million, including $135 million in costs shouldered by patients. Furthermore, the minority of clinicians with the lowest generic utilization was responsible for a large proportion of the potential cost savings.CONCLUSIONS: There are substantial potential cost savings from substituting brand-name medications with generic medications. These savings would be primarily driven by lower use of brand-name therapies by the minority of clinicians who prescribe them at increased rates.

  View details for DOI 10.1161/CIRCOUTCOMES.120.007559

  View details for PubMedID 34879702

• Health Status and Cardiac Rehabilitation-Putting a Dollar Amount on Improvement JAMA CARDIOLOGY Heidenreich, P. A. 2022; 7 (2): 148-149

  View details for DOI 10.1001/jamacardio.2021.4844

  View details for Web of Science ID 000722721000003

  View details for PubMedID 34817537

• Time to Relax the 40-Year Age Threshold for Pharmacologic Cholesterol Lowering. Journal of the American College of Cardiology Heidenreich, P. A., Clarke, S. L., Maron, D. J. 2021; 78 (20): 1965-1967

  View details for DOI 10.1016/j.jacc.2021.08.072

  View details for PubMedID 34763773

• Medical Therapy Before, During, and After Hospitalization in Medicare Beneficiaries With Heart Failure and Diabetes: The Get With the Guidelines - Heart Failure Registry Bhatt, A. S., Fonarow, G. C., Greene, S. J., Holmes, D. N., Alhanti, B., Devore, A. D., Butler, J., Heidenreich, P. A., Huang, J. LIPPINCOTT WILLIAMS & WILKINS. 2021

  View details for Web of Science ID 000752020008250

• Clinical Outcomes with Metformin and Sulfonylurea Initiation Among Patients with Heart Failure and Diabetes: From Get with the Guidelines-Heart Failure Khan, M. S., Solomon, N., Devore, A. D., Sharma, A., Felker, G., Hernandez, A. F., Heidenreich, P. A., Matsouaka, R., Green, J. B., Butler, J. LIPPINCOTT WILLIAMS & WILKINS. 2021

  View details for Web of Science ID 000752020002134

• Mortality and Readmission Among Medicare Beneficiaries Hospitalized for Heart Failure Who Are Treatment Candidates for SGLT-2 Inhibitors Vaduganathan, M., Greene, S. J., Zhang, S., Chiswell, K., Devore, A. D., Butler, J., Heidenreich, P. A., Huang, J., Kittleson, M. M., Maddox, K. LIPPINCOTT WILLIAMS & WILKINS. 2021

  View details for Web of Science ID 000752020008129

• Incident Dialysis and Acute Kidney Injury Among Medicare Beneficiaries After Hospitalization for Heart Failure in the US Vaduganathan, M., Greene, S. J., Patel, R. B., Zhang, S., Chiswell, K., Devore, A. D., Butler, J., Heidenreich, P. A., Huang, J., Kittleson, M. M. LIPPINCOTT WILLIAMS & WILKINS. 2021

  View details for Web of Science ID 000752020008188

• Productivity Targets and Performance Reviews for Cardiology Practices in the Veterans Health Administration: Do They Work? Kalwani, N. M., Heidenreich, P. A. LIPPINCOTT WILLIAMS & WILKINS. 2021

  View details for Web of Science ID 000752020004291

• Systematic Quantification of Sources of Variation in Ejection Fraction Calculation Using Deep Learning JACC-CARDIOVASCULAR IMAGING Yuan, N., Jain, I., Rattehalli, N., He, B., Pollick, C., Liang, D., Heidenreich, P., Zou, J., Cheng, S., Ouyang, D. 2021; 14 (11): 2360-2362

  View details for DOI 10.1016/j.jcmg.2021.06.018

  View details for Web of Science ID 000729265200029

  View details for PubMedID 34274282

• Interventions to Increase Leukocyte Testing during Treatment with Dimethyl Fumarate. International journal of environmental research and public health Heidenreich, P. A., Lin, S., Gholami, P., Moore, V. R., Burk, M. L., Glassman, P. A., Cunningham, F. E., Sahay, A. 2021; 18 (19)

  Abstract

  Dimethyl fumarate (DMF), a treatment for multiple sclerosis, may cause leukopenia and infection. Accordingly, periodic white blood cell (WBC) monitoring is recommended. We sought to evaluate the US Department of Veteran Affairs' safety program which provides facilities with a list of patients prescribed DMF therapy without a documented white blood cell count (WBC). We identified 118 sites with patients treated with DMF from 1 January 2016 through 30 September 2016. Each site was asked if any of seven interventions were used to improve WBC monitoring (academic detailing, provider education without academic detailing, electronic clinical reminders, request for provider action plan, draft orders for WBC monitoring, patient mailings, and patient calls). The survey response rate was 78%. For the 92 responding sites (78%) included sites (1115 patients) the mean rate of WBC monitoring was 54%. In multivariate analysis, academic detailing increased the rate by 17% (95% CI 4 to 30%, p = 0.011) and provider education increased the rate by 9% (95% CI 0.6 to 18%, p = 0.037). The WBC monitoring rate increased by 3.8% for each additional intervention used (95% CI 1.2-6.4%, p = 0.005). Interventions focused on the physician, including academic detailing, were associated with improved WBC monitoring for patients at risk for leukopenia from DMF treatment.

  View details for DOI 10.3390/ijerph181910312

  View details for PubMedID 34639610

• High-Intensity Statins Benefit High-Risk Patients: Why and How to Do Better. Mayo Clinic proceedings Grundy, S. M., Stone, N. J., Blumenthal, R. S., Braun, L. T., Heidenreich, P. A., Lloyd-Jones, D., Orringer, C. E., Saseen, J. J., Smith, S. C., Sperling, L. S., Virani, S. S. 2021

  Abstract

  Review of the US and European literature indicates that most patients at high risk for atherosclerotic cardiovascular disease (ASCVD are not treated with high-intensity statins, despite strong clinical-trial evidence of maximal statin benefit. High-intensity statins are recommended for 2 categories of patients: those with ASCVD (secondary prevention) and high-risk patients without clinical ASCVD. Most patients with ASCVD are candidates for high-intensity statins, with a goal for low-density lipoprotein cholesterol reduction of 50% or greater. A subgroup of patients with ASCVD are at very high risk and can benefit by the addition of nonstatin drugs (ezetimibe with or without bile acid sequestrant or bempedoic acid and/or a proprotein convertase subtilisin/kexin type 9 inhibitor). High-risk primary prevention patients are those with severe hypercholesterolemia, diabetes with associated risk factors, and patients aged 40 to 75 years with a 10-year risk for ASCVD of 20% or greater. In patients with a 10-year risk of 7.5% to less than 20%, coronary artery calcium scoring is an option; if the coronary artery calcium score is 300 or more Agatston units, the patient can be up-classified to high risk. If high-intensity statin treatment is not tolerated in high-risk patients, a reasonable approach is to combine a moderate-intensity statin with ezetimibe. In very high-risk patients, proprotein convertase subtilisin/kexin type 9 inhibitors lower low-density lipoprotein cholesterol levels substantially and hence reduce risk as well.

  View details for DOI 10.1016/j.mayocp.2021.02.032

  View details for PubMedID 34531060

• Medicare in the Age of COVID: A Case Study in HFSA Advocacy JOURNAL OF CARDIAC FAILURE Heidenreich, P., Jasak, B., HFSA Advocacy Comm 2021; 27 (9): 1039-1040

  View details for DOI 10.1016/j.cardfail.2021.08.005

  View details for Web of Science ID 000694741900019

  View details for PubMedID 34507803

• Inpatient versus outpatient intravenous diuresis for the acute exacerbation of chronic heart failure IJC HEART & VASCULATURE Halatchev, I. G., Wu, W., Heidenreich, P. A., Djukic, E., Balasubramanian, S., Ohlms, K. B., McDonald, J. R. 2021; 36: 100860

  Abstract

  We established an IV outpatient diuresis (IVOiD) clinic and conducted a quality improvement project to evaluate safety, effectiveness and costs associated with outpatient versus inpatient diuresis for patients presenting with acute decompensated heart failure (ADHF) to the emergency department (ED).Patients who were clinically diagnosed with ADHF in the ED, but did not have high-risk features, were either diuresed in the hospital or in the outpatient IVOiD clinic. The dose of IV diuretic was based on their home maintenance diuretic dose. The outcomes measured were the effects of diuresis (urine output, weight, hemodynamic and laboratory abnormalities), 30-90 day readmissions, 30-90 day death and costs.In total, 36 patients (22 inpatients and 14 outpatients) were studied. There were no significant differences in the baseline demographics between groups. The average inpatient stay was six days and the average IVOiD clinic days were 1.2. There was no significant difference in diuresis per day of treatment (1159 vs. 944 ml, p = 0.46). There was no significant difference in adverse outcomes, 30-90 day readmissions or 30-90 day deaths. There was a significantly lower cost in the IVOiD group compared to the inpatient group ($839.4 vs. $9895.7, p=<0.001).Outpatient IVOiD clinic diuresis may be a viable alternative to accepted clinical practice of inpatient diuresis for ADHF. Further studies are needed to validate this in a larger cohort and in different sites.

  View details for DOI 10.1016/j.ijcha.2021.100860

  View details for Web of Science ID 000704337200011

  View details for PubMedID 34485679

  View details for PubMedCentralID PMC8391052

• Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) guidelines for management of dyslipidemia and cardiovascular disease risk reduction: Putting evidence in context. Progress in cardiovascular diseases Al Rifai, M., Blumenthal, R. S., Stone, N. J., Schofield, R. S., Orringer, C. E., Michos, E. D., Heidenreich, P. A., Braun, L., Birtcher, K. K., Smith, S. C., Nambi, V., Grundy, S., Virani, S. S. 2021

  Abstract

  Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of morbidity and mortality in the United States (U.S.) and incurs significant cost to the healthcare system. Management of cholesterol remains central for ASCVD prevention and has been the focus of multiple national guidelines. In this review, we compare the American Heart Association (AHA)/American College of Cardiology (ACC) and the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) Cholesterol guidelines. We review the evidence base that was used to generate recommendations focusing on 4 distinct themes: 1) the threshold of absolute 10-year ASCVD risk to start a clinician-patient discussion for the initiation of statin therapy in primary prevention patients; 2) the utility of coronary artery calcium score to guide clinician-patient risk discussion pertaining to the initiation of statin therapy for primary ASCVD prevention; 3) the use of moderate versus high-intensity statin therapy in patients with established ASCVD; and 4) the utility of ordering lipid panels after initiation or intensification of lipid lowering therapy to document efficacy and monitor adherence to lipid lowering therapy. We discuss why the VA/DoD and AHA/ACC may have reached different conclusions on these key issues.

  View details for DOI 10.1016/j.pcad.2021.08.001

  View details for PubMedID 34371083

• Clinical Effectiveness of Sacubitril/Valsartan Among Patients Hospitalized for Heart Failure With Reduced Ejection Fraction. Journal of the American Heart Association Greene, S. J., Choi, S., Lippmann, S. J., Mentz, R. J., Greiner, M. A., Hardy, N. C., Hammill, B. G., Luo, N., Samsky, M. D., Heidenreich, P. A., Laskey, W. K., Yancy, C. W., Peterson, P. N., Curtis, L. H., Hernandez, A. F., Fonarow, G. C., O'Brien, E. C. 2021: e021459

  Abstract

  Background Sacubitril/Valsartan has been highly efficacious in randomized trials of heart failure with reduced ejection fraction (HFrEF). However, the effectiveness of sacubitril/valsartan in older patients hospitalized for HFrEF in real-world US practice is unclear. Methods and Results This study included Medicare beneficiaries age ≥65years who were hospitalized for HFrEF ≤40% in the Get With The Guidelines-Heart Failure registry between October 2015 and December 2018, and eligible for sacubitril/valsartan. Associations between discharge prescription of sacubitril/valsartan and clinical outcomes were assessed after inverse probability of treatment weighting and adjustment for other HFrEF medications. Overall, 1551 (10.9%) patients were discharged on sacubitril/valsartan. Of those not prescribed sacubitril/valsartan, 7857 (62.0%) were prescribed an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker. Over 12-month follow-up, compared with a discharge prescription of angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker, sacubitril/valsartan was independently associated with lower all-cause mortality (adjusted hazard ratio [HR], 0.82; 95% CI, 0.72-0.94; P=0.004) but not all-cause hospitalization (adjusted HR, 0.97; 95% CI, 0.89-1.07; P=0.55) or heart failure hospitalization (adjusted HR, 1.04; 95% CI, 0.91-1.18; P=0.59). Patients prescribed sacubitril/valsartan versus those without a prescription had lower risk of all-cause mortality (adjusted HR, 0.69; 95% CI, 0.60-0.79; P<0.001), all-cause hospitalization (adjusted HR, 0.90; 95% CI, 0.82-0.98; P=0.02), but not heart failure hospitalization (adjusted HR, 0.94; 95% CI, 0.82-1.08; P=0.40). Conclusions Among patients hospitalized for HFrEF, prescription of sacubitril/valsartan at discharge was independently associated with reduced postdischarge mortality compared with angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker, and reduced mortality and all-cause hospitalization compared with no sacubitril/valsartan. These findings support the use of sacubitril/valsartan to improve postdischarge outcomes among older patients hospitalized for HFrEF in routine US clinical practice.

  View details for DOI 10.1161/JAHA.121.021459

  View details for PubMedID 34350772

• Evidence-to-Practice Gap for Preventing Procedure-Related Acute Kidney Injury in Patients Undergoing Percutaneous Coronary Intervention. Journal of the American Heart Association Shoji, S., Sawano, M., Sandhu, A. T., Heidenreich, P. A., Shiraishi, Y., Noma, S., Suzuki, M., Numasawa, Y., Fukuda, K., Kohsaka, S. 2021; 10 (15): e020047

  Abstract

  Background Acute kidney injury (AKI) is a common complication of percutaneous coronary intervention. This risk can be minimized with reduction of contrast volume via preprocedural risk assessment. We aimed to identify quality gaps for implementing the available risk scores introduced to facilitate more judicious use of contrast volume. Methods and Results We grouped 14702 patients who underwent percutaneous coronary intervention according to the calculated NCDR (National Cardiovascular Data Registry) AKI risk score quartiles (Q1 [lowest]-Q4 [highest]). We compared the used contrast volume by the baseline renal function and NCDR AKI risk score quartiles. Factors associated with increased contrast volume usage were determined using multivariable linear regression analysis. The overall incidence of AKI was 8.9%. The used contrast volume decreased in relation to the stages of chronic kidney disease (168 mL [SD, 73.8 mL], 161 mL [SD, 75.0 mL], 140 mL [SD, 70.0 mL], and 120 mL [SD, 73.7 mL] for no, mild, moderate, and severe chronic kidney disease, respectively; P<0.001), albeit no significant correlation was observed with the calculated NCDR AKI risk quartiles. Of the variables included in the NCDR AKI risk score, anemia (7.31 mL [1.76-12.9 mL], P=0.01), heart failure on admission (10.2 mL [6.05-14.3 mL], P<0.001), acute coronary syndrome presentation (10.3 mL [7.87-12.7 mL], P<0.001), and use of an intra-aortic balloon pump (17.7 mL [3.9-31.5 mL], P=0.012) were associated with increased contrast volume. Conclusions The contrast volume was largely determined according to the baseline renal function, not the patients' overall AKI risk. These findings highlight the importance of comprehensive risk assessment to minimize the contrast volume used in susceptible patients.

  View details for DOI 10.1161/JAHA.120.020047

  View details for PubMedID 34310187

• Safety and effectiveness of prophylactic anticoagulation for prevention of COVID-19 mortality: A nationwide cohort study of hospitalised patients in the US Rentsch, C. T., Beckman, J. A., Tomlinson, L., Gellad, W. F., Alcorn, C., Kidwai-Khan, F., Skanderson, M., Brittain, E., King, J. T., Ho, Y., Eden, S., Kundu, S., Lann, M. F., Greevy, R. A., Ho, P., Heidenreich, P. A., Jacobson, D. A., Douglas, I. J., Tate, J. P., Evans, S. W., Atkins, D., Justice, A. C., Freiberg, M. S. WILEY. 2021: 80

  View details for Web of Science ID 000687807300159

• Disparity in the Setting of Incident Heart Failure Diagnosis. Circulation. Heart failure Sandhu, A. T., Tisdale, R. L., Rodriguez, F., Stafford, R. S., Maron, D. J., Hernandez-Boussard, T., Lewis, E., Heidenreich, P. A. 2021: CIRCHEARTFAILURE121008538

  Abstract

  BACKGROUND: Early heart failure (HF) recognition can reduce morbidity, yet HF is often initially diagnosed only after a patient clinically worsens. We sought to identify characteristics that predict diagnosis in the acute care setting versus the outpatient setting.METHODS: We estimated the proportion of incident HF diagnosed in the acute care setting (inpatient hospital or emergency department) versus outpatient setting based on diagnostic codes from a claims database covering commercial insurance and Medicare Advantage between 2003 and 2019. After excluding new-onset HF potentially caused by a concurrent acute cause (eg, acute myocardial infarction), we identified demographic, clinical, and socioeconomic predictors of diagnosis setting. Patients were linked to their primary care clinicians to evaluate diagnosis setting variation across clinicians.RESULTS: Of 959 438 patients with new HF, 38% were diagnosed in acute care. Of these, 46% had potential HF symptoms in the prior 6 months. Over time, the relative odds of acute care diagnosis increased by 3.2% annually after adjustment for patient characteristics (95% CI, 3.1%-3.3%). Acute care diagnosis setting was more likely for women compared with men (adjusted odds ratio, 1.11 [95% CI, 1.10-1.12]) and for Black patients compared with White patients (adjusted odds ratio, 1.18 [95% CI, 1.16-1.19]). The proportion of acute care diagnosis varied substantially (interquartile range: 24%-39%) among clinicians after adjusting for patient-level risk factors.CONCLUSIONS: A large proportion of first HF diagnoses occur in the acute care setting, particularly among women and Black patients, yet many had potential HF symptoms in the months before acute care visits. These results raise concerns that many HF diagnoses are missed in the outpatient setting. Earlier diagnosis could allow for timelier high-value interventions, addressing disparities and reducing the progression of HF.

  View details for DOI 10.1161/CIRCHEARTFAILURE.121.008538

  View details for PubMedID 34311559

• DISPARITIES IN VIRTUAL CARDIOLOGY VISITS AMONG VETERANS HEALTH ADMINISTRATION PATIENTS DURING THE COVID-19 PANDEMIC Tisdale, R. L., Ferguson, J. M., Van Campen, J., Greene, L., Sandhu, A., Heidenreich, P., Zulman, D. SPRINGER. 2021: S168

  View details for Web of Science ID 000679443300404

• Availability of Cost-effectiveness Studies for Drugs With High Medicare Part D Expenditures. JAMA network open Tisdale, R. L., Ma, I., Vail, D., Bhattacharya, J., Goldhaber-Fiebert, J. D., Heidenreich, P. A., Sandhu, A. T. 2021; 4 (6): e2113969

  Abstract

  Importance: Prescription drug spending in the US requires policy intervention to control costs and improve the value obtained from pharmaceutical spending. One such intervention is to apply cost-effectiveness evidence to decisions regarding drug coverage and pricing, but this intervention depends on the existence of such evidence to guide decisions.Objective: To characterize the availability and quality of cost-effectiveness studies for prescription drugs with the greatest Medicare Part D spending.Design, Setting, and Participants: In this national cross-sectional analysis, publicly available 2016 Medicare drug spending records were merged with 2016 US Food & Drug Administration Orange Book data and the Tufts Medical Center Cost-Effectiveness Analysis (CEA) Registry. All studies published through 2015 that evaluated the cost-effectiveness of the 250 drugs for which Medicare Part D spending was the greatest in US-based adult patient populations were included. Data were analyzed from September 2018 to June 2020.Main Outcomes and Measures: The presence and quality of published cost-effectiveness analyses for the 250 drugs for which Medicare Part D spending was greatest in 2016 were assessed based on the inclusion of key cost-effectiveness analysis elements and global ratings by independent reviewers for the Tufts CEA Registry.Results: Medicare Part D spending on the 250 drugs in the sample totaled $122.8 billion in 2016 (84.1% of total spending). Of these 250 drugs, 91 (36.4%) had a generic equivalent and 159 (63.6%) retained some patent exclusivity. There were 280 unique cost-effectiveness analyses for these drugs, representing data on 135 (54.0%) of the 250 drugs included and 67.0% of Part D spending on the top 250 drugs. The 115 drugs (46.0%) without cost-effectiveness studies accounted for 33.0% of Part D spending on the top 250 drugs. Of the 280 available studies, 128 (45.7%) were industry sponsored. A large proportion of the studies (250 [89.3%]) did not meet the minimum quality requirements.Conclusions and Relevance: In this cross-sectional study, a substantial proportion of 2016 Medicare Part D spending was for drugs with absent or low-quality cost-effectiveness analyses. The lack of quality analyses may present a challenge in efforts to develop policies addressing drug spending in terms of value.

  View details for DOI 10.1001/jamanetworkopen.2021.13969

  View details for PubMedID 34143189

• Cost-effectiveness of Dapagliflozin for Treatment of Patients With Heart Failure With Reduced Ejection Fraction. JAMA cardiology Parizo, J. T., Goldhaber-Fiebert, J. D., Salomon, J. A., Khush, K. K., Spertus, J. A., Heidenreich, P. A., Sandhu, A. T. 2021

  Abstract

  Importance: In the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF) trial, dapagliflozin was shown to reduce cardiovascular mortality and hospitalizations due to heart failure while improving patient-reported health status. However, the cost-effectiveness of adding dapagliflozin therapy to standard of care (SOC) is unknown.Objective: To estimate the cost-effectiveness of dapagliflozin therapy among patients with chronic heart failure with reduced ejection fraction (HFrEF).Design, Setting, and Participants: This Markov cohort cost-effectiveness model used estimates of therapy effectiveness, transition probabilities, and utilities from the DAPA-HF trial and other published literature. Costs were derived from published sources. Patients with HFrEF included subgroups based on diabetes status and health status impairment due to heart failure. We compiled parameters from the literature including DAPA-HF, on which our model is based, and many other sources from December 2019 to February 27, 2021. We performed our analysis in February 2021.Exposures: Dapagliflozin or SOC.Main Outcomes and Measures: Hospitalizations for heart failure, life-years, quality-adjusted life-years (QALYs), costs, and the cost per QALY gained (incremental cost-effectiveness ratio).Results: In the model, dapagliflozin therapy yielded a mean of 0.78 additional life-years and 0.46 additional QALYs compared with SOC at an incremental cost of $38 212, resulting in a cost per QALY gained of $83 650. The cost per QALY was similar for patients with or without diabetes and for patients with mild or moderate impairment of health status due to heart failure. The cost-effectiveness was most sensitive to estimates of the effect on mortality and duration of therapy effectiveness. If the cost of dapagliflozin decreased from $474 to $270 (43% decline), the cost per QALY gained would drop below $50 000.Conclusions and Relevance: These findings suggest that dapagliflozin provides intermediate value compared with SOC, based on American College of Cardiology/American Heart Association benchmarks. Additional data regarding the magnitude of mortality reduction would improve the precision of cost-effectiveness estimates.

  View details for DOI 10.1001/jamacardio.2021.1437

  View details for PubMedID 34037681

• CLINICAL PROFILES, MEDICAL THERAPIES, AND OUTCOMES AMONG PATIENTS HOSPITALIZED FOR HF ACROSS THE SPECTRUM OF KIDNEY FUNCTION: THE GWTG-HF REGISTRY Patel, R. B., Fonarow, G., Greene, S., Zhang, S., Alhanti, B., DeVore, A., Butler, J., Heidenreich, P., Huang, J., Kittleson, M., Maddox, K., McDermott, J., Owens, A., Peterson, P., Solomon, S., Vardeny, O., Yancy, C., Vaduganathan, M. ELSEVIER SCIENCE INC. 2021: 559

  View details for Web of Science ID 000647487500558

• PREDICTORS OF SETTING OF HEART FAILURE DIAGNOSIS Tisdale, R., Stafford, R., Maron, D., Hernandez-Boussard, T., Rodriguez, F., Heidenreich, P., Sandhu, A. ELSEVIER SCIENCE INC. 2021: 676

  View details for Web of Science ID 000647487500675

• Kidney Function and Outcomes in Patients Hospitalized with Heart Failure. Journal of the American College of Cardiology Patel, R. B., Fonarow, G. C., Greene, S. J., Zhang, S., Alhanti, B., DeVore, A. D., Butler, J., Heidenreich, P. A., Huang, J. C., Kittleson, M. M., Joynt Maddox, K. E., McDermott, J. J., Owens, A. T., Peterson, P. N., Solomon, S. D., Vardeny, O., Yancy, C. W., Vaduganathan, M. 2021

  Abstract

  BACKGROUND: Few contemporary data exist evaluating care patterns and outcomes in HF across the spectrum of kidney function.OBJECTIVES: To characterize differences in quality of care and outcomes in patients hospitalized for HF by degree of kidney dysfunction.METHODS: We evaluated quality metrics among patients hospitalized with HF at 418 sites in the GWTG-HF registry from 2014-2019 by discharge CKD-EPI-derived eGFR. We additionally evaluated the risk-adjusted association of admission eGFR with in-hospital mortality.RESULTS: Among 365,494 hospitalizations (age 72±15y, LVEF 43±17%), median discharge eGFR was 51(34-72) mL/min/1.73m2, 234,332 (64%) had eGFR<60 mL/min/1.73m2, and 18,869 (5%) were on dialysis. eGFR distribution remained stable from 2014-2019. Among 157,439 patients with HFrEF(≤40%), discharge guideline-directed medical therapies, including beta-blockers, were lowest in discharge eGFR<30 mL/min/1.73m2 or dialysis (P<0.001). "Triple therapy" with ACE inhibitor/ARB/ARNI+beta-blocker+MRA was used in 38%, 33%, 25%, 15%, 5%, and 3% for eGFR ≥90, 60-89, 45-59, 30-44, <30 mL/min/1.73m2 and dialysis, respectively; P<0.001. Mortality was higher in a graded fashion at lower admission eGFR groups (1.1%, 1.5%, 2.0%, 3.0%, 5.0%, and 4.2%, respectively; P<0.001). Steep covariate-adjusted associations between admission eGFR and mortality were observed across EF subgroups, but was slightly stronger in HFrEF compared with HF with mid-range or preserved EF (Pinteraction=0.045).CONCLUSION: Despite facing elevated risks of mortality, patients with comorbid HFrEF and kidney disease are not optimally treated with evidence-based medical therapies, even at levels of eGFR where such therapies would not be contraindicated by kidney dysfunction. Further efforts are required to mitigate risk in comorbid HF and kidney disease.

  View details for DOI 10.1016/j.jacc.2021.05.002

  View details for PubMedID 33989713

• Pre-procedural barriers to accessing novel treatments for aortic stenosis among racial/ethnic minorities in the veterans affairs healthcare system. American heart journal plus : cardiology research and practice Kerkar, A., Gummidipundi, S., Heidenreich, P. A., Yong, C. M. 2021; 5: 100029

  Abstract

  Novel structural heart procedures offer life-saving treatment advantages, yet little is known about pre-procedural barriers to care by race/ethnicity.All echocardiograms performed at a Veterans Affairs hospital from 2015 to 2019 were reviewed to identify patients with severe aortic stenosis and their access to transcatheter aortic valve replacement (TAVR) by race/ethnicity.From 19,403 echocardiograms, 355 individuals were identified to have severe aortic stenosis (72.6% White, 9.8% Hispanic, 3.9% Black). There was a non-significant trend towards increased TAVR treatment among White compared to non-White patients (OR 2.02, CI 0.96-4.24, p = 0.063), which attenuated after adjustment for age and comorbidities. Reasons for not undergoing replacement included poor procedural candidacy (25.3%), loss of follow-up (17.8%), and patient refusal (16.4%).Racial/ethnic inequities were not detected in novel structural heart treatment within the VA. However, a high proportion of eligible patients did not receive procedural treatment due to patient refusal or loss of follow-up, highlighting barriers that require further study.

  View details for DOI 10.1016/j.ahjo.2021.100029

  View details for PubMedID 38560411

  View details for PubMedCentralID PMC10976283

• 2021 ACC/AHA Key Data Elements and Definitions for Heart Failure JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Bozkurt, B., Hershberger, R. E., Butler, J., Grady, K. L., Heidenreich, P. A., Isler, M., Kirklin, J. K., Weintraub, W. S. 2021; 77 (16): 2053-2150

  View details for DOI 10.1016/j.jacc.2020.11.012

  View details for Web of Science ID 000642055600011

  View details for PubMedID 33250265

• Association of Dual Eligibility for Medicare and Medicaid With Heart Failure Quality and Outcomes Among Get With The Guidelines-Heart Failure Hospitals. JAMA cardiology Bahiru, E., Ziaeian, B., Moucheraud, C., Agarwal, A., Xu, H., Matsouaka, R. A., DeVore, A. D., Heidenreich, P. A., Allen, L. A., Yancy, C. W., Fonarow, G. C. 2021

  Abstract

  Importance: The Centers for Medicare & Medicaid Services uses a new peer group-based payment system to compare hospital performance as part of its Hospital Readmissions Reduction Program, which classifies hospitals into quintiles based on their share of dual-eligible beneficiaries for Medicare and Medicaid. However, little is known about the association of a hospital's share of dual-eligible beneficiaries with the quality of care and outcomes for patients with heart failure (HF).Objective: To evaluate the association between a hospital's proportion of patients with dual eligibility for Medicare and Medicaid and HF quality of care and outcomes.Design, Setting, and Participants: This retrospective cohort study evaluated 436 196 patients hospitalized for HF using the Get With The Guidelines-Heart Failure registry from January 1, 2010, to December 31, 2017. The analysis included patients 65 years or older with available data on dual-eligibility status. Hospitals were divided into quintiles based on their share of dual-eligible patients. Quality and outcomes were analyzed using unadjusted and adjusted multivariable logistic regression models. Data analysis was performed from April 1, 2020, to January 1, 2021.Main Outcomes and Measures: The primary outcome was 30-day all-cause readmission. The secondary outcomes included in-hospital mortality, 30-day HF readmissions, 30-day all-cause mortality, and HF process of care measures.Results: A total of 436 196 hospitalized HF patients 65 years or older from 535 hospital sites were identified, with 258 995 hospitalized patients (median age, 81 years; interquartile range, 74-87 years) at 455 sites meeting the study criteria and included in the primary analysis. A total of 258 995 HF hospitalizations from 455 sites were included in the primary analysis of the study. Hospitals in the highest dual-eligibility quintile (quintile 5) tended to care for patients who were younger, were more likely to be female, belonged to racial minority groups, or were located in rural areas compared with quintile 1 sites. After multivariable adjustment, hospitals with the highest quintile of dual eligibility were associated with lower rates of key process measures, including evidence-based beta-blocker prescription, measure of left ventricular function, and anticoagulation for atrial fibrillation or atrial flutter. Differences in clinical outcomes were seen with higher 30-day all-cause (adjusted odds ratio, 1.24; 95% CI, 1.14-1.35) and HF (adjusted odds ratio, 1.14; 95% CI, 1.03-1.27) readmissions in higher dual-eligible quintile 5 sites compared with quintile 1 sites. Risk-adjusted in-hospital and 30-day mortality did not significantly differ in quintile 1 vs quintile 5 hospitals.Conclusions and Relevance: In this cohort study, hospitals with a higher share of dual-eligible patients provided care with lower rates of some of the key HF quality of care process measures and with higher 30-day all-cause or HF readmissions compared with lower dual-eligibility quintile hospitals.

  View details for DOI 10.1001/jamacardio.2021.0611

  View details for PubMedID 33825802

• Universal Definition and Classification of Heart Failure A Report of the Heart Failure Society of America, Heart Failure Association of the European Society of Cardiology, Japanese Heart Failure Society and Writing Committee of the Universal Definition of Heart Failure JOURNAL OF CARDIAC FAILURE Bozkurt, B., Coats, A. S., Tsutsui, H., Abdelhamid, M., Adamopoulos, S., Albert, N., Anker, S. D., Atherton, J., Bohm, M., Butler, J., Drazner, M. H., Felker, G., Filippatos, G., Fonarow, G. C., Fiuzat, M., Gomez-Mesa, J., Heidenreich, P., Imamura, T., Januzzi, J., Jankowska, E. A., Khazanie, P., Kinugawa, K., Lam, C. P., Matsue, Y., Metra, M., Ohtani, T., Piepoli, M., Ponikowski, P., Rosano, G. C., Sakata, Y., Starling, R. C., Teerlink, J. R., Vardeny, O., Yamamoto, K., Yancy, C., Zhang, J., Zieroth, S. 2021; 27 (4): 387-413

  View details for Web of Science ID 000632816500003

• The Growing Case for Routine Collection of Patient-Reported Outcomes. JAMA cardiology Heidenreich, P. A. 2021

  View details for DOI 10.1001/jamacardio.2021.0391

  View details for PubMedID 33760011

• Universal definition and classification of heart failure: A report of the Heart Failure Society of America, Heart Failure Association of the European Society of Cardiology, Japanese Heart Failure Society and Writing Committee of the Universal Definition of Heart Failure Endorsed by Canadian Heart Failure Society, Heart Failure Association of India, the Cardiac Society of Australia and New Zealand, and the Chinese Heart Failure Association. EUROPEAN JOURNAL OF HEART FAILURE Bozkurt, B., Coats, A. S., Tsutsui, H., Abdelhamid, M., Adamopoulos, S., Albert, N., Anker, S. D., Atherton, J., Bohm, M., Butler, J., Drazner, M. H., Felker, G., Filippatos, G., Fiuzat, M., Fonarow, G. C., Gomez-Mesa, J., Heidenreich, P., Imamura, T., Jankowska, E. A., Januzzi, J., Khazanie, P., Kinugawa, K., Lam, C. P., Matsue, Y., Metra, M., Ohtani, T., Piepoli, M., Ponikowski, P., Rosano, G. C., Sakata, Y., Seferovic, P., Starling, R. C., Teerlink, J. R., Vardeny, O., Yamamoto, K., Yancy, C., Zhang, J., Zieroth, S. 2021

  Abstract

  In this document, we propose a universal definition of heart failure (HF) as a clinical syndrome with symptoms and/or signs caused by a structural and/or functional cardiac abnormality and corroborated by elevated natriuretic peptide levels and/or objective evidence of pulmonary or systemic congestion. We also propose revised stages of HF as: At-risk for HF (Stage A), Pre-heart failure (Stage B), Symptomatic HF (Stage C) and Advanced HF (Stage D). Finally, we propose a new and revised classification of HF according to left ventricular ejection fraction (LVEF). These include HF with reduced ejection fraction (HFrEF): symptomatic HF with LVEF ≤40%; HF with mildly reduced ejection fraction (HFmrEF): symptomatic HF with LVEF 41-49%; HF with preserved ejection fraction (HFpEF): symptomatic HF with LVEF ≥50%; and HF with improved ejection fraction (HFimpEF): symptomatic HF with a baseline LVEF ≤40%, a ≥10 point increase from baseline LVEF, and a second measurement of LVEF > 40%.

  View details for DOI 10.1002/ejhf.2115

  View details for Web of Science ID 000624807000001

  View details for PubMedID 33605000

• Temporal trends in risk profiles among patients hospitalized for heart failure AMERICAN HEART JOURNAL Hamo, C. E., Fonarow, G. C., Greene, S. J., Vaduganathan, M., Yancy, C. W., Heidenreich, P., Lu, D., Matsouaka, R. A., DeVore, A. D., Butler, J. 2021; 232: 154-163

  Abstract

  Postdischarge mortality following hospitalization for heart failure with reduced ejection fraction (HFrEF) has remained high and unchanged over the past 2 decades, despite effective therapies for HFrEF. We aimed to explore whether these patterns could in part be explained by changes in longitudinal risk profile and HF severity over time.Among patients hospitalized for HF in the GWTG-HF registry from January 2005 to December 2018 with available data, we evaluated GWTG-HF and ADHERE risk scores, observing in-hospital mortality per-year. The risk profiles and outcomes were described overall and by subgroups based on ejection fraction (EF), diabetes mellitus (DM), sex, and age.Overall, 335,735 patients were included (50% HFrEF, 46% DM, 48% female, mean age 74 years). In-hospital mortality increased by 2.0% per year from 2005 to 2018. There was no significant change in mean GWTG-HF risk score overall or when stratified by EF groups (P = 0.46 HFrEF, p = 0.26 HF mid-range EF [HFmrEF], and P = 0.72 HF preserved EF [HFpEF]), age, sex, or presence of DM. The observed/expected ratio based on the GWTG-HF risk score was 0.93 (0.91-0.96), 0.83 (0.77-0.90), 0.92 (0.89-95) for HFrEF, HFmrEF, and HFpEF, respectively. Similar findings were seen when risk was assessed using ADHERE risk score.There were no significant changes in average risk profiles among hospitalized HF patients over the study duration. These data do not support the notion that worsening risk profile explains the lack of improved outcomes despite therapeutic advances, underscoring the importance of aggressive implementation of guideline-recommended therapies and investigation of novel treatments.

  View details for DOI 10.1016/j.ahj.2020.11.015

  View details for Web of Science ID 000613552300016

  View details for PubMedID 33264607

  View details for PubMedCentralID PMC8120737

• 2020 Update to the 2016 ACC/AHA Clinical Performance and Quality Measures for Adults With Atrial Fibrillation or Atrial Flutter JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Heidenreich, P. A., III, N., Fonarow, G. C., Jurgens, C. Y., Kittleson, M. M., Marine, J. E., McManus, D. D., McNamara, R. L., Writing Comm, ACC-AHA Task Force Performance 2021; 77 (3): 326-341

  View details for DOI 10.1016/j.jacc.2020.08.037

  View details for Web of Science ID 000612766700013

  View details for PubMedID 33303319

• Statin Use in Older Adults with Stable Atherosclerotic Cardiovascular Disease. Journal of the American Geriatrics Society Spencer-Bonilla, G., Chung, S., Sarraju, A., Heidenreich, P., Palaniappan, L., Rodriguez, F. 2021

  Abstract

  BACKGROUND/OBJECTIVES: Older adults (>75years of age) represent two-thirds of atherosclerotic cardiovascular disease (ASCVD) deaths. The 2013 and 2018 American multi-society cholesterol guidelines recommend using at least moderate intensity statins for older adults with ASCVD. We examined annual trends and statin prescribing patterns in a multiethnic population of older adults with ASCVD.DESIGN: Retrospective longitudinal study using electronic health record (EHR) data from 2007 to 2018.SETTING: A large multi-specialty health system in Northern California.PARTICIPANTS: A total of 24,651 adults older than 75years with ASCVD.MEASUREMENTS: Statin prescriptions for older adults with known ASCVD were trended over time. Multivariable regression models were used to identify predictors of statin prescription (logistic) after controlling for relevant demographic and clinical factors.RESULTS: The study cohort included 24,651 patients older than 75years; 48% were women. Although prescriptions for moderate/high intensity statins increased over time for adults over 75, fewer than half of the patients (45%) received moderate/high intensity statins in 2018. Women (odds ratio (OR) = 0.77; 95% confidence interval (CI) = 0.74, 0.80), patients who had heart failure (OR = 0.69; 95% CI = 0.65, 0.74), those with dementia (OR = 0.88; 95% CI = 0.82, 0.95) and patients who were underweight (OR = 0.64; 95% CI = 0.57, 0.73) were less likely to receive moderate/high intensity statins.CONCLUSIONS: Despite increasing prescription rates between 2007 and 2018, guideline-recommended statins remained underused in older adults with ASCVD, with more pronounced disparities among women and those with certain comorbidities. Future studies are warranted to examine reasons for statin underuse in older adults with ASCVD.

  View details for DOI 10.1111/jgs.16975

  View details for PubMedID 33410499

• The Affordability of Guideline-Directed Medical Therapy: Cost Sharing is a Critical Barrier to Therapy Adoption. Circulation Sandhu, A. T., Heidenreich, P. A. 2021; 143 (11): 1073–75

  View details for DOI 10.1161/CIRCULATIONAHA.120.053291

  View details for PubMedID 33720777

• 2020 Update to the 2016 ACC/AHA Clinical Performance and Quality Measures for Adults With Atrial Fibrillation or Atrial Flutter A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES Heidenreich, P. A., Estes, N., Fonarow, G. C., Jurgens, C. Y., Kittleson, M. M., Marine, J. E., McManus, D. D., McNamara, R. L. 2021; 14 (1): 120-134

  View details for DOI 10.1161/HCQ.0000000000000100

  View details for Web of Science ID 000639307700001

  View details for PubMedID 33284642

• Projected Clinical Benefits of Implementation of SGLT-2 Inhibitors among Medicare Beneficiaries Hospitalized for Heart Failure. Journal of cardiac failure Vaduganathan, M., Greene, S. J., Zhang, S., Solomon, N., Chiswell, K., DeVore, A. D., Butler, J., Heidenreich, P. A., Huang, J. C., Kittleson, M. M., Maddox, K. E., McDermott, J. J., Owens, A. T., Peterson, P. N., Solomon, S. D., Vardeny, O., Yancy, C. W., Fonarow, G. C. 2021

  Abstract

  The sodium-glucose cotransporter-2 (SGLT-2) inhibitors form the latest pillar in the management of heart failure with reduced ejection fraction (HFrEF) and appear effective across a range of patient profiles. There is increasing interest around initiation of SGLT-2 inhibitor during hospitalization, yet little is known about the putative benefits of this implementation strategy.We evaluated Medicare beneficiaries with HFrEF (≤40%) hospitalized at 228 sites in the Get With The Guidelines®-Heart Failure (GWTG-HF) Registry in 2016 who had linked claims data for ≥1 year post-discharge. We identified those eligible for dapagliflozin under the latest US Food and Drug Administration label (excluding eGFR<25 mL/min per 1.73 m2, dialysis, or type 1 diabetes). We evaluated 1-year outcomes overall and among key subgroups (age≥75 years, sex, race, hospital region, kidney function, diabetes status, triple therapy). We then projected the potential benefits of implementation of dapagliflozin based on risk reductions from DAPA-HF.Among 7,523 patients hospitalized for HFrEF, 6,576 (87%) would be dapagliflozin candidates (mean age 79±8 years, 39% women, 11% Black). Among eligible candidates, discharge use of β-blockers, ACEi/ARB, MRA, ARNI, and triple therapy (ACEi/ARB/ARNI+β-blocker+MRA) was recorded in 88%, 64%, 29%, 3%, and 20%, respectively. Among treatment-eligible patients, 1-year incidence (95% CI) of mortality was 37% (36-38%) and of HF readmission was 33% (32-34%), and each exceeded 25% across all key subgroups. Among 1,333 beneficiaries eligible for dapagliflozin who were already on triple therapy, 1-year incidence of mortality was 26% (24-29%) and 1-year HF readmission was 30% (27-32%). Applying the relative risk reductions observed in DAPA-HF, absolute risk reductions with complete implementation of dapagliflozin among treatment-eligible Medicare beneficiaries are projected to be 5% (1-9%) for mortality and 9% (5-12%) for HF readmission by 1 year. The projected number of Medicare beneficiaries that would need to be treated for 1 year to prevent 1 death is 19 (11-114) and 12 (8-21) would need to be treated to prevent 1 HF readmission.Medicare beneficiaries with HFrEF eligible for dapagliflozin after HF hospitalization, including those well-treated with other disease-modifying therapies, face high risks of mortality and HF readmission by 1 year. If benefits in reduction in death and HF hospitalization observed in clinical trials can be fully realized, absolute benefits of implementation of SGLT-2 inhibitors among treatment eligible candidates are anticipated to be substantial in this high-risk post-discharge setting.

  View details for DOI 10.1016/j.cardfail.2021.11.010

  View details for PubMedID 34785402

• Cardiovascular Procedural Deferral and Outcomes over COVID-19 Pandemic Phases: A Multi-Center Study. American heart journal Yong, C. M., Spinelli, K. J., Chiu, S. T., Jones, B., Penny, B., Gummidipundi, S., Beach, S., Perino, A., Turakhia, M., Heidenreich, P., Gluckman, T. J. 2021

  Abstract

  The COVID-19 pandemic has disrupted routine cardiovascular care, with unclear impact on procedural deferrals and associated outcomes across diverse patient populations.Cardiovascular procedures performed at 30 hospitals across six Western states in two large, non-profit healthcare systems (Providence St. Joseph Health and Stanford Healthcare) from December 2018-June 2020 were analyzed for changes over time. Risk-adjusted in-hospital mortality was compared across pandemic phases with multivariate logistic regression.Among 36,125 procedures (69% percutaneous coronary intervention, 13% coronary artery bypass graft surgery, 10% transcatheter aortic valve replacement, and 8% surgical aortic valve replacement), weekly volumes changed in two distinct phases after the initial inflection point on February 23, 2020: an initial period of significant deferral (COVID I: March 15 to April 11) followed by recovery (COVID II: April 12 onwards). Compared to pre-COVID, COVID I patients were less likely to be female (p=0.0003), older (p<0.0001), Asian or Black (p=0.02), or Medicare insured (p<0.0001), and COVID I procedures were higher acuity (p<0.0001), but not higher complexity. In COVID II, there was a trend towards more procedural deferral in regions with a higher COVID-19 burden (p=0.05). Compared to pre-COVID, there were no differences in risk-adjusted in-hospital mortality during both COVID phases.Significant decreases in cardiovascular procedural volumes occurred early in the COVID-19 pandemic, with disproportionate impacts by race, gender, and age. These findings should inform our approach to future healthcare disruptions.

  View details for DOI 10.1016/j.ahj.2021.06.011

  View details for PubMedID 34181910

• Direct Oral Anticoagulant Adherence of Patients With Atrial Fibrillation Transitioned from Warfarin. Journal of the American Heart Association Pundi, K. N., Perino, A. C., Fan, J., Schmitt, S., Kothari, M., Szummer, K., Askari, M., Heidenreich, P. A., Turakhia, M. P. 2021: e020904

  Abstract

  Background Reduced time in international normalized ratio therapeutic range (TTR) limits warfarin safety and effectiveness. In patients switched from warfarin to direct oral anticoagulants (DOACs), patient factors associated with low TTR could also increase risk of DOAC nonadherence. We investigated the relationship between warfarin TTR and DOAC adherence in warfarin-treated patients with atrial fibrillation switched to DOAC. Methods and Results Using data from the Veterans Health Administration, we identified patients with atrial fibrillation switched from warfarin to DOAC (switchers) or treated with warfarin alone (non-switchers). Logistic regression was used to evaluate association between warfarin TTR and DOAC adherence. We analyzed 128 605 patients (age, 71±9; 1.6% women; CHA2DS2-VASc 3.5±1.6); 32 377 switchers and 96 228 non-switchers. In 8016 switchers with international normalized ratio data to calculate 180-day TTR before switch, TTR was low (median 0.45; IQR, 0.26-0.64). Patients with TTR <0.5 were more likely to be switched to DOAC (odds ratio [OR],1.68 [95% CI,1.62-1.74], P<0.0001), as were those with TTR <0.6 or TTR <0.7. Proportion of days covered ≥0.8 was achieved by 76% of switchers at 365 days. In low-TTR individuals, proportion of days covered ≥0.8 was achieved by 70%, 72%, and 73% of switchers with TTR <0.5, 0.6, and 0.7, respectively. After multivariable adjustment, TTR <0.5 decreased odds of achieving 365-day proportion of days covered ≥0.8 (OR, 0.49; 0.43-0.57, P<0.0001), with similar relationships for TTR <0.6 and TTR <0.7. In non-switchers with TTR <0.5, long-term TTR remained low. Conclusions In patients with atrial fibrillation switched from warfarin to DOAC, most achieved adequate DOAC adherence despite low pre-switch TTRs. However, TTR trajectories remained low in non-switchers. Patients with low warfarin TTR more consistently achieved treatment targets after switching to DOACs, although adherence-oriented interventions may be beneficial.

  View details for DOI 10.1161/JAHA.121.020904

  View details for PubMedID 34779243

• Evaluation of Quality of Care for US Veterans With Recent-Onset Heart Failure With Reduced Ejection Fraction. JAMA cardiology Sandhu, A. T., Kohsaka, S., Turakhia, M. P., Lewis, E. F., Heidenreich, P. A. 2021

  Abstract

  Multiple guideline-recommended therapies for heart failure with reduced ejection fraction (HFrEF) are available and promoted by performance measures. However, contemporary data on the use of these therapies are limited.To evaluate trends in guideline-directed medical therapy, implantable cardioverter-defibrillator (ICD) use, and risk-adjusted mortality among patients with recent-onset HFrEF.This cohort study analyzed claims and electronic health record data of patients with recent-onset HFrEF diagnosed at US Department of Veterans Affairs (VA) health care system facilities from July 1, 2013, through June 30, 2019. Veterans who had a history of heart transplant or used a ventricular assist device were among the patients who were excluded.Guideline-directed medical therapy (any β-blocker, guideline-recommended β-blocker [bisoprolol, carvedilol, or metoprolol succinate], angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, angiotensin receptor-neprilysin inhibitor, mineralocorticoid receptor antagonist, and hydralazine plus nitrate) and ICD.Treatment rates for guideline-directed medical therapies and ICDs were calculated within 6 months of the index HFrEF date using medication fills, procedural codes for implantation and monitoring, and diagnosis codes. Risk-adjusted mortality was calculated after adjusting for baseline patient characteristics. For both treatment rates and risk-adjusted mortality, we evaluated the change over 3 periods (period 1: July 1, 2013, to June 30, 2015; period 2: July 1, 2015, to June 30, 2017; and period 3: July 1, 2017, to June 30, 2019) and variation across VA facilities.The final cohort comprised 144 074 eligible patients with incident HFrEF that was diagnosed between July 1, 2013, and June 30, 2019. The cohort had a mean (SD) age of 71.0 (11.4) years and was mostly composed of men (140 765 [97.7%]). Overall, changes in medical therapy rates were minimal over time, with the use of a guideline-recommended β-blocker increasing from 64.2% in 2013 to 72.0% in 2019. Rates for mineralocorticoid receptor antagonist therapy increased from 23.9% in 2013 to 26.9% in 2019, and rates for hydralazine plus nitrate therapy remained stable at 24.2% over the study period. Rates for angiotensin receptor-neprilysin inhibitor therapy increased since its introduction in 2015 but only to 22.6% in 2019. Among patients with an ICD indication, early use rates decreased over time. Substantial variation in medical therapy rates persisted across VA facilities. Risk-adjusted mortality decreased over the study period from 19.9% (95% CI, 19.6%-20.2%) in July 1, 2013, to June 30, 2015, to 18.4% (95% CI, 18.0%-18.7%) in July 1, 2017, to June 30, 2019 (OR, 0.96 per additional year; 95% CI, 0.96-0.97).This study found only marginal improvement between 2013 and 2019 in the guideline-recommended therapy and mortality rates among patients with recent-onset HFrEF. New approaches to increase the uptake of evidence-based HFrEF treatment are urgently needed and could lead to larger reductions in mortality.

  View details for DOI 10.1001/jamacardio.2021.4585

  View details for PubMedID 34757380

• Statin Use in Older Adults for Primary Cardiovascular Disease Prevention Across a Spectrum of Cardiovascular Risk. Journal of general internal medicine Sarraju, A., Spencer-Bonilla, G., Chung, S., Gomez, S., Li, J., Heidenreich, P., Palaniappan, L., Rodriguez, F. 2021

  Abstract

  There remains uncertainty regarding optimal primary atherosclerotic cardiovascular disease (ASCVD) prevention practices for older adults.To assess statin treatment patterns and incident ASCVD among older patients for primary prevention across the spectrum of ASCVD risk.Retrospective cohort study of participants without ASCVD aged 65-79 years. Patients were stratified by age (65-69, 70-75, > 75 years) and 10-year ASCVD risk category (low/borderline, intermediate, high) based on the Pooled Cohort Equations. Multivariable logistic regressions were used to identify predictors of moderate- or high-intensity statin prescriptions. Cox proportional models were used to estimate hazard ratios (HRs) for incident ASCVD.Patients aged 65-79 years without ASCVD from a Northern California health system.Statin prescriptions and incident ASCVD events.There were 54,066 patients, with 10,288 (19%) aged > 75 years and 57% women. Compared with younger groups, adults > 75 years were less likely to be prescribed moderate- or high-intensity statin prescriptions across ASCVD risk groups (all p < 0.001); this persisted after multivariable adjustment including for ASCVD risk (odds ratio [OR] 0.80, 95% confidence interval [CI] 0.74-0.86). Adults > 75 years were more likely to experience incident ASCVD (HR 1.42, 95% CI 1.23-1.63). Women (OR 0.85, 95% CI 0.81-0.89) and underweight older adults (OR 0.45, 95% CI 0.33-0.61) were also less likely to receive moderate- or high-intensity statins.Among older adults aged 65-79 years without prior ASCVD, those > 75 years of age were less likely to receive moderate- or high-intensity statins regardless of ASCVD risk compared with their younger counterparts, while experiencing more incident ASCVD. Efforts are warranted to study the reasons for age-based differences in statin use in older adults, particularly those at highest ASCVD risk.

  View details for DOI 10.1007/s11606-021-07107-7

  View details for PubMedID 34505981

• Physicians Leading Physicians: A Physician Engagement Intervention Decreases Inappropriate Use of IICU Level of Care Accommodations. American journal of medical quality : the official journal of the American College of Medical Quality Ruiz Colón, G. n., Yang, J. n., Svec, D. n., Heidenreich, P. n., Britt, P. n., Smith, M. n., Sharp, C. n., Shieh, L. n. 2021

  Abstract

  Following the adoption of an acuity-adaptable unit model in an academic medical center, a $13M increase in cost of intermediate intensive care unit (IICU) accommodations was observed. The authors followed A3 methodology to determine the root cause of this increase and developed a 3-prong intervention centered on physician engagement, given that physicians have the ability to order a patient's level of care. This intervention consisted of: (1) identifying physician champions to promote appropriate IICU use, (2) visual changes to essential electronic medical record tools, and (3) data-driven feedback to physician champions. In the year following intervention deployment, average IICU length of stay decreased from 1.08 to 0.62 days and average IICU use decreased from 21.4% to 12.3%, corresponding to ~$5.7M cost savings with no significant change in balancing measures observed. Together, these results demonstrate that a multicomponent intervention aimed at engaging physicians reduced inappropriate IICU use with no increase in adverse events.

  View details for DOI 10.1097/01.JMQ.0000735480.43566.f9

  View details for PubMedID 33883423

• Early initiation of prophylactic anticoagulation for prevention of coronavirus disease 2019 mortality in patients admitted to hospital in the United States: cohort study. BMJ (Clinical research ed.) Rentsch, C. T., Beckman, J. A., Tomlinson, L. n., Gellad, W. F., Alcorn, C. n., Kidwai-Khan, F. n., Skanderson, M. n., Brittain, E. n., King, J. T., Ho, Y. L., Eden, S. n., Kundu, S. n., Lann, M. F., Greevy, R. A., Ho, P. M., Heidenreich, P. A., Jacobson, D. A., Douglas, I. J., Tate, J. P., Evans, S. J., Atkins, D. n., Justice, A. C., Freiberg, M. S. 2021; 372: n311

  Abstract

  To evaluate whether early initiation of prophylactic anticoagulation compared with no anticoagulation was associated with decreased risk of death among patients admitted to hospital with coronavirus disease 2019 (covid-19) in the United States.Observational cohort study.Nationwide cohort of patients receiving care in the Department of Veterans Affairs, a large integrated national healthcare system.All 4297 patients admitted to hospital from 1 March to 31 July 2020 with laboratory confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and without a history of anticoagulation.The main outcome was 30 day mortality. Secondary outcomes were inpatient mortality, initiating therapeutic anticoagulation (a proxy for clinical deterioration, including thromboembolic events), and bleeding that required transfusion.Of 4297 patients admitted to hospital with covid-19, 3627 (84.4%) received prophylactic anticoagulation within 24 hours of admission. More than 99% (n=3600) of treated patients received subcutaneous heparin or enoxaparin. 622 deaths occurred within 30 days of hospital admission, 513 among those who received prophylactic anticoagulation. Most deaths (510/622, 82%) occurred during hospital stay. Using inverse probability of treatment weighted analyses, the cumulative incidence of mortality at 30 days was 14.3% (95% confidence interval 13.1% to 15.5%) among those who received prophylactic anticoagulation and 18.7% (15.1% to 22.9%) among those who did not. Compared with patients who did not receive prophylactic anticoagulation, those who did had a 27% decreased risk for 30 day mortality (hazard ratio 0.73, 95% confidence interval 0.66 to 0.81). Similar associations were found for inpatient mortality and initiation of therapeutic anticoagulation. Receipt of prophylactic anticoagulation was not associated with increased risk of bleeding that required transfusion (hazard ratio 0.87, 0.71 to 1.05). Quantitative bias analysis showed that results were robust to unmeasured confounding (e-value lower 95% confidence interval 1.77 for 30 day mortality). Results persisted in several sensitivity analyses.Early initiation of prophylactic anticoagulation compared with no anticoagulation among patients admitted to hospital with covid-19 was associated with a decreased risk of 30 day mortality and no increased risk of serious bleeding events. These findings provide strong real world evidence to support guidelines recommending the use of prophylactic anticoagulation as initial treatment for patients with covid-19 on hospital admission.

  View details for DOI 10.1136/bmj.n311

  View details for PubMedID 33574135

• Donor and Recipient Size Matching in Heart Transplantation with Predicted Heart and Lean Body Mass. Seminars in thoracic and cardiovascular surgery Miller, R. J., Hedman, K. n., Amsallem, M. n., Tulu, Z. n., Kent, W. n., Fatehi, A. n., Clarke, B. n., Heidenreich, P. n., Hiesinger, W. n., Khush, K. K., Teuteberg, J. n., Haddad, F. n. 2021

  Abstract

  Donor and recipient size matching during heart transplant can be assessed using weight or predicted heart mass (PHM) ratios. We developed sex-specific allomteric equations for PHM and predicted lean body mass (PLBM) using the United Kingdom Biobank (UKB) and evaluated their predictive value in the United Network of Organ Sharing (UNOS) database. Donor and recipient size matching was based on weight, PHM and PLBM ratios. PHM was calculated using the Multi-ethnic Study of Atherosclerosis and UKB equations. PLBM was calculated using the UKB and National Health and Nutrition Examination Survey (NHANES) equations. Relative prognostic utility was compared using multivariable Cox analysis, adjusted for predictors of one-year survival in the Scientific Registry of Transplant Recipients (SRTR) model. Of 53,648 adult patients in the UNOS database between 1996 and 2016, 6528 (12.2%) died within the first year. In multivariable analysis, undersized matches by any metric were associated with increased one-year mortality (all p<0.01). Oversized matches were at increased risk using PHM or PLBM (all p<0.01), but not weight ratio. There were significant differences in classification of size matching by weight or PHM in sex-mismatched donor-recipient pairs. A significant interaction was observed between pulmonary hypertension and donor undersizing (hazard ratio 1.15, p=0.026) suggesting increased risk of undersizing in pulmonary hypertension. Donor and recipient size matching with simplified PHM and PLBM offered an advantage over total body weight and may be more important for sex-mismatched donor-recipient pairs. Donor undersizing is associated with worse outcomes in patients with pulmonary hypertension.

  View details for DOI 10.1053/j.semtcvs.2021.01.001

  View details for PubMedID 33444763

• Early initiation of prophylactic anticoagulation for prevention of COVID-19 mortality: a nationwide cohort study of hospitalized patients in the United States. medRxiv : the preprint server for health sciences Rentsch, C. T., Beckman, J. A., Tomlinson, L., Gellad, W. F., Alcorn, C., Kidwai-Khan, F., Skanderson, M., Brittain, E., King, J. T., Ho, Y. L., Eden, S., Kundu, S., Lann, M. F., Greevy, R. A., Ho, P. M., Heidenreich, P. A., Jacobson, D. A., Douglas, I. J., Tate, J. P., Evans, S. J., Atkins, D., Justice, A. C., Freiberg, M. S. 2020

  Abstract

  Deaths among patients with coronavirus disease 2019 (COVID-19) are partially attributed to venous thromboembolism and arterial thromboses. Anticoagulants prevent thrombosis formation, possess anti-inflammatory and anti-viral properties, and may be particularly effective for treating patients with COVID-19.To evaluate whether initiation of prophylactic anticoagulation within 24 hours of admission is associated with decreased risk of death among patients hospitalized with COVID-19.Observational cohort study.Nationwide cohort of patients receiving care in the Department of Veterans Affairs, the largest integrated healthcare system in the United States.All patients hospitalized with laboratory-confirmed SARS-CoV-2 infection March 1 to July 31, 2020, without a history of therapeutic anticoagulation.Prophylactic doses of subcutaneous heparin, low-molecular-weight heparin, or direct oral anticoagulants.30-day mortality. Secondary outcomes: inpatient mortality and initiating therapeutic anticoagulation.Of 4,297 patients hospitalized with COVID-19, 3,627 (84.4%) received prophylactic anticoagulation within 24 hours of admission. More than 99% (n=3,600) received subcutaneous heparin or enoxaparin. We observed 622 deaths within 30 days of admission, 513 among those who received prophylactic anticoagulation. Most deaths (510/622, 82%) occurred during hospitalization. In inverse probability of treatment weighted analyses, cumulative adjusted incidence of mortality at 30 days was 14.3% (95% CI 13.1-15.5) among those receiving prophylactic anticoagulation and 18.7% (95% CI 15.1-22.9) among those who did not. Compared to patients who did not receive prophylactic anticoagulation, those who did had a 27% decreased risk for 30-day mortality (HR 0.73, 95% CI 0.66-0.81). Similar associations were found for inpatient mortality and initiating therapeutic anticoagulation. Quantitative bias analysis demonstrated that results were robust to unmeasured confounding (e-value lower 95% CI 1.77). Results persisted in a number of sensitivity analyses.Early initiation of prophylactic anticoagulation among patients hospitalized with COVID-19 was associated with a decreased risk of mortality. These findings provide strong real-world evidence to support guidelines recommending the use of prophylactic anticoagulation as initial therapy for COVID-19 patients upon hospital admission.

  View details for DOI 10.1101/2020.12.09.20246579

  View details for PubMedID 33330896

  View details for PubMedCentralID PMC7743107

• Association of Diagnostic Coding-Based Frailty and Outcomes in Patients With Heart Failure: A Report From the Veterans Affairs Health System. Journal of the American Heart Association Kohsaka, S., Sandhu, A. T., Parizo, J. T., Shoji, S., Kumamamru, H., Heidenreich, P. A. 2020: e016502

  Abstract

  Background The aim of this study was to determine whether frailty is associated with increased admission and mortality risk in the setting of heart failure. Methods and Results This retrospective cohort analysis included patients treated within the Veterans Affairs Health System who had International Classification of Diseases, Ninth Revision (ICD-9) codes for heart failure on 2 or more dates over a 2-year period. The clinical variables identifiable in claims data, such as demographic variables and markers of physical and cognitive dysfunction, were used to identify patients meeting the frailty phenotype. Of 388785 extracted patients with coding of heart failure between 2015 and 2018, 163085 patients (41.9%) with ejection fraction (EF) measurement were included in the present analysis (38.3% with reduced EF and 61.7% with preserved EF). There were 16660 patients (10.2%) who were identified as frail (9.1% in heart failure with reduced EF and 10.9% in heart failure with preserved EF). Frail patients were older, more often depressed, and were likely to have been admitted in the previous year. One-year all-cause mortality rate was 9.7% and 28.1%, and admission rate was 58.1% and 79.5% for nonfrail and frail patients, respectively. Frailty was associated with mortality and admission risk compared with the nonfrail group (adjusted odds ratio [OR], 1.71; 95% CI, 1.65-1.77 for mortality; adjusted OR, 1.29; 95% CI, 1.24-1.34 for admission) independent of EF. Conclusions Frailty based on diagnostic coding was associated with particularly higher risk of mortality despite adjustment for known clinical variables. Our findings underscore the importance of nontraditional parameters in the prognostic assessment.

  View details for DOI 10.1161/JAHA.120.016502

  View details for PubMedID 33283587

• Quality of Care and Outcomes Among Medicare Advantage vs Fee-for-Service Medicare Patients Hospitalized With Heart Failure JAMA CARDIOLOGY Figueroa, J. F., Wadhera, R. K., Frakt, A. B., Fonarow, G. C., Heidenreich, P. A., Xu, H., Lytle, B., DeVore, A. D., Matsouaka, R., Yancy, C. W., Bhatt, D. L., Maddox, K. 2020; 5 (12): 1349-1357

  Abstract

  Medicare Advantage (MA), a private insurance plan option, now covers one-third of all Medicare beneficiaries. Although patients with cardiovascular disease enrolled in MA have been reported to receive higher quality of care in the ambulatory setting than patients enrolled in fee-for-service (FFS) Medicare, it is unclear whether MA is associated with higher quality in patients hospitalized with heart failure, or alternatively, if incentives to reduce utilization under MA plans may be associated with worse care.To determine whether there are differences in quality of care received and in-hospital outcomes among patients enrolled in MA vs FFS Medicare.Observational, retrospective cohort study of patients hospitalized with heart failure in hospitals participating in the Get With the Guidelines-Heart Failure registry.Medicare Advantage enrollment.In-hospital mortality, discharge disposition, length of stay, and 4 heart failure achievement measures.Of 262 626 patients hospitalized with heart failure, 93 549 (35.6%) were enrolled in MA and 169 077 (64.4%) in FFS Medicare. The median (interquartile range) age was 78 (70-85) years for patients enrolled in MA and 78 (69-86) years for patients enrolled in FFS Medicare. Standard mean differences in age, sex, prevalence of comorbidities, or objective measures on admission, including vital signs and laboratory values, were less than 10%. After adjustment, there were no statistically significant differences in receipt of evidence-based β-blockers when indicated; angiotensin-converting enzyme inhibitor, angiotensin II receptor blockers, or angiotensin receptor-neprilysin inhibitors at discharge; measurement of left ventricular function; and postdischarge appointments by Medicare insurance type. Patients enrolled in MA, however, had higher odds of being discharged directly home (adjusted odds ratio [AOR], 1.16; 95% CI, 1.13-1.19; P < .001) relative to patients enrolled in FFS Medicare and lower odds of being discharged within 4 days (AOR, 0.97; 95% CI, 0.93-1.00; P = .04). There was no significant difference in in-hospital mortality between patients with MA and patients with FFS Medicare (AOR, 0.98; 95% CI, 0.92-1.03; P = .42).Among patients hospitalized with heart failure, no observable benefit was noted in quality of care or in-hospital mortality between those enrolled in MA vs FFS Medicare, except lower use of post-acute care facilities. As MA continues to grow, it will be important to ensure that participating private plans provide an added value to the patients they cover to justify the higher administrative costs compared with traditional FFS Medicare.

  View details for DOI 10.1001/jamacardio.2020.3638

  View details for Web of Science ID 000604742700001

  View details for PubMedID 32876650

  View details for PubMedCentralID PMC7489427

• 2020 ACC/AHA Clinical Performance and Quality Measures for Adults With Heart Failure JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Heidenreich, P. A., Fonarow, G. C., Taylor, K. G., Thibodeau, J. T., Yancy, C. W., Ziaeian, B., Breathett, K., Jurgens, C. Y., Pisani, B. A., Pozehl, B. J., Spertus, J. A., Ho, P., Anderson, H., Bhatt, A. S., Bozkurt, B., Das, S., Ferreira, J., Fonarow, G. C., Garcia, S., Hall, M. E., Jneid, H., Keegan, P. A., Lee, C., Lopez, L., Olin, J. W., Patel, M. R., Rahman, F., Roe, M., Salciccioli, K. B., Sandhu, A., Thomas, R. J., Ye, S., Ziaeian, B., Poppas, A., Gates, C., Rumsfeld, J. S., Slattery, L., Ronan, G., Schutt, T. W., Abdullah, A. R., Diekemper, R. L., Harrington, R. A., Brown, N., Jessup, M., Singh, R., St Laurent, P., Shahriary, M., Hundley, J., Amer Assoc Cardiovasc Pulm Rehabil, Amer Soc Hlth Syst Parmacists, Heart Rhythm Soc, Int Soc Heart Lung Transplantation, Amer Coll Cardiology, Amer Heart Assoc, Amer Heart Assoc 2020; 76 (21): 2527-2564

  View details for DOI 10.1016/j.jacc.2020.07.023

  View details for Web of Science ID 000591738100014

  View details for PubMedID 33153861

  View details for PubMedCentralID PMC8341828

• Association Of Dual Eligibility For Medicare And Medicaid With Heart Failure Quality And Outcomes Among Gwtg-hf Hospitals Bahiru, E. M., Ziaeian, B., Moucheraud, C., Agarwal, A., Xu Haolin, Matsouak, R. A., Devore, A. D., Heidenreich, P. A., Allen, L. A., Yancy, C. W., Fonarow, G. C. LIPPINCOTT WILLIAMS & WILKINS. 2020

  View details for DOI 10.1161/circ.142.suppl_3.15007

  View details for Web of Science ID 000607190402387

• Percutaneous Coronary Intervention in Ambulatory Surgery Centers: Is It Safe? Li, K., Kalwani, N. M., Heidenreich, P. A., Fearon, W. F. LIPPINCOTT WILLIAMS & WILKINS. 2020

  View details for Web of Science ID 000607190401009

• Generalizability of the US FDA Label for Dapagliflozin to Patients With Heart Failure With Reduced Ejection Fraction in the GWTG-HF Registry Vaduganathan, M., Greene, S., Zhang, S., Grau-Sepulveda, M. V., Devore, A. D., Butler, J., Heidenreich, P. A., Huang, J. C., Kittleson, M. M., Maddox, K., McDermott, J., Owens, A. T., Peterson, P., Solomon, S. D., Vardeny, O., Yancy, C. W., Fonarow, G. C. LIPPINCOTT WILLIAMS & WILKINS. 2020

  View details for Web of Science ID 000607190405284

• Atrial Fibrillation Bleeding Risk and Prediction While Treated With Direct Oral Anticoagulants in Warfarin Naive and Experienced Patients Perino, A. C., Pundi, K., Fan, J., Schmitt, S. K., Kothari, M., Heidenreich, P. A., Turakhia, M. LIPPINCOTT WILLIAMS & WILKINS. 2020

  View details for DOI 10.1161/circ.142.suppl_3.15396

  View details for Web of Science ID 000607190403160

• Anticoagulation Treatment of Venous Thromboembolism Across the Weight Spectrum: Insights From the Veterans Health Administration Perino, A. C., Fan, J., Kothari, M., Mohammad, A., Hlavacek, P., Wygant, G. D., Schmitt, S. K., Pundi, K., Heidenreich, P. A., Guo, J., Turakhia, M. LIPPINCOTT WILLIAMS & WILKINS. 2020

  View details for DOI 10.1161/circ.142.suppl_3.15444

  View details for Web of Science ID 000607190403196

• Applicability of US Food and Drug Administration Labeling for Dapagliflozin to Patients With Heart Failure With Reduced Ejection Fraction in US Clinical Practice: The Get With the Guidelines-Heart Failure (GWTG-HF) Registry. JAMA cardiology Vaduganathan, M., Greene, S. J., Zhang, S., Grau-Sepulveda, M., DeVore, A. D., Butler, J., Heidenreich, P. A., Huang, J. C., Kittleson, M. M., Joynt Maddox, K. E., McDermott, J. J., Owens, A. T., Peterson, P. N., Solomon, S. D., Vardeny, O., Yancy, C. W., Fonarow, G. C. 2020

  Abstract

  Importance: In May 2020, dapagliflozin was approved by the US Food and Drug Administration (FDA) as the first sodium-glucose cotransporter 2 inhibitor for heart failure with reduced ejection fraction (HFrEF), based on the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF) trial. Limited data are available characterizing the generalizability of dapagliflozin to US clinical practice.Objective: To evaluate candidacy for initiation of dapagliflozin based on the FDA label among contemporary patients with HFrEF in the US.Design, Setting, and Participants: This cohort study included 154 714 patients with HFrEF (left ventricular ejection fraction ≤40%) hospitalized at 406 sites in the Get With the Guidelines-Heart Failure (GWTG-HF) registry admitted between January 1, 2014, and September 30, 2019. Patients who left against medical advice, transferred to an acute care facility or to hospice, or had missing data were excluded. The FDA label (which excluded patients with an estimated glomerular filtration rate [eGFR] <30 mL/min/1.73 m2, those undergoing dialysis, and those with type 1 diabetes) was applied to the GWTG-HF registry sample. Data analyses were conducted from April 1 to June 30, 2020.Main Outcomes and Measures: The proportion of patients hospitalized with HFrEF who would be candidates for dapagliflozin under the FDA label.Results: Among 154 714 patients hospitalized with HFrEF, 125 497 (81.1%; 83 481 men [66.5%]; mean [SD] age, 68 [15] years) would be candidates for dapagliflozin according to the FDA label. Across 355 sites with patients with 10 or more hospitalizations, the median proportion of candidates for dapagliflozin according to the FDA label was 81.1% (interquartile range, 77.8%-84.6%) at each site. This proportion was similar across all study years (interquartile range, 80.4%-81.7%) and was higher among those without type 2 diabetes than with type 2 diabetes (85.5% vs 75.6%). Among GWTG-HF participants, the most frequent reason for not meeting the FDA label criteria was eGFR less than 30 mL/min/1.73 m2 at discharge (18.5%). Among 75 654 patients with available paired admission and discharge data, 14.2% had an eGFR less than 30 mL/min/1.73 m2 at both time points, while 3.8% developed an eGFR less than 30 mL/min/1.73 m2 by discharge. Although there were more older adults, women, and Black patients in the GWTG-HF registry than in the DAPA-HF trial, most clinical characteristics were qualitatively similar between the 2 groups. Compared with the DAPA-HF trial cohort, there was lower use of evidence-based HF therapies among patients in GWTG-HF.Conclusions and Relevance: These data from a large, contemporary US registry of patients hospitalized with heart failure suggest that 4 of 5 patients with HFrEF (with or without type 2 diabetes) would be candidates for initiation of dapagliflozin, supporting its broad generalizability to US clinical practice.

  View details for DOI 10.1001/jamacardio.2020.5864

  View details for PubMedID 33185662

• Elective Percutaneous Coronary Intervention in Ambulatory Surgery Centers. JACC. Cardiovascular interventions Li, K., Kalwani, N. M., Heidenreich, P. A., Fearon, W. F. 2020

  Abstract

  OBJECTIVES: The aim of this study was to explore characteristics and outcomes of patients undergoing elective percutaneous coronary intervention (PCI) in ambulatory surgery centers (ASCs).BACKGROUND: Little is known about patients who underwent ASC PCI before Medicare reimbursement was instituted in2020.METHODS: Using commercial insurance claims from MarketScan, adults who underwent hospital outpatient department (HOPD) or ASC PCI for stable ischemic heart disease from 2007 to 2016 were studied. Propensity score analysis was used to measure the association between treatment setting and the primary composite outcome of 30-day myocardial infarction, bleeding complications, and hospital admission.RESULTS: The unmatched sample consisted of 95,492 HOPD and 849 ASC PCIs. Patients who underwent ASC PCI were more likely to be younger than 65 years, to live in the southern United States, and to have managed or consumer-driven health insurance. ASC PCI was also associated with decreased fractional flow reserve utilization (odds ratio [OR]: 0.31; 95% confidence interval [CI]: 0.20 to 0.48; p<0.001). In unmatched, multivariate analysis, ASC PCI was associated with increased odds of the primary outcome (OR: 1.25; 95%CI: 1.01 to 1.56; p=0.039) and bleeding complications (OR: 1.80; 95%CI: 1.11 to 2.90; p=0.016). In propensity-matched analysis, ASC PCI was not associated with the primary outcome (OR: 1.23; 95%CI: 0.94 to 1.60; p=0.124) but was significantly associated with increased bleeding complications (OR: 2.49; 95%CI: 1.25 to 4.95; p=0.009).CONCLUSIONS: Commercially insured patients undergoing ASC PCI were less likely to undergo fractional flow reserve testing and had higher odds of bleeding complications than HOPD-treated patients. Further study is warranted as Medicare ASC PCI volume increases.

  View details for DOI 10.1016/j.jcin.2020.10.015

  View details for PubMedID 33183992

• Building a Heart Failure Clinic: A Practical Guide from the Heart Failure Society of America. Journal of cardiac failure Greene, S. J., Adusumalli, S., Albert, N. M., Hauptman, P. J., Rich, M. W., Heidenreich, P. A., Butler, J., Heart Failure Society of America Quality of Care Committee 2020

  Abstract

  Heart failure (HF) remains a leading cause of mortality and morbidity and a primary driver of health care resource use in the United States. As such, there continues to be much interest in the development and refinement of HF clinics that manage patients with HF in a guideline-directed, technology-enabled, and coordinated approach. Optimization of resource use and maintenance of collaboration with other providers are also important themes when considering implementation of HF clinics. Through this document, the Heart Failure Society of America aims to provide a contemporary, practical guide to creating and sustaining a HF clinic. The guide discusses (1) patient care considerations for delivering guideline-directed and patient-centered care, and (2) operational considerations including development of a HF clinic business plan, setting goals, leadership support, triggers for patient referral and patient follow-up, patient population served, optimal clinic staffing models, relationships with subspecialists, and continuous quality improvement. This document was developed to empower providers and clinicians who wish to build and sustain community-based, successful HF clinics.

  View details for DOI 10.1016/j.cardfail.2020.10.008

  View details for PubMedID 33289664

• Patients' Journey's In Living with Heart Failure - Its A Bumpy Road Albert, N. M., Heidenreich, P. A., Fletcher, B., Rasmusson, K. D., Bena, J. F., Lattimer, C., Morrison, S. L., Onwuanyi, A. E., Smith, D. CHURCHILL LIVINGSTONE INC MEDICAL PUBLISHERS. 2020: S126

  View details for Web of Science ID 000579889600337

• Measurement of implementation strategies for pharmacy benefits management MUET initiatives to optimize medication management Sahay, A., Cunningham, F., Glassman, P., Moore, V., Burk, M., Gholami, P., Lin, S., Mittman, B., Heidenreich, P. BMC. 2020

  View details for Web of Science ID 000576910000114

• Trends in Left Ventricular Ejection Fraction for Patients With a New Diagnosis of Heart Failure. Circulation. Heart failure Tisdale, R. L., Haddad, F., Kohsaka, S., Heidenreich, P. A. 2020: CIRCHEARTFAILURE119006743

  Abstract

  BACKGROUND: The left ventricular ejection fraction (LVEF) guides treatment of heart failure, yet this data has not been systematically collected in large data sets. We sought to characterize the epidemiology of incident heart failure using the initial LVEF.METHODS: We identified 219 537 patients in the Veterans Affairs system between 2011 and 2017 who had an LVEF documented within 365 days before and 30 days after the heart failure diagnosis date. LVEF was obtained from natural language processing from imaging and provider notes. In multivariate analysis, we assessed characteristics associated with having an initial LVEF <40%.RESULTS: Most patients were male and White; a plurality were within the 60 to 69 year age decile. A majority of patients had ischemic heart disease and a high burden of co-morbidities. Over time, presentation with an LVEF <40% became slightly less common, with a nadir in 2015. Presentation with an initial LVEF <40% was more common in younger patients, men, Black and Hispanic patients, an inpatient presentation, lower systolic blood pressure, lower pulse pressure, and higher heart rate. Ischemic heart disease, alcohol use disorder, peripheral arterial disease, and ventricular arrhythmias were associated with an initial LVEF <40%, while most other comorbid conditions (eg, atrial fibrillation, chronic obstructive pulmonary disease, malignancy) were more strongly associated with an initial LVEF >50%.CONCLUSIONS: For patients with heart failure, particularly at the extremes of age, an initial preserved LVEF is common. In addition to clinical characteristics, certain races (Black and Hispanic) were more likely to present with a reduced LVEF. Further studies are needed to determine if racial differences are due to patient or health systems issues such as access to care.

  View details for DOI 10.1161/CIRCHEARTFAILURE.119.006743

  View details for PubMedID 32867526

• Independent and cumulative association of clinical and morphological heart failure with long-term outcome after percutaneous coronary intervention. Journal of cardiology Kimura, M., Kohno, T., Sawano, M., Heidenreich, P. A., Ueda, I., Takahashi, T., Matsubara, T., Ueno, K., Hayashida, K., Yuasa, S., Ohki, T., Fukuda, K., Kohsaka, S. 2020

  Abstract

  BACKGROUND: Heart failure (HF) is a risk factor for adverse post-procedural outcome after revascularization; however, it is unclear how left ventricular systolic dysfunction (LVSD) and clinical HF symptoms affect percutaneous coronary intervention (PCI) outcomes. We investigated the characteristics and long-term outcomes of patients with clinical HF or LVSD after PCI.METHODS: This was a Japanese multicenter registry study of adult patients receiving PCI. Among 4689 consecutive patients who underwent PCI at 15 hospitals from January 2009 to December 2012, we analyzed 2634 (56.2%) with documented left ventricular ejection fraction (LVEF). They were divided into four groups based on clinical HF (symptoms or HF hospitalization) and LVEF [≥35% and <35% (HF due to LVSD)]. The primary outcome was major adverse cardiovascular events (MACE), comprising all-cause death, acute coronary syndrome, HF hospitalization, performance of coronary artery bypass grafting, and stroke within 2 years after the initial PCI.RESULTS: Our findings revealed 354 patients (13.4%) with HF (clinical HF, n=173, 48.9%; LVSD, n=132, 37.3%; both, n=49; 13.8%). The incidence of MACE was higher in patients with clinical HF or LVSD, and was largely due to higher non-cardiac death and HF hospitalization. After adjustment, clinical HF (hazard ratio 2.16, 95% confidence interval; 1.49-3.14) and lower LVEF (per 10%, hazard ratio 0.89, 95% confidence interval; 0.81-0.99) were independently associated with higher MACE risk.CONCLUSIONS: Clinical HF and LVSD were independently associated with adverse long-term clinical outcomes, particularly with non-cardiac death and HF readmission, in patients treated with PCI.

  View details for DOI 10.1016/j.jjcc.2020.06.014

  View details for PubMedID 32888830

• Trends in cardiovascular procedural volumes in the setting of COVID-19: Insights from the VA clinical assessment, reporting, and tracking program CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS Waldo, S. W., Plomondon, M. E., O'Donnell, C. I., Heidenreich, P. A., Riatt, M. H., Ballard-Hernandez, J., Ortiz, J., Varosy, P. D., Vidovich, M. I., O'Donnell, C. J., Schofield, R. 2021; 98 (2): E326-E328

  View details for DOI 10.1002/ccd.29204

  View details for Web of Science ID 000561934500001

  View details for PubMedID 32833343

  View details for PubMedCentralID PMC7461497

• The association between Asian patient race/ethnicity and lower satisfaction scores. BMC health services research Liao, L., Chung, S., Altamirano, J., Garcia, L., Fassiotto, M., Maldonado, B., Heidenreich, P., Palaniappan, L. 2020; 20 (1): 678

  Abstract

  BACKGROUND: Patient satisfaction is increasingly being used to assess, and financially reward, provider performance. Previous studies suggest that race/ethnicity (R/E) may impact satisfaction, yet few practices adjust for patient R/E. The objective of this study is to examine R/E differences in patient satisfaction ratings and how these differences impact provider rankings.METHODS: Patient satisfaction survey data linked to electronic health records from two large outpatient centers in northern California - a non-profit organization of community-based clinics (Site A) and an academic medical center (Site B) - was collected and analyzed. Participants consisted of adult patients who received outpatient care at Site A from December 2010 to November 2014 and Site B from March 2013 to August 2014, and completed Press-Ganey Medical Practice Survey questionnaires (N=216,392 (Site A) and 30,690 (Site B)). Self-reported non-Hispanic white (NHW), Black, Latino, and Asian patients were studied. For six questions each representing a survey subdomain, favorable ratings were defined as top-box ("very good") compared to all other categories ("very poor," "poor," "fair," and "good"). Using multivariable logistic regression with provider random effects, we assessed whether the likelihood of giving favorable ratings differed by patient R/E, adjusting for patient age and sex.RESULTS: Asian, younger and female patients provided less favorable ratings than other R/E, older and male patients. After adjustment, Asian patients were less likely than NHW patients to provide top-box ratings to the overall assessment question "likelihood of recommending this practice to others" (Site A: Asian predicted probability (PP) 0.680, 95% confidence interval (CI): 0.675-0.685 compared to NHW PP 0.820, 95% CI: 0.818-0.822; Site B: Asian PP 0.734, 95% CI: 0.733-0.736 compared to NHW PP 0.859, 95% CI: 0.859-0.859). The effect sizes for Asian R/E were greater than the effect sizes for older age and female sex. An absolute 3% decrease in mean composite score between providers serving different percentages of Asian patients translated to an absolute 40% drop in national ranking.CONCLUSIONS: Patient satisfaction scores may need to be adjusted for patient R/E, particularly for providers caring for high panel percentages of Asian patients.

  View details for DOI 10.1186/s12913-020-05534-6

  View details for PubMedID 32698825

• Association Between Neighborhood Social Risk and Hospital Readmission Reduction Penalties Under the New Stratified Approach: Is Dual Eligibility Adjustment Enough? Circulation. Cardiovascular quality and outcomes Sandhu, A. T., Tisdale, R., Joynt Maddox, K. E., Heidenreich, P. A. 2020: CIRCOUTCOMES119006353

  View details for DOI 10.1161/CIRCOUTCOMES.119.006353

  View details for PubMedID 32600063

• Trends in Readmission and Mortality Rates Following Heart Failure Hospitalization in the Veterans Affairs Health Care System From 2007 to 2017. JAMA cardiology Parizo, J. T., Kohsaka, S., Sandhu, A. T., Patel, J., Heidenreich, P. A. 2020

  Abstract

  Importance: The Centers for Medicare & Medicaid Services and the Veterans Affairs Health Care System provide incentives for hospitals to reduce 30-day readmission and mortality rates. In contrast with the large body of evidence describing readmission and mortality in the Medicare system, it is unclear how heart failure readmission and mortality rates have changed during this period in the Veterans Affairs Health Care System.Objectives: To evaluate trends in readmission and mortality after heart failure admission in the Veterans Affairs Health Care System, which had no financial penalties, in a decade involving focus on heart failure readmission reduction (2007-2017).Design, Setting, and Participants: This cohort study used data from all Veterans Affairs-paid heart failure admissions from January 2007 to September 2017. All Veterans Affairs-paid hospital admissions to Veterans Affairs and non-Veterans Affairs facilities for a primary diagnosis of heart failure were included, when the admission was paid for by the Veterans Affairs. Data analyses were conducted from October 2018 to March 2020.Exposures: Admission for a primary diagnosis of heart failure at discharge.Main Outcomes and Measures: Thirty-day all-cause readmission and mortality rates.Results: A total of 164 566 patients with 304 374 hospital admissions were included. Among the 304 374 hospital admissions between 2007 and 2017, 298 260 (98.0%) were for male patients, and 195 205 (64.4%) were for white patients. The mean (SD) age was 70.8 (11.5) years. The adjusted odds ratio of 30-day readmission declined throughout the study period to 0.85 (95% CI, 0.83-0.88) in 2015 to 2017 compared with 2007 to 2008. The adjusted odds ratio of 30-day mortality remained stable, with an adjusted odds ratio of 1.01 (95% CI, 0.96-1.06) in 2015 to 2017 compared with 2007 to 2008. Stratification by left ventricular ejection fraction showed similar readmission reduction trends and no significant change in mortality, regardless of strata.Conclusions and Relevance: In this analysis of an integrated health care system that provided guidance and nonfinancial incentives for reducing readmissions, such as public reporting of readmission rates, risk-adjusted 30-day readmission declined despite inclusion of clinical variables in risk adjustment, but mortality did not decline. Future investigations should focus on evaluating the effectiveness of specific approaches to readmission reduction to inform efficient and effective application in individual health systems, hospitals, and practices.

  View details for DOI 10.1001/jamacardio.2020.2028

  View details for PubMedID 32584921

• Comparative Effectiveness of Primary Prevention Implantable Cardioverter-Defibrillators in Older Heart Failure Patients With Diabetes Mellitus JOURNAL OF THE AMERICAN HEART ASSOCIATION Sharma, A., Wu, J., Xu, H., Hernandez, A., Felker, G., Al-Khatib, S., Green, J., Matsouaka, R., Fonarow, G. C., Singh, J. P., Heidenreich, P. A., Ezekowitz, J. A., DeVore, A. 2020; 9 (12): e012405

  Abstract

  Background There are conflicting data regarding the benefit of primary prevention implantable cardioverter-defibrillators (ICDs) in patients with diabetes mellitus and heart failure (HF) with reduced ejection fraction. We aimed to assess the comparative effectiveness of ICD placement in patients with diabetes mellitus and HF with reduced ejection fraction. Methods and Results Data were obtained from the Get With the Guidelines-Health Failure registry, linked with claims from the Centers for Medicare & Medicaid Services. We used a Cox proportional hazards model censored at 5 years with propensity score matching. Of the 17 186 patients with HF with reduced ejection fraction from the Centers for Medicare & Medicaid Services claims database (6540 with diabetes mellitus; 38%), 1677 (646 with diabetes mellitus; 39%) received an ICD during their index HF hospitalization or were prescribed an ICD at discharge. Patients with diabetes mellitus and an ICD (n=646), as compared with those without an ICD (n=1031), were more likely to be younger (74 versus 78 years of age) and have coronary artery disease (68% versus 60%). After propensity matching, ICD use among patients with diabetes mellitus, as compared with those without an ICD, was associated with a reduced risk of all-cause mortality at 5 years after HF discharge (54% versus 59%; multivariable hazard ratio, 0.73; 95% CI, 0.64-0.82; P<0.0001). Ischemic heart disease did not modify the association between ICD use and all-cause mortality (P=0.95 for interaction). Similar results were seen in patients without diabetes mellitus. Conclusions Primary prevention ICD use among older patients with HF with reduced ejection fraction and diabetes mellitus was associated with a reduced risk of all-cause mortality. Our analysis supports current guideline recommendations for implantation of primary prevention ICDs among older patients with diabetes mellitus and HF with reduced ejection fraction.

  View details for DOI 10.1161/JAHA.119.012405

  View details for Web of Science ID 000550987700007

  View details for PubMedID 32476539

  View details for PubMedCentralID PMC7429066

• Endpoints in Heart Failure Drug Development History and Future JACC-HEART FAILURE Fiuzat, M., Lowy, N., Stockbridge, N., Sbolli, M., Latta, F., Lindenfeld, J., Lewis, E. F., Abraham, W. T., Teerlink, J., Walsh, M., Heidenreich, P., Bozkurt, B., Starling, R. C., Solomon, S., Felker, G., Butler, J., Yancy, C., Stevenson, L. W., O'Connor, C., Unger, E., Temple, R., McMurray, J. 2020; 8 (6): 429-440

  Abstract

  Heart failure (HF) patients experience a high burden of symptoms and functional limitations, and morbidity and mortality remain high despite successful therapies. The majority of HF drugs in the United States are approved for reducing hospitalization and mortality, while only a few have indications for improving quality of life, physical function, or symptoms. Patient-reported outcomes that directly measure patient's perception of health status (symptoms, physical function, or quality of life) are potentially approvable endpoints in drug development. This paper summarizes the history of endpoints used for HF drug approvals in the United States and reviews endpoints that measure symptoms, physical function, or quality of life in HF patients.

  View details for DOI 10.1016/j.jchf.2019.12.011

  View details for Web of Science ID 000536491400001

  View details for PubMedID 32278679

• Prognostic Implications of Early and Midrange Readmissions After Acute Heart Failure Hospitalizations: A Report From a Japanese Multicenter Registry. Journal of the American Heart Association Kitakata, H., Kohno, T., Kohsaka, S., Shiraishi, Y., Parizo, J. T., Niimi, N., Goda, A., Nishihata, Y., Heidenreich, P. A., Yoshikawa, T. 2020: e014949

  Abstract

  Background Although 30-day readmission is thought to be an important quality indicator in patients with hospitalized heart failure, its prognostic impact and comparison of patients who were readmitted beyond 30days has not been investigated. We assessed early (0-30days) versus midrange (31-90days) readmission in terms of incidence and distribution, and elucidated whether the timing of readmission could have a different prognostic significance. Methods and Results We examined patients with hospitalized heart failure registered in the WET-HF (West Tokyo Heart Failure) registry. The primary outcomes analyzed were all-cause death and HF readmission. Data of 3592 consecutive patients with hospitalized heart failure (median follow-up, 2.0 years [interquartile range, 0.8-3.1 years]; 39.6% women, mean age 73.9±13.3years) were analyzed. Within 90days after discharge, HF readmissions occurred in 11.1% patients. Of them, patients readmitted within 30 and 31 to 90days after discharge accounted for 43.1% and 56.9%, respectively. Independent predictors of 30- and 90-day readmission were almost identical, and after adjustment, readmission for HF within 90days (including both early and midrange readmission) was an independent predictor of subsequent all-cause death (hazard ratio, 2.36; P<0.001). Among 90-day readmitted patients, the time interval from discharge to readmission was not significantly associated with subsequent all-cause death. Conclusions Among patients readmitted within 90days after index hospitalization discharge, 60% of readmission events occurred beyond 30days. Patients readmitted within 90days had a higher risk of long-term mortality, regardless of the temporal proximity of readmission to the index hospitalization.

  View details for DOI 10.1161/JAHA.119.014949

  View details for PubMedID 32378443

• Discrepancy in recognition of symptom burden among patients with atrial fibrillation. American heart journal Katsumata, Y., Kimura, T., Kohsaka, S., Ikemura, N., Ueda, I., Fujisawa, T., Nakajima, K., Nishiyama, T., Aizawa, Y., Oki, T., Suzuki, M., Heidenreich, P. A., Fukuda, K., Takatsuki, S. 2020

  Abstract

  Our aim was to investigate the variability in physician recognition of atrial fibrillation (AF)-related symptoms, which greatly contributes to the management of AF patients. METHODS AND RESULTS: A total of 1493 newly-referredAF patients (67 ± 11 y/o, 1057 men) consecutively registered in an outpatient-based Japanese multicenter database (KiCS-AF) from September 2012 to December 2016 were analyzed. Self-reportedAF symptom burden was assessed via symptom and daily activities domains within the Atrial Fibrillation Effect on QualiTy-of-life (AFEQT) questionnaire. Physician symptom under-recognition (UR) was defined as no subjective complaints recorded in the medical records despite AFEQT score of <80; and physician's apparent over-recognition (OvR) was defined as documentation of subjective complaints despite total AFEQT score of ≥80. There was poor agreement between patient-reported and physicians-estimated symptom burden (kappa 0.28, 95% CI 0.23 to 0.33). In the logistic regression analysis, age> 75 (odds ratio [OR], 1.72; 95% confidence interval [CI], 1.13-2.62), male sex (OR, 1.82; 95% CI, 1.22-2.74), and persistent/permanent AF (OR 2.54/3.36; CI, 1.63-3.99/1.91-5.89, respectively) were predictors of UR. Conversely, heart failure (OR, 2.46; 95% CI, 1.44-4.25) and treatment in an ablation facility (OR, 1.43; 95% CI, 1.02-2.02) were associated with greater odds of OvR in addition to age, sex, and type of AF. CONCLUSIONS: Discordance in recognition of AF symptom burden by physicians was frequent in AF patients seen in outpatient management and involved both patient- and physician-related factors.

  View details for DOI 10.1016/j.ahj.2020.03.024

  View details for PubMedID 32517853

• Testing for Coronary Artery Disease in Older Patients With New-Onset Heart Failure: Findings From Get With The Guidelines-Heart Failure. Circulation. Heart failure O'Connor, K. D., Brophy, T., Fonarow, G. C., Blankstein, R., Swaminathan, R. V., Xu, H., Matsouaka, R. A., Albert, N. M., Velazquez, E. J., Yancy, C. W., Heidenreich, P. A., Hernandez, A. F., DeVore, A. D. 2020; 13 (4): e006963

  Abstract

  BACKGROUND: Current guidelines recommend evaluation for underlying heart disease and reversible conditions for patients with new-onset heart failure (HF). There are limited data on contemporary testing for coronary artery disease (CAD) in patients with new-onset HF.METHODS: We performed an observational cohort study using the Get With The Guidelines-Heart Failure registry linked to Medicare claims. All patients were aged ≥65 and hospitalized for new-onset HF from 2009 to 2015. We collected left ventricular ejection fraction (LVEF), prior HF history, and in-hospital CAD testing from the registry, as well as testing for CAD using claims from 90 days before to 90 days after index HF hospitalization.RESULTS: Among 17 185 patients with new-onset HF, 6672 (39%) received testing for CAD, including 3997 (23%) during the index hospitalization. Testing for CAD differed by LVEF: 53% in HF with reduced EF (LVEF ≤40%), 42% in HF with borderline EF (LVEF, 41%-49%), and 31% in HF with preserved EF (LVEF ≥50%). After multivariable adjustment, patients who received testing for CAD, compared with those who did not, were younger and more likely to be male, have a smoking history, have hyperlipidemia, and have HF with reduced ejection fraction or HF with borderline ejection fraction (all P<0.05).CONCLUSIONS: The majority of patients hospitalized for new-onset HF did not receive testing for CAD either during the hospitalization or in the 90 days before and after. The rates of testing for CAD were higher in patients with LVEF ≤40% though remained low. These data highlight an opportunity to improve care by identifying appropriate candidates for optimal CAD medical therapy and revascularization.

  View details for DOI 10.1161/CIRCHEARTFAILURE.120.006963

  View details for PubMedID 32207996

• Representativeness of the PIONEER-HF Clinical Trial Population in Patients Hospitalized With Heart Failure and Reduced Ejection Fraction CIRCULATION-HEART FAILURE Fudim, M., Sayeed, S., Xu, H., Matsouaka, R. A., Heidenreich, P. A., Velazquez, E. J., Yancy, C. W., Fonarow, G. C., Hernandez, A. F., DeVore, A. D. 2020; 13 (4): e006645

  Abstract

  In PIONEER-HF (Comparison of Sacubitril/Valsartan Versus Enalapril on Effect on NT-pro BNP in Patients Stabilized From an Acute Heart Failure Episode), the in-hospital initiation of sacubitril/valsartan in patients hospitalized for acute decompensated heart failure (ADHF) was well-tolerated and led to improved outcomes. We aim to determine the representativeness of the PIONEER-HF trial among patients hospitalized for ADHF using real-world data.The study population was derived from all patients discharged alive for ADHF in the Get With The Guidelines-HF registry from 2006 to 2018 with HF with reduced ejection fraction (HFrEF; all HFrEF with ADHF). We then determined the proportion of patients meeting PIONEER-HF eligibility criteria (PIONEER-HF eligible) and those meeting a set of limited eligibility criteria (actionable cohort). Rates of HF readmissions and all-cause mortality were then compared between the all HFrEF with ADHF, PIONEER-HF eligible, and actionable cohorts using linked Medicare claims data.A total of 99 767 patients with HFrEF in Get With The Guidelines-HF were hospitalized for ADHF. PIONEER-HF inclusion criteria were met by 71 633 (71.8%) patients, and both inclusion and exclusion criteria were met by 20 704 (20.8%) patients. Further, 68 739 (68.9%) patients met the criteria for the actionable cohort. Among the Centers for Medicare and Medicaid-linked patients, the HF rehospitalization rate at 1 year was 35.1% (95% CI, 34.5-35.8) for all HFrEF with ADHF patients, 32.6% (95% CI, 31.3-33.9) for the PIONEER-HF eligible cohort, and 33.1% (95% CI, 32.3-33.9) for the actionable cohort. The 1-year all-cause mortality was 36.7% (95% CI, 36.1-7.4) for all HFrEF with ADHF patients, 31.6% (95% CI, 30.3-32.9) for the PIONEER-HF eligible cohort, and 32.2% (95% CI, 31.4-33.0) for the actionable cohort.Patient characteristics and clinical outcomes for patients eligible for PIONEER-HF only modestly differ when compared with those encountered in routine practice, suggesting that the in-hospital initiation of sacubitril/valsartan should be routinely considered for patients with HFrEF hospitalized for ADHF.

  View details for DOI 10.1161/CIRCHEARTFAILURE.119.006645

  View details for Web of Science ID 000530285600011

  View details for PubMedID 32248695

• Video-based AI for beat-to-beat assessment of cardiac function. Nature Ouyang, D., He, B., Ghorbani, A., Yuan, N., Ebinger, J., Langlotz, C. P., Heidenreich, P. A., Harrington, R. A., Liang, D. H., Ashley, E. A., Zou, J. Y. 2020; 580 (7802): 252-256

  Abstract

  Accurate assessment of cardiac function is crucial for the diagnosis of cardiovascular disease1, screening for cardiotoxicity2 and decisions regarding the clinical management of patients with a critical illness3. However, human assessment of cardiac function focuses on a limited sampling of cardiac cycles and has considerable inter-observer variability despite years of training4,5. Here, to overcome this challenge, we present a video-based deep learning algorithm-EchoNet-Dynamic-that surpasses the performance of human experts in the critical tasks of segmenting the left ventricle, estimating ejection fraction and assessing cardiomyopathy. Trained on echocardiogram videos, our model accurately segments the left ventricle with a Dice similarity coefficient of 0.92, predicts ejection fraction with a mean absolute error of 4.1% and reliably classifies heart failure with reduced ejection fraction (area under the curve of 0.97). In an external dataset from another healthcare system, EchoNet-Dynamic predicts the ejection fraction with a mean absolute error of 6.0% and classifies heart failure with reduced ejection fraction with an area under the curve of 0.96. Prospective evaluation with repeated human measurements confirms that the model has variance that is comparable to or less than that of human experts. By leveraging information across multiple cardiac cycles, our model can rapidly identify subtle changes in ejection fraction, is more reproducible than human evaluation and lays the foundation for precise diagnosis of cardiovascular disease in real time. As a resource to promote further innovation, we also make publicly available a large dataset of 10,030 annotated echocardiogram videos.

  View details for DOI 10.1038/s41586-020-2145-8

  View details for PubMedID 32269341

• Novel Methods for Donor and Recipient Size Matching in Heart Transplantation Miller, R. J., Hedman, K., Vrotec, B., Ingelsson, E., Heidenreich, P., Hiesinger, W., Oyer, P., Teuteberg, J., Haddad, F. ELSEVIER SCIENCE INC. 2020: S50

  View details for Web of Science ID 000522637200100

• Ischemic and Bleeding Events Among Patients With Acute Coronary Syndrome Associated With Low-Dose Prasugrel vs Standard-Dose Clopidogrel Treatment. JAMA network open Shoji, S., Sawano, M., Sandhu, A. T., Heidenreich, P. A., Shiraishi, Y., Ikemura, N., Ueno, K., Suzuki, M., Numasawa, Y., Fukuda, K., Kohsaka, S. 2020; 3 (4): e202004

  Abstract

  Importance: Prasugrel was approved at a lower dose in 2014 in Japan than in the West because East Asian patients are considered more susceptible to bleeding than Western patients. However, real-world outcomes with low-dose prasugrel treatment remain unclear.Objective: To investigate the association of low-dose prasugrel vs standard-dose clopidogrel administration with short-term outcomes among patients with acute coronary syndrome undergoing percutaneous coronary intervention (PCI).Design, Setting, and Participants: This study used data from the Japan Cardiovascular Database-Keio Interhospital Cardiovascular Studies registry, a large, ongoing, multicenter, retrospective cohort of consecutive patients who underwent PCI. The present cohort study evaluated 2770 patients with acute coronary syndrome who underwent PCI and received either low-dose prasugrel (loading dose, 20 mg; maintenance dose, 3.75 mg) or clopidogrel (loading dose, 300 mg; maintenance dose, 75 mg) in combination with aspirin between 2014 and 2018. Propensity score-matching analysis was conducted to balance the baseline characteristics of patients receiving low-dose prasugrel and those receiving clopidogrel. Data analysis was conducted in June 2019.Exposures: Prescription of either low-dose prasugrel or standard-dose clopidogrel prior to PCI.Main Outcomes and Measures: Primary ischemic events (in-hospital death, recurrent myocardial infarction, and ischemic stroke) and primary bleeding events, defined as bleeding complications within 72 hours after PCI consistent with the National Cardiovascular Data Registry CathPCI Registry definition.Results: Of 2559 patients included in the study, the mean (SD) age was 67.8 (12.7) years, and 78.2% were male. In total, 1297 patients (50.7%) received low-dose prasugrel, and 1262 patients (49.3%) received clopidogrel. After propensity score matching, primary ischemic events among patients receiving low-dose prasugrel and those receiving clopidogrel were comparable (odds ratio [OR], 1.42; 95% CI, 0.90-2.23), but primary bleeding events were significantly higher among patients receiving prasugrel (OR, 2.91; 95% CI, 1.63-5.18). This increase in bleeding events was associated with the presence of a profile of high-bleeding risk (≥75 years of age, body weight <60 kg, or history of stroke or transient ischemic attack) (OR, 4.08; 95% CI, 1.86-8.97), being female (OR, 3.84; 95% CI, 1.05-14.0), or the presence of ST-segment elevation myocardial infarction (OR, 2.07; 95% CI, 1.05-4.09) or chronic kidney disease (OR, 4.78; 95% CI, 1.95-11.7).Conclusions and Relevance: Since its approval, low-dose prasugrel has been used by nearly 80% of patients who undergo PCI. Despite the modified dose, bleeding events were higher among patients receiving low-dose prasugrel than among patients receiving clopidogrel, with no difference in ischemic events between the 2 groups. These results suggest the importance of a risk assessment of bleeding prior to selecting a P2Y12 inhibitor, even for the use of a lower approved dose, when treating patients of East Asian descent.

  View details for DOI 10.1001/jamanetworkopen.2020.2004

  View details for PubMedID 32239221

• STATIN USE FOR SECONDARY PREVENTION OF CARDIOVASCULAR DISEASE IN THE ELDERLY Spencer-Bonilla, G., Chung, S., Heidenreich, P. A., Palaniappan, L. P., Rodriguez, F. ELSEVIER SCIENCE INC. 2020: 1891

  View details for Web of Science ID 000522979101878

• SACUBITRIL-VALSARTAN FOLLOWING HOSPITAL DISCHARGE FOR HEART FAILURE Cooper, L., Kaltenbach, L., Al-Khalidi, H., Cole, R., Allen, L. A., Fonarow, G. C., Butler, J., Albert, N. M., Lanfear, D. E., Granger, B., Kociol, R., Pina, I., Heidenreich, P., Granger, C. B., Felker, G., Lewis, E., McRae, A., Hernandez, A., DeVore, A. ELSEVIER SCIENCE INC. 2020: 1063

  View details for Web of Science ID 000522979101051

• TEMPORAL TRENDS IN SEVERITY IN CLINICAL RISK PROFILES AMONG PATIENTS HOSPITALIZED FOR HEART FAILURE Hamo, C., DeVore, A., Fonarow, G. C., Greene, S., Vaduganathan, M., Yancy, C. W., Heidenreich, P. A., Lu, D., Matsouaka, R., Butler, J. ELSEVIER SCIENCE INC. 2020: 924

  View details for Web of Science ID 000522979100910

• LIMITED TESTING FOR CORONARY ARTERY DISEASE IN PATIENTS WITH NEW-ONSET HEART FAILURE: FINDINGS FROM GET WITH THE GUIDELINES - HEART FAILURE O'Connor, K., Brophy, T., Fonarow, G. C., Blankstein, R., Swaminathan, R. V., Xu, H., Matsouaka, R., Albert, N. M., Velazquez, E. J., Yancy, C. W., Heidenreich, P. A., Hernandez, A., DeVore, A. ELSEVIER SCIENCE INC. 2020: 866

  View details for Web of Science ID 000522979100852

• WARFARIN TIME IN THERAPEUTIC RANGE TRAJECTORIES IN POTENTIAL SWITCHERS TO DIRECT ORAL ANTICOAGULANTS Pundi, K., Perino, A., Fan, J., Schmitt, S., Kothari, M., Szummer, K., Askari, M., Heidenreich, P. A., Turakhia, M. ELSEVIER SCIENCE INC. 2020: 416

  View details for Web of Science ID 000522979100406

• Patient Perceptions and Familiarity With Medical Therapy for Heart Failure Samsky, M. D., Lin, L., Greene, S. J., Lippmann, S. J., Peterson, P. N., Heidenreich, P. A., Laskey, W. K., Yancy, C. W., Greiner, M. A., Hardy, N., Kavati, A., Park, S., Mentz, R. J., Fonarow, G. C., O'Brien, E. C. AMER MEDICAL ASSOC. 2020: 292-299

  Abstract

  There are major gaps in use of guideline-directed medical therapy (GDMT) for patients with heart failure (HF). Patient-reported data outlining patient goals and preferences associated with GDMT are not available.To survey patients with chronic HF to better understand their experiences and perceptions of living with HF, including their familiarity and concerns with important GDMT therapies.Study participants were recruited from the GfK KnowledgePanel, a probability-sampled online panel representative of the US adult population. English-speaking adults who met the following criteria were eligible if they were (1) previously told by a physician that they had HF; (2) currently taking medications for HF; and (3) had no history of left ventricular assist device or cardiac transplant. Data were collected between October and November 2018. Analysis began in December 2018.The survey included 4 primary domains: (1) relative importance of disease-related goals, (2) challenges associated with living with HF, (3) decision-making process associated with HF medication use, and (4) awareness and concerns about available HF medications.Of 30 707 KnowledgePanel members who received the initial survey, 15 091 (49.1%) completed the screening questions, 440 were eligible and began the survey, and 429 completed the survey. The median (interquartile range) age was 68 (60-75) years and most were white (320 [74.6%]), male (304 [70.9%]), and had at least a high school education (409 [95.3%]). Most survey responders reported familiarity with β-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and diuretics. Overall, 107 (24.9%) reported familiarity with angiotensin receptor-neprilysin inhibitors or mineralocorticoid receptor antagonists. Overall, 136 patients (42.5%) reported have safety concerns regarding angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and 133 (38.5%) regarding β-blockers, 35 (37.9%) regarding mineralocorticoid receptor antagonists, 38 (36.5%) regarding angiotensin receptor-neprilysin inhibitors, and 123 (37.2%) regarding diuretics. Between 27.7% (n = 26) and 38.5% (n = 136) reported concerns regarding the effectiveness of β-blockers, angiotensin receptor-neprilysin inhibitors, mineralocorticoid receptor antagonists, or diuretics, while 41% (n = 132) were concerned with the effectiveness of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers.In this survey study, many patients were not familiar with GDMT for HF, with familiarity lowest for angiotensin receptor-neprilysin inhibitors and mineralocorticoid receptor antagonists. Among patients not familiar with these therapies, significant proportions questioned their effectiveness and/or safety. Enhanced patient education and shared decision-making support may be effective strategies to improve the uptake of GDMT for HF in US clinical practice.

  View details for DOI 10.1001/jamacardio.2019.4987

  View details for Web of Science ID 000527736400011

  View details for PubMedID 31734700

  View details for PubMedCentralID PMC6865328

• Is Our Diet Turning Our Gut Microbiome Against Us? Journal of the American College of Cardiology Heidenreich, P. A., Mamic, P. 2020; 75 (7): 773–75

  View details for DOI 10.1016/j.jacc.2019.12.023

  View details for PubMedID 32081287

• Care Optimization Through Patient and Hospital Engagement Clinical Trial for Heart Failure: Rationale and design of CONNECT-HF AMERICAN HEART JOURNAL DeVore, A. D., Granger, B. B., Fonarow, G. C., Al-Khalidi, H. R., Albert, N. M., Lewis, E. F., Butler, J., Pina, I. L., Heidenreich, P. A., Allen, L. A., Yancy, C. W., Cooper, L. B., Felker, G., Kaltenbach, L. A., McRae, A., Lanfear, D. E., Harrison, R. W., Kociol, R. D., Disch, M., Ariely, D., Miller, J. M., Granger, C. B., Hernandez, A. F. 2020; 220: 41-50

  Abstract

  Many therapies have been shown to improve outcomes for patients with heart failure (HF) in controlled settings, but there are limited data available to inform best practices for hospital and post-discharge quality improvement initiatives. The CONNECT-HF study is a prospective, cluster-randomized trial of 161 hospitals in the United States with a 2×2 factorial design. The study is designed to assess the effect of a hospital and post-discharge quality improvement intervention compared with usual care (primary objective) on HF outcomes and quality-of-care, as well as to evaluate the effect of hospitals implementing a patient-level digital intervention compared with usual care (secondary objective). The hospital and post-discharge intervention includes audit and feedback on HF clinical process measures and outcomes for patients with HF with reduced ejection fraction (HFrEF) paired with education to sites and clinicians by a trained, nationally representative group of HF and quality improvement experts. The patient-level digital intervention is an optional ancillary study and includes a mobile application and behavioral tools that are intended to facilitate improved use of guideline-directed recommendations for self-monitoring and self-management of activity and medications for HFrEF. The effects of the interventions will be measured through an opportunity-based composite score on quality and time-to-first HF readmission or death among patients with HFrEF who present to study hospitals with acute HF and who consent to participate. The CONNECT-HF study is evaluating approaches for implementing HF guideline recommendations into practice and is one of the largest HF implementation science trials performed to date.

  View details for DOI 10.1016/j.ahj.2019.09.012

  View details for Web of Science ID 000510852400005

  View details for PubMedID 31770656

• Cost-Effectiveness of Transitional Care Services After Hospitalization With Heart Failure. Annals of internal medicine Blum, M. R., Øien, H. n., Carmichael, H. L., Heidenreich, P. n., Owens, D. K., Goldhaber-Fiebert, J. D. 2020

  Abstract

  Patients with heart failure (HF) discharged from the hospital are at high risk for death and rehospitalization. Transitional care service interventions attempt to mitigate these risks.To assess the cost-effectiveness of 3 types of postdischarge HF transitional care services and standard care.Decision analytic microsimulation model.Randomized controlled trials, clinical registries, cohort studies, Centers for Disease Control and Prevention life tables, Centers for Medicare & Medicaid Services data, and National Inpatient Sample (Healthcare Cost and Utilization Project) data.Patients with HF who were aged 75 years at hospital discharge.Lifetime.Health care sector.Disease management clinics, nurse home visits (NHVs), and nurse case management.Quality-adjusted life-years (QALYs), costs, net monetary benefits, and incremental cost-effectiveness ratios (ICERs).All 3 transitional care interventions examined were more costly and effective than standard care, with NHVs dominating the other 2 interventions. Compared with standard care, NHVs increased QALYs (2.49 vs. 2.25) and costs ($81 327 vs. $76 705), resulting in an ICER of $19 570 per QALY gained.Results were largely insensitive to variations in in-hospital mortality, age at baseline, or costs of rehospitalization. Probabilistic sensitivity analysis confirmed that transitional care services were preferred over standard care in nearly all 10 000 samples, at willingness-to-pay thresholds of $50 000 or more per QALY gained.Transitional care service designs and implementations are heterogeneous, leading to uncertainty about intervention effectiveness and costs when applied in particular settings.In older patients with HF, transitional care services are economically attractive, with NHVs being the most cost-effective strategy in many situations. Transitional care services should become the standard of care for postdischarge management of patients with HF.Swiss National Science Foundation, Research Council of Norway, and an Intermountain-Stanford collaboration.

  View details for DOI 10.7326/M19-1980

  View details for PubMedID 31986526

• The Hospital Readmissions Reduction Program Nationwide Perspectives and Recommendations: A JACC: Heart Failure Position Paper JACC-HEART FAILURE Psotka, M. A., Fonarow, G. C., Allen, L. A., Maddox, K., Fiuzat, M., Heidenreich, P., Hernandez, A. F., Konstam, M. A., Yancy, C. W., O'Connor, C. M. 2020; 8 (1): 1-11

  Abstract

  The mandatory federal pay-for-performance Hospital Readmissions Reduction Program (HRRP) was created to decrease 30-day hospital readmissions by instituting accountability and stimulating quality care and coordination, particularly during care transitions. The HRRP has changed the landscape of hospital readmissions and reimbursement within the United States by imposing substantial Medicare payment penalties on hospitals with higher-than-expected readmission rates. However, the HRRP has been controversial since its inception, particularly in the field of heart failure. Proponents argue that it has reduced national readmission rates, in part by raising awareness and investment in mechanisms to better assist patients during discharge and transitions; opponents contend that it unfairly penalizes hospitals for issues beyond their control, has unintended negative consequences due to incentivizing readmission over survival, that it encourages "gaming" the system, was not tested before implementation, and that it does not specify how hospitals can improve their performance. This paper incorporates the diverse, nuanced, and sometimes divergent interpretations presented during a multifaceted expert clinician discussion regarding the HRRP and heart failure; in cases in which consensus opinions were achieved, they are presented, including regarding potential new iterations of the HRRP for the future. Potential improvements include more comprehensive incorporation of outcomes into the HRRP measure and better risk adjustment to improve equality and fairness.

  View details for DOI 10.1016/j.jchf.2019.07.012

  View details for Web of Science ID 000504899900001

  View details for PubMedID 31606360

• Machine learning and atherosclerotic cardiovascular disease risk prediction in a multi-ethnic population. NPJ digital medicine Ward, A., Sarraju, A., Chung, S., Li, J., Harrington, R., Heidenreich, P., Palaniappan, L., Scheinker, D., Rodriguez, F. 2020; 3 (1): 125

  Abstract

  The pooled cohort equations (PCE) predict atherosclerotic cardiovascular disease (ASCVD) risk in patients with characteristics within prespecified ranges and has uncertain performance among Asians or Hispanics. It is unknown if machine learning (ML) models can improve ASCVD risk prediction across broader diverse, real-world populations. We developed ML models for ASCVD risk prediction for multi-ethnic patients using an electronic health record (EHR) database from Northern California. Our cohort included patients aged 18 years or older with no prior CVD and not on statins at baseline (n = 262,923), stratified by PCE-eligible (n = 131,721) or PCE-ineligible patients based on missing or out-of-range variables. We trained ML models [logistic regression with L2 penalty and L1 lasso penalty, random forest, gradient boosting machine (GBM), extreme gradient boosting] and determined 5-year ASCVD risk prediction, including with and without incorporation of additional EHR variables, and in Asian and Hispanic subgroups. A total of 4309 patients had ASCVD events, with 2077 in PCE-ineligible patients. GBM performance in the full cohort, including PCE-ineligible patients (area under receiver-operating characteristic curve (AUC) 0.835, 95% confidence interval (CI): 0.825-0.846), was significantly better than that of the PCE in the PCE-eligible cohort (AUC 0.775, 95% CI: 0.755-0.794). Among patients aged 40-79, GBM performed similarly before (AUC 0.784, 95% CI: 0.759-0.808) and after (AUC 0.790, 95% CI: 0.765-0.814) incorporating additional EHR data. Overall, ML models achieved comparable or improved performance compared to the PCE while allowing risk discrimination in a larger group of patients including PCE-ineligible patients. EHR-trained ML models may help bridge important gaps in ASCVD risk prediction.

  View details for DOI 10.1038/s41746-020-00331-1

  View details for PubMedID 34552202

• Hospital meal intake in acute heart failure patients and its association with long-term outcomes. Open heart Yoshida, T. n., Shoji, S. n., Shiraishi, Y. n., Kawana, M. n., Kohno, T. n., Inoue, K. n., Fukuda, K. n., Heidenreich, P. A., Kohsaka, S. n. 2020; 7 (1)

  Abstract

  Risk prediction for hospitalised heart failure (HF, HHF) patients remains suboptimal. We aimed to determine the prognostic value of hospital food intake (FI) immediately before discharge among HHF patients.We analysed the data of 255 HHF patients extracted from the records of a single university hospital. The FI percentage of the three meals the day before hospital discharge was averaged. Patients were stratified into adequate FI (100% consumption) and inadequate FI (less than 100% consumption) groups. The primary outcome was the composite of all-cause mortality and/or HF readmission within 1 year.Only 49.3% of HHF patients consumed 100% of their meals. Patients with inadequate FI were older; predominantly women; and had a lower body mass index, higher brain natriuretic peptide levels and Clinical Frailty Scale scores at discharge than those with adequate FI. Inadequate FI was significantly associated with adverse outcomes after adjustments (HR 2.00; 95% CI 1.09 to 3.67; p=0.026). The effect of interaction by ejection fraction (EF) was highly significant: HF with preserved EF (≥40%) was significantly associated with inadequate FI with adverse outcomes (HR 4.95; 95% CI 1.71 to 14.36; p=0.003) but HF with reduced EF (<40%) was not (HR 0.77; 95% CI 0.31 to 1.95; p=0.590).The hospital FI assessment might be a simple, useful tool for predicting and stratifying risk for HHF patients.

  View details for DOI 10.1136/openhrt-2020-001248

  View details for PubMedID 32393659

• Trends in Readmission and Mortality Rates Following Heart Failure Hospitalization in the Veterans Affairs Health Care System From 2007 to 2017. JAMA cardiology Parizo, J. T., Kohsaka, S. n., Sandhu, A. T., Patel, J. n., Heidenreich, P. A. 2020; 5 (9): 1042–47

  Abstract

  The Centers for Medicare & Medicaid Services and the Veterans Affairs Health Care System provide incentives for hospitals to reduce 30-day readmission and mortality rates. In contrast with the large body of evidence describing readmission and mortality in the Medicare system, it is unclear how heart failure readmission and mortality rates have changed during this period in the Veterans Affairs Health Care System.To evaluate trends in readmission and mortality after heart failure admission in the Veterans Affairs Health Care System, which had no financial penalties, in a decade involving focus on heart failure readmission reduction (2007-2017).This cohort study used data from all Veterans Affairs-paid heart failure admissions from January 2007 to September 2017. All Veterans Affairs-paid hospital admissions to Veterans Affairs and non-Veterans Affairs facilities for a primary diagnosis of heart failure were included, when the admission was paid for by the Veterans Affairs. Data analyses were conducted from October 2018 to March 2020.Admission for a primary diagnosis of heart failure at discharge.Thirty-day all-cause readmission and mortality rates.A total of 164 566 patients with 304 374 hospital admissions were included. Among the 304 374 hospital admissions between 2007 and 2017, 298 260 (98.0%) were for male patients, and 195 205 (64.4%) were for white patients. The mean (SD) age was 70.8 (11.5) years. The adjusted odds ratio of 30-day readmission declined throughout the study period to 0.85 (95% CI, 0.83-0.88) in 2015 to 2017 compared with 2007 to 2008. The adjusted odds ratio of 30-day mortality remained stable, with an adjusted odds ratio of 1.01 (95% CI, 0.96-1.06) in 2015 to 2017 compared with 2007 to 2008. Stratification by left ventricular ejection fraction showed similar readmission reduction trends and no significant change in mortality, regardless of strata.In this analysis of an integrated health care system that provided guidance and nonfinancial incentives for reducing readmissions, such as public reporting of readmission rates, risk-adjusted 30-day readmission declined despite inclusion of clinical variables in risk adjustment, but mortality did not decline. Future investigations should focus on evaluating the effectiveness of specific approaches to readmission reduction to inform efficient and effective application in individual health systems, hospitals, and practices.

  View details for DOI 10.1001/jamacardio.2020.2028

  View details for PubMedID 32936253

• Machine learning and atherosclerotic cardiovascular disease risk prediction in a multi-ethnic population. NPJ digital medicine Ward, A. n., Sarraju, A. n., Chung, S. n., Li, J. n., Harrington, R. n., Heidenreich, P. n., Palaniappan, L. n., Scheinker, D. n., Rodriguez, F. n. 2020; 3: 125

  Abstract

  The pooled cohort equations (PCE) predict atherosclerotic cardiovascular disease (ASCVD) risk in patients with characteristics within prespecified ranges and has uncertain performance among Asians or Hispanics. It is unknown if machine learning (ML) models can improve ASCVD risk prediction across broader diverse, real-world populations. We developed ML models for ASCVD risk prediction for multi-ethnic patients using an electronic health record (EHR) database from Northern California. Our cohort included patients aged 18 years or older with no prior CVD and not on statins at baseline (n = 262,923), stratified by PCE-eligible (n = 131,721) or PCE-ineligible patients based on missing or out-of-range variables. We trained ML models [logistic regression with L2 penalty and L1 lasso penalty, random forest, gradient boosting machine (GBM), extreme gradient boosting] and determined 5-year ASCVD risk prediction, including with and without incorporation of additional EHR variables, and in Asian and Hispanic subgroups. A total of 4309 patients had ASCVD events, with 2077 in PCE-ineligible patients. GBM performance in the full cohort, including PCE-ineligible patients (area under receiver-operating characteristic curve (AUC) 0.835, 95% confidence interval (CI): 0.825-0.846), was significantly better than that of the PCE in the PCE-eligible cohort (AUC 0.775, 95% CI: 0.755-0.794). Among patients aged 40-79, GBM performed similarly before (AUC 0.784, 95% CI: 0.759-0.808) and after (AUC 0.790, 95% CI: 0.765-0.814) incorporating additional EHR data. Overall, ML models achieved comparable or improved performance compared to the PCE while allowing risk discrimination in a larger group of patients including PCE-ineligible patients. EHR-trained ML models may help bridge important gaps in ASCVD risk prediction.

  View details for DOI 10.1038/s41746-020-00331-1

  View details for PubMedID 33043149

  View details for PubMedCentralID PMC7511400

• Is Cost of Care an Expected Competency of Clinicians? Circulation. Heart failure Heidenreich, P. n. 2020: CIRCHEARTFAILURE120007866

  View details for DOI 10.1161/CIRCHEARTFAILURE.120.007866

  View details for PubMedID 33176454

• Using Discontinuity to Cross the Quality Chasm. Circulation. Cardiovascular interventions Heidenreich, P. A. 2020: CIRCINTERVENTIONS120009887

  View details for DOI 10.1161/CIRCINTERVENTIONS.120.009887

  View details for PubMedID 32883105

• Review: Adding focused cardiac US to clinical exam improves sensitivity, not specificity, for detecting CV pathology ANNALS OF INTERNAL MEDICINE Heidenreich, P. 2019; 171 (12): JC69

  View details for DOI 10.7326/ACPJ201912170-069

  View details for Web of Science ID 000506428800010

  View details for PubMedID 31842227

• Rhythm Control Versus Rate Control in Patients With Atrial Fibrillation and Heart Failure With Preserved Ejection Fraction: Insights From Get With The Guidelines-Heart Failure JOURNAL OF THE AMERICAN HEART ASSOCIATION Kelly, J. P., DeVore, A. D., Wu, J., Hammill, B. G., Sharma, A., Cooper, L. B., Felker, G., Piccini, J. P., Allen, L. A., Heidenreich, P. A., Peterson, E. D., Yancy, C. W., Fonarow, G. C., Hernandez, A. F. 2019; 8 (24): e011560

  Abstract

  Background Limited data exist to guide treatment for patients with heart failure with preserved ejection fraction and atrial fibrillation, including the important decision regarding rate versus rhythm control. Methods and Results We analyzed the Get With The Guidelines-Heart Failure (GWTG-HF) registry linked to Medicare claims data from 2008 to 2014 to describe current treatments for rate versus rhythm control and subsequent outcomes in patients with heart failure with preserved ejection fraction and atrial fibrillation using inverse probability weighted analysis. Rhythm control was defined as use of an antiarrhythmic medication, cardioversion, or AF ablation or surgery. Rate control was defined as use of any combination of β-blocker, calcium channel blocker, and digoxin without evidence of rhythm control. Among 15 682 fee-for-service Medicare patients, at the time of discharge, 1857 were treated with rhythm control and 13 825 with rate control, with minimal differences in baseline characteristics between groups. There was higher all-cause death at 1 year in the rate control compared with the rhythm control group (37.5% and 30.8%, respectively, P<0.01). The lower 1-year all-cause death in the rhythm control group remained after risk adjustment (adjusted hazard ratio, 0.86; 95% CI, 0.75-0.98; P=0.02). Conclusions Rhythm control in patients aged 65 and older with heart failure with preserved ejection fraction and AF was associated with a lower risk of 1 year all-cause mortality. Future prospective randomized studies are needed to explore this potential benefit.

  View details for DOI 10.1161/JAHA.118.011560

  View details for Web of Science ID 000514326200019

  View details for PubMedID 31818219

  View details for PubMedCentralID PMC6951063

• PARAGON-HF Clinical Trial Eligibility in a Population of Patients Hospitalized With Heart Failure JOURNAL OF CARDIAC FAILURE Sayeed, S., Fudim, M., Devore, A. D., Xu, H., Matsouaka, R. A., Heidenreich, P. A., Yancy, C. W., Fonarow, G. C., Hernandez, A. F. 2019; 25 (12): 1009-1011

  View details for DOI 10.1016/j.cardfail.2019.10.003

  View details for Web of Science ID 000504524500010

  View details for PubMedID 31626949

• 2019 AHA/ACC Clinical Performance and Quality Measures for Adults With High Blood Pressure JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Casey, D. E., Thomas, R. J., Bhalla, V., Commodore-Mensah, Y., Heidenreich, P. A., Kolte, D., Muntner, P., Smith, S. C., Spertus, J. A., Windle, J. R., Wozniak, G. D., Ziaeian, B. 2019; 74 (21): 2661-2706

  View details for DOI 10.1016/j.jacc.2019.10.001

  View details for Web of Science ID 000497667700015

  View details for PubMedID 31732293

  View details for PubMedCentralID PMC7673043

• Direct Oral Anticoagulant Adherence of Atrial Fibrillation Patients Transitioned From Warfarin: Insights From the Veterans Health Administration Pundi, K., Perino, A. C., Fan, J., Schmitt, S., Askari, M., Szummer, K., Heidenreich, P. A., Turakhia, M. LIPPINCOTT WILLIAMS & WILKINS. 2019

  View details for Web of Science ID 000529998002122

• Patient Perceptions and Familiarity With Medical Therapy for Heart Failure Samsky, M. D., Lin, L., Greene, S. J., Lippmann, S., Peterson, P., Heidenreich, P. A., Laskey, W. K., Yancy, C. W., Greiner, M., Hardy, C., Kavati, A., Park, N., Mentz, R. J., Fonarow, G. C., Obrien, E. C. LIPPINCOTT WILLIAMS & WILKINS. 2019

  View details for Web of Science ID 000529998006349

• Clinical Effectiveness of Sacubitril/valsartan among Patients Hospitalized for Heart Failure with Reduced Ejection Fraction Greene, S. J., Lippmann, S. J., Mentz, R. J., Greiner, M. A., Hardy, N., Chang, C., Hammill, B. G., Luo, N., Samsky, M. D., Heidenreich, P. A., Laskey, W. K., Yancy, C. W., Peterson, P. N., Curtis, L. H., Hernandez, A. F., Fonarow, G. C., O'Brien, E. C. CHURCHILL LIVINGSTONE INC MEDICAL PUBLISHERS. 2019: 937

  View details for DOI 10.1016/j.cardfail.2019.11.003

  View details for Web of Science ID 000501939800014

• 2019 AHA/ACC Clinical Performance and Quality Measures for Adults With High Blood Pressure: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES Casey, D. E., Thomas, R. J., Bhalla, V., Commodore-Mensah, Y., Heidenreich, P. A., Kolte, D., Muntner, P., Smith, S. C., Spertus, J. A., Windle, J. R., Wozniak, G. D., Ziaeian, B. 2019; 12 (11): e000057

  View details for DOI 10.1161/HCQ.0000000000000057

  View details for Web of Science ID 000502609000001

  View details for PubMedID 31714813

• Differences in Transcatheter Aortic Valve Replacement (TAVR) Outcomes by Gender and Race Over Time Yong, C., Jaluba, K., Heidenreich, P. ELSEVIER SCIENCE INC. 2019: B732

  View details for Web of Science ID 000487306300733

• Incidence of Amyloidosis in the US Veterans Health Administration Kovacsovics, T., Redd, A., Kalsy, M., Heidenreich, P., Garvin, J., Nativi-Nicolau, J. CIG MEDIA GROUP, LP. 2019: E322-E323

  View details for DOI 10.1016/j.clml.2019.09.530

  View details for Web of Science ID 000491229800527

• Characteristics of Academic Physicians Associated With Patient Satisfaction AMERICAN JOURNAL OF MEDICAL QUALITY Heidenreich, P., Shieh, L., Fassiotto, M., Kahn, J., Weinacker, A., Smith, R., Trockel, M., Shanafelt, T., Palaniappan, L. 2019: 1062860619876344

  View details for DOI 10.1177/1062860619876344

  View details for Web of Science ID 000488727200001

  View details for PubMedID 31529975

• Electronic health record-based clinical decision support alert for severe sepsis: a randomised evaluation BMJ QUALITY & SAFETY Downing, N., Rolnick, J., Poole, S. F., Hall, E., Wessels, A. J., Heidenreich, P., Shieh, L. 2019; 28 (9): 762–68

  View details for DOI 10.1136/bmjqs-2018-008765

  View details for Web of Science ID 000511918800011

• 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society HEART RHYTHM January, C. T., Wann, L., Calkins, H., Chen, L. Y., Cigarroa, J. E., Cleveland, J. C., Ellinor, P. T., Ezekowitz, M. D., Field, M. E., Furie, K. L., Heidenreich, P. A., Murray, K. T., Shea, J. B., Tracy, C. M., Yancy, C. W. 2019; 16 (8): E66–E93

  View details for DOI 10.1016/j.hrthm.2019.01.024

  View details for Web of Science ID 000477570700008

  View details for PubMedID 30703530

• Increasing Number of Amyloidosis Diagnosis in the Veterans Affairs Populations Nativi-Nicolau, J., Redd, A., Kelly, N., Kalsy, M., Garvin, J. H., Heidenreich, P. CHURCHILL LIVINGSTONE INC MEDICAL PUBLISHERS. 2019: S96

  View details for Web of Science ID 000482698000258

• Representativeness of the PIONEER-HF Clinical Trial Population in Patients Hospitalized with Heart Failure Sayeed, S., Fudim, M., Xu, H., Matsouaka, R., Heidenreich, P. A., Yancy, C. W., Fonarows, G. C., Velazquez, E. J., Hernandez, A. F., DeVore, A. D. CHURCHILL LIVINGSTONE INC MEDICAL PUBLISHERS. 2019: S151

  View details for DOI 10.1016/j.cardfail.2019.07.436

  View details for Web of Science ID 000482698000415

• Patient-Reported Outcomes: The Future of HeartFailure Care. JACC. Heart failure Heidenreich, P. A. 2019

  View details for DOI 10.1016/j.jchf.2019.06.006

  View details for PubMedID 31401093

• 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society (vol 74, pg 104, 2019) JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY January, C. T., Wann, L. S., Calkins, H., Chen, L. Y., Cigarroa, J. E., Cleveland, J. C., Ellinor, P. T., Ezekowitz, M. D., Field, M. E., Furie, K. L., Heidenreich, P. A., Murray, K. T., Shea, J. B., Tracy, C. M., Yancy, C. W. 2019; 74 (4): 599

  View details for DOI 10.1016/j.jacc.2019.06.034

  View details for Web of Science ID 000476594000023

• Body mass index and outcomes of cardiac resynchronization with implantable cardioverter-defibrillator therapy in older patients with heart failure. European journal of heart failure Echouffo-Tcheugui, J. B., Masoudi, F. A., Bao, H., Curtis, J. P., Heidenreich, P. A., Fonarow, G. C. 2019

  Abstract

  AIMS: To assess the association of body mass index (BMI) with heart failure (HF) outcomes after cardiac resynchronization therapy with defibrillator (CRT-D) implantation.METHODS AND RESULTS: Medicare beneficiaries with HF aged ≥65years (n=18922) undergoing first-time CRT-D from the National Cardiovascular Data Registry (NCDR) Implantable Cardioverter-Defibrillator Registry between 2010 and 2013, were followed for 3years post-implantation. Survival curves and covariate adjusted hazard ratio (aHR) or odds ratio were used to assess the risks for death, readmission, and device-related complications by BMI status. Of 18922 HF patients receiving CRT-D, 5265 (27.8%) were normal weight, 6896 (37%) were overweight, 6318 (33.4%) were obese, and 353 (1.8%) were underweight. Compared to those of normal weight (BMI 18.5-24.9kg/m2 ), underweight patients had a higher 3-year post-device implantation risk of death [aHR: 1.34 (95% confidence interval 1.09-1.65); P<0.001] and of readmission [sub-aHR: 1.25 (1.09-1.42); P<0.001]. The corresponding 3-year aHRs for death were 0.83 (0.77-0.89) for overweight, 0.74 (0.67-0.82) for obesity class I (BMI 30-34.9kg/m2 ), 0.78 (0.68-0.90) for obesity class II (BMI 35-39.9kg/m2 ), and 0.75 (0.60-0.93) for obesity class III (BMI ≥40kg/m2 , P for all categories <0.001). Individuals with class III obesity had a higher risk of readmission [sub-aHR: 1.17 (1.06-1.30)]. There were no differences in rates of device-related complications within 90days across BMI categories.CONCLUSION: Most elderly patients with HF receiving CRT-D were overweight or obese. While being underweight was associated with greater risks of death and hospitalization, overweight and obese patients were at lower risk of death after CRT-D.

  View details for DOI 10.1002/ejhf.1552

  View details for PubMedID 31359595

• Association Between Heart Failure and Postoperative Mortality Among Patients Undergoing Ambulatory Noncardiac Surgery. JAMA surgery Lerman, B. J., Popat, R. A., Assimes, T. L., Heidenreich, P. A., Wren, S. M. 2019

  Abstract

  Importance: Heart failure is an established risk factor for postoperative mortality, but how heart failure is associated with operative outcomes specifically in the ambulatory surgical setting is not well characterized.Objective: To assess the risk of postoperative mortality and complications in patients with vs without heart failure at various levels of echocardiographic (left ventricular systolic dysfunction) and clinical (symptoms) severity who were undergoing ambulatory surgery.Design, Setting, and Participants: In this US multisite retrospective cohort study of all adult patients undergoing ambulatory, elective, noncardiac surgery in the Veterans Affairs Surgical Quality Improvement Project database during fiscal years 2009 to 2016, a total of 355 121 patient records were identified and analyzed with 1 year of follow-up after surgery (final date of follow-up September 1, 2017).Exposures: Heart failure, left ventricular ejection fraction, and presence of signs or symptoms of heart failure within 30 days of surgery.Main Outcomes and Measures: The primary outcomes were postoperative mortality at 90 days and any postoperative complication at 30 days.Results: Among 355 121 total patients, outcome data from 19 353 patients with heart failure (5.5%; mean [SD] age, 67.9 [10.1] years; 18 841 [96.9%] male) and 334 768 patients without heart failure (94.5%; mean [SD] age, 57.2 [14.0] years; 301 198 [90.0%] male) were analyzed. Compared with patients without heart failure, patients with heart failure had a higher risk of 90-day postoperative mortality (crude mortality risk, 2.00% vs 0.39%; adjusted odds ratio [aOR], 1.95; 95% CI, 1.69-2.44), and risk of mortality progressively increased with decreasing systolic function. Compared with patients without heart failure, symptomatic patients with heart failure had a greater risk of mortality (crude mortality risk, 3.57%; aOR, 2.76; 95% CI, 2.07-3.70), as did asymptomatic patients with heart failure (crude mortality risk, 1.85%; aOR, 1.85; 95% CI, 1.60-2.15). Patients with heart failure had a higher risk of experiencing a 30-day postoperative complication than did patients without heart failure (crude risk, 5.65% vs 2.65%; aOR, 1.10; 95% CI, 1.02-1.19).Conclusions and Relevance: In this study, among patients undergoing elective, ambulatory surgery, heart failure with or without symptoms was significantly associated with 90-day mortality and 30-day postoperative complications. These data may be helpful in preoperative discussions with patients with heart failure undergoing ambulatory surgery.

  View details for DOI 10.1001/jamasurg.2019.2110

  View details for PubMedID 31290953

• 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY January, C. T., Wann, L., Calkins, H., Chen, L. Y., Cigarroa, J. E., Cleveland, J. C., Ellinor, P. T., Ezekowitz, M. D., Field, M. E., Furie, K. L., Heidenreich, P. A., Murray, K. T., Shea, J. B., Tracy, C. M., Yancy, C. W., Levine, G. N., O'Gara, P. T., Halperin, J. L., Al-Khatib, S. M., Beckman, J. A., Birtcher, K. K., Bozkurt, B., Brindis, R. G., Cigarroa, J. E., Curtis, L. H., Deswal, A., Fleisher, L. A., Gentile, F., Gidding, S., Goldberger, Z. D., Hlatky, M. A., Ikonomidis, J., Joglar, J. A., Mauri, L., Piano, M. R., Pressler, S. J., Riegel, B., Wijeysundera, D. N., ACC AHA Task Force Members 2019; 74 (1): 104–32

  View details for DOI 10.1016/j.jacc.2019.01.011

  View details for Web of Science ID 000473259200015

  View details for PubMedID 30703431

• 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons CIRCULATION January, C. T., Wann, L., Calkins, H., Chen, L. Y., Cigarroa, J. E., Cleveland, J. C., Ellinor, P. T., Ezekowitz, M. D., Field, M. E., Furie, K. L., Heidenreich, P. A., Murray, K. T., Shea, J. B., Tracy, C. M., Yancy, C. W., Levine, G. N., O'Gara, P. T., Halperin, J. L., Al-Khatib, S. M., Beckman, J. A., Birtcher, K. K., Bozkurt, B., Brindis, R. G., Cigarroa, J. E., Curtis, L. H., Deswal, A., Fleisher, L. A., Gentile, F., Gidding, S., Goldberger, Z. D., Hlatky, M. A., Ikonomidis, J., Joglar, J. A., Mauri, L., Piano, M. R., Pressler, S. J., Riegel, B., Wijeysundera, D. N., Valentine, C., Attebery, T. W., Oetgen, W. J., Elma, M., Scholtz, A., Sheehan, K. A., Abdullah, A. R., Getchius, T. D., Benjamin, I. J., Brown, N., Robertson, R., Whitman, G. R., Leonard, A., Hundley, J., ACC AHA Task Force, Amer Coll Cardiology 2019; 140 (2): E125–E151

  View details for DOI 10.1161/CIR.0000000000000665

  View details for Web of Science ID 000476768100010

  View details for PubMedID 30686041

• Studies Evaluating Statin Adherence and Outcome Should Adjust for Smoking Persistence and Antiplatelet Treatment Discontinuation-Reply. JAMA cardiology Rodriguez, F., Maron, D. J., Heidenreich, P. A. 2019

  View details for DOI 10.1001/jamacardio.2019.1969

  View details for PubMedID 31241723

• 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines (vol 73, pg 3168, 2019) JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., Braun, L. T., de Ferranti, S., Faiella-Tommasino, J., Forman, D. E., Goldberg, R., Heidenreich, P. A., Hlatky, M. A., Jones, D. W., Lloyd-Jones, D., Lopez-Pajares, N., Ndumele, C. E., Orringer, C. E., Peralta, C. A., Saseen, J. J., Smith, S. C., Sperling, L., Virani, S. S., Yeboah, J. 2019; 73 (24): 3234-3237

  View details for DOI 10.1016/j.jacc.2019.05.012

  View details for Web of Science ID 000471773400023

• 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., Braun, L. T., de Ferranti, S., Faiella-Tommasino, J., Forman, D. E., Goldberg, R., Heidenreich, P. A., Hlatky, M. A., Jones, D. W., Lloyd-Jones, D., Lopez-Pajares, N., Ndumele, C. E., Orringer, C. E., Peralta, C. A., Saseen, J. J., Smith, S. C., Sperling, L., Virani, S. S., Yeboah, J., Levine, G. N., O'Gara, P. T., Al-Khatib, S. M., Beckman, J. A., Birtcher, K. K., Bozkurt, B., Brindis, R. G., Cigarroa, J. E., Curtis, L. H., Deswal, A., Fleisher, L. A., Gentile, F., Gidding, S., Goldberger, Z. D., Hlatky, M. A., Ikonomidis, J., Joglar, J. A., Mauri, L., Piano, M. R., Pressler, S. J., Riegel, B., Wijeysundera, D. N., Amer Coll Cardiology, Amer Heart Assoc Task Force 2019; 73 (24): E285-U87

  View details for DOI 10.1016/j.jacc.2018.11.003

  View details for Web of Science ID 000471773400001

  View details for PubMedID 30423393

• 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., Braun, L. T., de Ferranti, S., Faiella-Tommasino, J., Forman, D. E., Goldberg, R., Heidenreich, P. A., Hlatky, M. A., Jones, D. W., Lloyd-Jones, D., Lopez-Pajares, N., Ndumele, C. E., Orringer, C. E., Peralta, C. A., Saseen, J. J., Smith, S. C., Sperling, L., Virani, S. S., Yeboah, J., Levine, G. N., O'Gara, P. T., Halperin, J. L., Al-Khatib, S. M., Beckman, J. A., Birtcher, K. K., Bozkurt, B., Brindis, R. G., Cigarroa, J. E., Curtis, L. H., Deswal, A., Fleisher, L. A., Gentile, F., Gidding, S., Goldberger, Z. D., Hlatky, M. A., Ikonomidis, J., Joglar, J. A., Mauri, L., Piano, M. R., Pressler, S. J., Riegel, B., Wijeysundera, D. N., Amer Coll Cardiology, Amer Heart Assoc Task Force 2019; 73 (24): 3168-3209

  View details for DOI 10.1016/j.jacc.2018.11.002

  View details for Web of Science ID 000471773400017

  View details for PubMedID 30423391

• 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines CIRCULATION Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., Braun, L. T., de Ferranti, S., Faiella-Tommasino, J., Forman, D. E., Goldberg, R., Heidenreich, P. A., Hlatky, M. A., Jones, D. W., Lloyd-Jones, D., Lopez-Pajares, N., Ndumele, C. E., Orringer, C. E., Peralta, C. A., Saseen, J. J., Smith, S. C., Sperling, L., Virani, S. S., Yeboah, J. 2019; 139 (25): E1046–E1081

  View details for DOI 10.1161/CIR.0000000000000624

  View details for Web of Science ID 000471794100004

  View details for PubMedID 30565953

• 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines CIRCULATION Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., Braun, L. T., de Ferranti, S., Faiella-Tommasino, J., Forman, D. E., Goldberg, R., Heidenreich, P. A., Hlatky, M. A., Jones, D. W., Lloyd-Jones, D., Lopez-Pajares, N., Ndumele, C. E., Orringer, C. E., Peralta, C. A., Saseen, J. J., Smith, S. C., Sperling, L., Virani, S. S., Yeboah, J. 2019; 139 (25): E1082–E1143

  View details for DOI 10.1161/CIR.0000000000000625

  View details for Web of Science ID 000471794100005

  View details for PubMedID 30586774

• 2018 Cholesterol Clinical Practice Guidelines: Synopsis of the 2018 American Heart Association/American College of Cardiology/Multisociety Cholesterol Guideline ANNALS OF INTERNAL MEDICINE Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., Braun, L. T., de Ferranti, S., Faiella-Tommasino, J., Forman, D. E., Goldberg, R., Heidenreich, P. A., Hlatky, M. A., Jones, D. W., Lloyd-Jones, D., Lopez-Pajares, N., Ndumele, C. E., Orringer, C. E., Peralta, C. A., Saseen, J. J., Smith, S. C., Sperling, L., Virani, S. S., Yeboah, J., Guideline Writing Comm 2018 Choles 2019; 170 (11): 779-+

  Abstract

  In November 2018, the American Heart Association and American College of Cardiology (AHA/ACC) released a new clinical practice guideline on cholesterol management. It was accompanied by a risk assessment report on primary prevention of atherosclerotic cardiovascular disease (ASCVD).A panel of experts free of recent and relevant industry-related conflicts was chosen to carry out systematic reviews and meta-analyses of randomized controlled trials (RCTs) that examined cardiovascular outcomes. High-quality observational studies were used for estimation of ASCVD risk. An independent panel systematically reviewed RCT evidence about the benefits and risks of adding nonstatin medications to statin therapy compared with receiving statin therapy alone in persons who have or are at high risk for ASCVD.The guideline endorses a heart-healthy lifestyle beginning in childhood to reduce lifetime risk for ASCVD. It contains several new features compared with the 2013 guideline. For secondary prevention, patients at very high risk may be candidates for adding nonstatin medications (ezetimibe or proprotein convertase subtilisin/kexin type 9 [PCSK9] inhibitors) to statin therapy. In primary prevention, a clinician-patient risk discussion is still strongly recommended before a decision is made about statin treatment. The AHA/ACC risk calculator first triages patients into 4 risk categories. Those at intermediate risk deserve a focused clinician-patient discussion before initiation of statin therapy. Among intermediate-risk patients, identification of risk-enhancing factors and coronary artery calcium testing can assist in the decision to use a statin. Compared with the 2013 guideline, the new guideline gives more attention to percentage reduction in low-density lipoprotein cholesterol as a treatment goal and to long-term monitoring of therapeutic efficacy. To simplify monitoring, nonfasting lipid measurements are allowed.

  View details for DOI 10.7326/M19-0365

  View details for Web of Science ID 000470015600007

  View details for PubMedID 31132793

• Accuracy of Administrative Coding to Identify Reduced and Preserved Left Ventricular Ejection Fraction JOURNAL OF CARDIAC FAILURE Heidenreich, P. A., Natarajan, S., Bahrami, H. 2019; 25 (6): 486–89

  View details for DOI 10.1016/j.cardfail.2019.01.019

  View details for Web of Science ID 000472240500011

• Can We Do More With Less While Building Predictive Models? A Study in Parsimony of Risk Models for Predicting Heart Failure Readmissions. Computers, informatics, nursing : CIN Mahajan, S. M., Mahajan, A., Burman, P., Heidenreich, P. 2019; 37 (6): 306-314

  Abstract

  Hospital readmission due to heart failure is a topic of concern for patients and hospitals alike: it is both the most frequent and expensive diagnosis for hospitalization. Therefore, accurate prediction of readmission risk while patients are still in the hospital helps to guide appropriate postdischarge interventions. As our understanding of the disease and the volume of electronic health record data both increase, the number of predictors and model-building time for predicting risk grow rapidly. This suggests a need to use methods for reducing the number of predictors without losing predictive performance. We explored and described three such methods and demonstrated their use by applying them to a real-world dataset consisting of 57 variables from health data of 1210 patients from one hospital system. We compared all models generated from predictor reduction methods against the full, 57-predictor model for predicting risk of 30-day readmissions for patients with heart failure. Our predictive performance, measured by the C-statistic, ranged from 0.630 to 0.840, while model-building time ranged from 10 minutes to 10 hours. Our final model achieved a C-statistic (0.832) comparable to the full model (0.840) in the validation cohort while using only 16 predictors and providing a 66-fold improvement in model-building time.

  View details for DOI 10.1097/CIN.0000000000000499

  View details for PubMedID 33055494

• Can We Do More With Less While Building Predictive Models? A Study in Parsimony of Risk Models for Predicting Heart Failure Readmissions CIN-COMPUTERS INFORMATICS NURSING Mahajan, S. M., Mahajan, A., Burman, P., Heidenreich, P. 2019; 37 (6): 306–14

  View details for DOI 10.1097/CIN.0000000000000499

  View details for Web of Science ID 000470750000005

• Association of post-discharge specialty outpatient visits with readmissions and mortality in high-risk heart failure patients AMERICAN HEART JOURNAL Edmonston, D. L., Wu, J., Matsouaka, R. A., Yancy, C., Heidenreich, P., Pina, I. L., Hernandez, A., Fonarow, G. C., DeVore, A. D. 2019; 212: 101–12

  View details for DOI 10.1016/j.ahj.2019.03.005

  View details for Web of Science ID 000468402300011

• Practice Variation in Anticoagulation Prescription and Outcomes After Device-Detected Atrial Fibrillation Insights From the Veterans Health Administration CIRCULATION Perino, A. C., Fan, J., Askari, M., Heidenreich, P. A., Keung, E., Raitt, M. H., Piccini, J. P., Ziegler, P. D., Turakhia, M. P. 2019; 139 (22): 2502–12

  View details for DOI 10.1161/CIRCULATIONAHA.118.038988

  View details for Web of Science ID 000478903500005

• Engaging Cardiology Providers in Quality Measurement. Journal of the American Heart Association Heidenreich, P., Sandhu, A., Schofield, R. 2019; 8 (9): e012519

  Abstract

  See Article Segal etal.

  View details for PubMedID 31020894

• Engaging Cardiology Providers in Quality Measurement JOURNAL OF THE AMERICAN HEART ASSOCIATION Heidenreich, P., Sandhu, A., Schofield, R. 2019; 8 (9)

  View details for DOI 10.1161/JAHA.119.012519

  View details for Web of Science ID 000484574700058

• A paradoxical relationship between hemoglobin A1C and in-hospital mortality in intracerebral hemorrhage patients. Heliyon Dandapat, S., Siddiqui, F. M., Fonarow, G. C., Bhatt, D. L., Xu, H., Matsouaka, R., Heidenreich, P. A., Xian, Y., Schwamm, L. H., Smith, E. E. 2019; 5 (5): e01659

  Abstract

  Objectives: The relationship between prior glycemic status and outcomes in intracerebral hemorrhage (ICH) is not established. We hypothesized that higher hemoglobin (Hb) A1c is associated with worse outcomes in ICH.Patients and methods: Using the GWTG-Stroke registry, data on patients with ICH between April 1, 2003 and September 30, 2015 were harvested. Patients were divided into four ordinal groups based on HbA1c values of <5.7%, 5.7-6.4%, 6.5-8.0% and >8.0%. Outcomes (mortality, modified Rankin Scale (mRS), home discharge and independent ambulatory status) were analyzed for patients overall and separately for patients with or without history of diabetes using multivariable regression models.Results: Among 75,455 patients with ICH (with available HbA1c data), patients with lower HbA1c (<5.7%) had higher rates of in-hospital mortality in the entire cohort (15.5%; 3947/25473); as well as those with history of diabetes (19.0%; 542/2852). Among those without history of diabetes, both lower HbA1c (15.1%; 3405/22621) and higher HbA1c (>8.0%), (15.0%; 205/1364) were associated with higher in-hospital mortality. Lower HbA1c was also associated with higher mRS, less chance of going home, and lower likelihood of having independent ambulatory status in patients with prior history of diabetes.Conclusions: Among patients with no reported history of diabetes, both very low and very high HbA1c were directly associated with higher in-hospital mortality. Only very low HbA1c was associated with higher mortality in known diabetic patients. Further studies are needed to better define the relationship between HbA1c and outcomes, for it may have important implications for care of ICH patients.

  View details for DOI 10.1016/j.heliyon.2019.e01659

  View details for PubMedID 31111113

• Long-term outcomes for heart failure patients with and without diabetes: From the Get With The Guidelines-Heart Failure Registry AMERICAN HEART JOURNAL Ziaeian, B., Hernandez, A. F., DeVore, A. D., Wu, J., Xu, H., Heidenreich, P. A., Matsouaka, R. A., Bhatt, D. L., Yancy, C. W., Fonarow, G. C. 2019; 211: 1-10

  Abstract

  Diabetes mellitus is an increasingly prevalent condition among heart failure (HF) patients. The long-term morbidity and mortality among patients with and without diabetes with HF with reduced (HFrEF), borderline (HFbEF), and preserved ejection fraction (HFpEF) are not well described.Using the Get With The Guidelines (GWTG)-HF Registry linked to Centers for Medicare & Medicaid Services claims data, we evaluated differences between HF patients with and without diabetes. Adjusted Cox proportional-hazard models controlling for patient and hospital characteristics were used to evaluate mortality and readmission outcomes.A cohort of 86,659 HF patients aged ≥65 years was followed for 3 years from discharge. Unadjusted all-cause mortality was between 4.4% and 5.5% and all-cause hospitalization was between 19.4% and 22.6% for all groups at 30 days. For all-cause mortality at 3 years from hospital discharge, diabetes was associated with an adjusted hazard ratio of 1.27 (95% CI 1.07-1.49, P = .0051) for HFrEF, 0.95 (95% CI 0.55-1.65, P = .8536) for HFbEF, 1.02 (95% CI 0.87-1.19, P = .8551) for HFpEF. For all-cause readmission, diabetes was associated with an adjusted hazard ratio of 1.06 (95% CI 0.87-1.29, P = .5585) for HFrEF, 1.48 (95% CI 1.15-1.90, P = .0023) for HFbEF, and 1.06 (95% CI 0.91-1.22, P = .4747) for HFpEF.HFrEF and HFbEF patients with diabetes are at increased risk for mortality and rehospitalization after hospitalization for HF, independent of other patient and hospital characteristics. Among HFpEF patients, diabetes does not appear to be independently associated with significant additional risks.

  View details for DOI 10.1016/j.ahj.2019.01.006

  View details for Web of Science ID 000464522600001

  View details for PubMedID 30818060

  View details for PubMedCentralID PMC7664459

• Association of post-discharge specialty outpatient visits with readmissions and mortality in high-risk heart failure patients. American heart journal Edmonston, D. L., Wu, J., Matsouaka, R. A., Yancy, C., Heidenreich, P., Pina, I. L., Hernandez, A., Fonarow, G. C., DeVore, A. D. 2019; 212: 101–12

  Abstract

  Heart failure (HF) outcomes are especially poor in high-risk patients with certain comorbidities including diabetes mellitus (DM), chronic kidney disease (CKD), and chronic obstructive pulmonary disease (COPD). Whether early specialty or primary care provider (PCP) follow-up after HF discharge affects outcomes in high-risk patients is unknown.METHODS: We analyzed patients discharged from a Get With The Guidelines HF-participating hospital from 2007-2012 with linked Medicare claims to investigate the association of medical specialist visit within 14 days of discharge stratified by comorbidity with the primary outcome of 90-day HF readmission. Secondary outcomes included 90-day and 1-year all-cause mortality.RESULTS: Out of 33,243 patients, 39.4% had DM, 19.8% had CKD, 30.0% had COPD, and 36.3% had no key comorbidity. Nephrologist visit in patients with CKD was associated with a 35% reduction in 90-day HF readmission (hazard ratio [HR] 0.65, 95% confidence interval [CI] 0.49-0.85). Pulmonologist visit in patients with COPD was associated with a 29% reduction in 90-day HF readmission (HR 0.71, 95% CI 0.55-0.91). In patients with no key comorbidity, PCP and Cardiologist visits were associated with decreased 90-day mortality (HR for PCP 0.79, 95% CI 0.66-0.94; HR for Cardiologist 0.78, 95% CI 0.63-0.96). In patients with DM, Endocrinologist visit was associated with a 42% reduction of 90-day mortality (HR 0.58, 95% CI 0.34-0.99).CONCLUSIONS: Specialist and PCP visit in the immediate post-discharge period may improve 90-day HF readmission and mortality in certain high-risk groups of patients with HF.

  View details for PubMedID 30978555

• Practice Variation in Anticoagulation Prescription and Outcomes after Device-Detected Atrial Fibrillation: Insights from the Veterans Health Administration. Circulation Perino, A. C., Fan, J., Askari, M., Heidenreich, P. A., Keung, E., Raitt, M. H., Piccini, J. P., Ziegler, P. D., Turakhia, M. P. 2019

  Abstract

  BACKGROUND: Device-detected atrial fibrillation (AF) is associated with increased risk of stroke. However, there are no clearly-defined thresholds of AF burden for which to initiate oral anticoagulation (OAC). We sought to describe OAC prescription practice variation in response to new device-detected AF and the association to outcomes.METHODS: We performed a retrospective cohort study using data from the Veterans Health Administration linked to remote monitoring data that included day-level AF burden. We included patients with cardiac implantable electronic devices (CIED) and remote monitoring from 2011-2014, CHA2DS2-VASc ≥2, and no prior stroke or OAC receipt in the preceding 2 years. We determined the proportion of patients prescribed OAC within 90-days following new device-detected AF across a range of AF thresholds (≥6 minutes to >24 hours), and examined site variation in OAC prescription. We used multivariable Cox proportional hazards regressions to determine the association of OAC prescription with stroke by device-detected AF burden.RESULTS: Among 10,212 patients with CIEDs, 4,570 patients (45%), 3,969 patients (39%), 3,263 patients (32%), and 2,469 patients (24%) had device-detected AF >6 minutes, >1 hour, >6 hours, and >24 hours, respectively. For device-detected AF >1 hour, 1,712 patients met inclusion criteria (72±10 years; 1.5% female; CHA2DS2-VASc 4.0±1.4; HAS-BLED 2.6±1.1). The proportion receiving OAC varied based on device-detected AF burden (≥6 minutes: 272/2,101 (13%); >1 hour: 273/1,712 (16%); >6 hours: 263/1,279 (21%); >24 hours: 224/818 (27%)). Across 52 sites (N=1,329 patients), there was substantial site-level variation in OAC prescription after device-detected AF >1 hour (median: 16%; range: 3%-67%; median odds ratio: 1.56 [95% credible interval 1.49-1.71]). In adjusted models, OAC prescription after device-detected AF >24 hours was associated with reduced stroke risk (HR 0.28, 95% CI 0.10-0.81, p=0.02), although the propensity-adjusted model was significant when AF lasted at least 6 minutes.CONCLUSIONS: Among Veterans with CIEDs, device-detected AF is common. There is large practice variation in 90-day OAC initiation after new device-detected AF with low rates of treatment overall, even for episodes >24 hours. The strongest association of OAC with reduction in stroke was observed after device-detected AF >24 hours. Randomized trials are needed to confirm these observational findings.

  View details for PubMedID 30880434

• Electronic health record-based clinical decision support alert for severe sepsis: a randomised evaluation. BMJ quality & safety Downing, N. L., Rolnick, J., Poole, S. F., Hall, E., Wessels, A. J., Heidenreich, P., Shieh, L. 2019

  Abstract

  BACKGROUND: Sepsis remains the top cause of morbidity and mortality of hospitalised patients despite concerted efforts. Clinical decision support for sepsis has shown mixed results reflecting heterogeneous populations, methodologies and interventions.OBJECTIVES: To determine whether the addition of a real-time electronic health record (EHR)-based clinical decision support alert improves adherence to treatment guidelines and clinical outcomes in hospitalised patients with suspected severe sepsis.DESIGN: Patient-level randomisation, single blinded.SETTING: Medical and surgical inpatient units of an academic, tertiary care medical centre.PATIENTS: 1123 adults over the age of 18 admitted to inpatient wards (intensive care units (ICU) excluded) at an academic teaching hospital between November 2014 and March 2015.INTERVENTIONS: Patients were randomised to either usual care or the addition of an EHR-generated alert in response to a set of modified severe sepsis criteria that included vital signs, laboratory values and physician orders.MEASUREMENTS AND MAIN RESULTS: There was no significant difference between the intervention and control groups in primary outcome of the percentage of patients with new antibiotic orders at 3hours after the alert (35% vs 37%, p=0.53). There was no difference in secondary outcomes of in-hospital mortality at 30 days, length of stay greater than 72hours, rate of transfer to ICU within 48hours of alert, or proportion of patients receiving at least 30mL/kg of intravenous fluids.CONCLUSIONS: An EHR-based severe sepsis alert did not result in a statistically significant improvement in several sepsis treatment performance measures.

  View details for PubMedID 30872387

• EVALUATION OF TRENDS IN READMISSION AND MORTALITY RATES AFTER HEART FAILURE HOSPITALIZATION IN THE VETERANS AFFAIRS HEALTH CARE SYSTEM BETWEEN 2007 AND 2017 Parizo, J., Kohsaka, S., Sandhu, A., Patel, J., Heidenreich, P. ELSEVIER SCIENCE INC. 2019: 737

  View details for Web of Science ID 000460565900737

• HOW MUCH ATRIAL FIBRILLATION IS TOO MUCH? TREATMENT BENEFIT OF ANTICOAGULATION BASED ON THRESHOLD OF DEVICE-DETECTED AF Perino, A., Fan, J., Askari, M., Heidenreich, P., Keung, E., Piccini, J., Ziegler, P., Turakhia, M. ELSEVIER SCIENCE INC. 2019: 290

  View details for Web of Science ID 000460565900290

• IMPACT OF PATIENT FRAILTY ON ONE-YEAR MORTALITY ACROSS CHA2DS2-VASC SCORES: FROM THE TREAT-AF STUDY Pundi, K., Perino, A., Fan, J., Askari, M., Heidenreich, P., Turakhia, M. ELSEVIER SCIENCE INC. 2019: 539

  View details for Web of Science ID 000460565900539

• Association of Statin Adherence With Mortality in Patients With Atherosclerotic Cardiovascular Disease JAMA CARDIOLOGY Rodriguez, F., Maron, D. J., Knowles, J. W., Virani, S. S., Lin, S., Heidenreich, P. A. 2019; 4 (3): 206–13

  View details for DOI 10.1001/jamacardio.2018.4936

  View details for Web of Science ID 000461901600006

• Observational Outcomes or Use of Guideline Recommended Treatments? Which Demonstrates Better Care? JAMA CARDIOLOGY Heidenreich, P. A. 2019; 4 (3): 271-272

  View details for DOI 10.1001/jamacardio.2019.0050

  View details for Web of Science ID 000461901600017

  View details for PubMedID 30785591

• Comparison of the change in heart failure readmission and mortality rates between hospitals subject to hospital readmission reduction program penalties and critical access hospitals AMERICAN HEART JOURNAL Sandhu, A. T., Heidenreich, P. A. 2019; 209: 63–67

  View details for DOI 10.1016/j.ahj.2018.12.002

  View details for Web of Science ID 000461306800008

• Glycated Hemoglobin and Outcomes of Heart Failure (from Get With the Guidelines-Heart Failure) AMERICAN JOURNAL OF CARDIOLOGY Echouffo-Tcheugui, J. B., Sheng, S., DeVore, A. D., Matsouaka, R. A., Hernandez, A. F., Yancy, C. W., Heidenreich, P. A., Bhatt, D. L., Fonarow, G. C. 2019; 123 (4): 618–26

  View details for DOI 10.1016/j.amjcard.2018.11.023

  View details for Web of Science ID 000459226300014

• Heart Failure With Preserved Ejection Fraction and Diabetes JACC State-of-the-Art Review JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY McHugh, K., DeVore, A. D., Wu, J., Matsouaka, R. A., Fonarow, G. C., Heidenreich, P. A., Yancy, C. W., Green, J. B., Altman, N., Hernandez, A. F. 2019; 73 (5): 602–11

  View details for DOI 10.1016/j.jacc.2018.11.033

  View details for Web of Science ID 000457567000010

• Heart Failure With Preserved EjectionFraction and Diabetes: JACC State-of-the-Art Review. Journal of the American College of Cardiology McHugh, K., DeVore, A. D., Wu, J., Matsouaka, R. A., Fonarow, G. C., Heidenreich, P. A., Yancy, C. W., Green, J. B., Altman, N., Hernandez, A. F. 2019; 73 (5): 602–11

  Abstract

  Heart failure with preserved ejection fraction (HFpEF) is now the most common form of HF, affecting over 3 million adults in the United States alone. HFpEF is a heterogenous syndrome. One important phenotype may be related to comorbid conditions, including diabetes mellitus (DM). DM has a prevalence of approximately 45% in HFpEF, but characteristics and outcomes of this population are poorly understood. In this review, the authors summarize data from several clinical trials of HFpEF therapeutics and provide original data from a large cohort using the Get With The Guidelines-HF registry, which together suggest that DM is associated with increased morbidity and long-term mortality in HFpEF. The authors then discuss several common pathological mechanisms in HFpEF and DM, including sodium retention, metabolic derangements, impaired skeletal muscle function, and potential therapeutic targets. As the understanding of comorbid HFpEF and DM improves, it is hoped clinicians will be better equipped to offer effective, patient-centered treatments.

  View details for PubMedID 30732715

• Association of Left Ventricular Ejection Fraction and Symptoms With Mortality After Elective Noncardiac Surgery Among Patients With Heart Failure. JAMA Lerman, B. J., Popat, R. A., Assimes, T. L., Heidenreich, P. A., Wren, S. M. 2019; 321 (6): 572-579

  Abstract

  Heart failure is an established risk factor for postoperative mortality, but how left ventricular ejection fraction and heart failure symptoms affect surgical outcomes is not fully described.To determine the risk of postoperative mortality among patients with heart failure at various levels of echocardiographic (left ventricular systolic dysfunction) and clinical (symptoms) severity compared with those without heart failure and to evaluate how risk varies across levels of surgical complexity.US multisite retrospective cohort study of all adult patients receiving elective, noncardiac surgery in the Veterans Affairs Surgical Quality Improvement Project database from 2009 through 2016. A total of 609 735 patient records were identified and analyzed with 1 year of follow-up after having surgery (final study follow-up: September 1, 2017).Heart failure, left ventricular ejection fraction, and presence of signs or symptoms of heart failure within 30 days of surgery.The primary outcome was postoperative mortality at 90 days.Outcome data from 47 997 patients with heart failure (7.9%; mean [SD] age, 68.6 [10.1] years; 1391 women [2.9%]) and 561 738 patients without heart failure (92.1%; mean [SD] age, 59.4 [13.4] years; 50 862 women [9.1%]) were analyzed. Compared with patients without heart failure, those with heart failure had a higher risk of 90-day postoperative mortality (2635 vs 6881 90-day deaths; crude mortality risk, 5.49% vs 1.22%; adjusted absolute risk difference [RD], 1.03% [95% CI, 0.91%-1.15%]; adjusted odds ratio [OR], 1.67 [95% CI, 1.57-1.76]). Compared with patients without heart failure, symptomatic patients with heart failure (n = 5906) had a higher risk (597 deaths [10.11%]; adjusted absolute RD, 2.37% [95% CI, 2.06%-2.57%]; adjusted OR, 2.37 [95% CI, 2.14-2.63]). Asymptomatic patients with heart failure (n = 42 091) (2038 deaths [crude risk, 4.84%]; adjusted absolute RD, 0.74% [95% CI, 0.63%-0.87%]; adjusted OR, 1.53 [95% CI, 1.44-1.63]), including the subset with preserved left ventricular systolic function (1144 deaths [4.42%]; adjusted absolute RD, 0.66% [95% CI, 0.54%-0.79%]; adjusted OR, 1.46 [95% CI, 1.35-1.57]), also experienced elevated risk.Among patients undergoing elective noncardiac surgery, heart failure with or without symptoms was significantly associated with 90-day postoperative mortality. These data may be helpful in preoperative discussions with patients with heart failure undergoing noncardiac surgery.

  View details for DOI 10.1001/jama.2019.0156

  View details for PubMedID 30747965

  View details for PubMedCentralID PMC6439591

• Accuracy of Administrative Coding to Identify Reduced and Preserved Left Ventricular Ejection Fraction. Journal of cardiac failure Heidenreich, P. A., Natarajan, S., Bahrami, H. 2019

  Abstract

  BACKGROUND: Coding of systolic function in heart failure is important but the accuracy is uncertain.METHODS: We used data from chart review of VA heart failure hospitalizations between 2006 and 2013. Trained abstractors determined the documented diagnosis of heart failure and the left ventricular ejection fraction (LVEF). We compared this LVEF to the primary and secondary International Classification of Disease (ICD)-9 codes for heart failure for the same hospitalization.RESULTS: Among 43,044 hospitalizations for heart failure, the primary discharge diagnosis was coded as systolic heart failure in 18%, diastolic heart failure in 17% and other heart failure codes in 65%. For an LVEF less than 40%, a systolic heart failure code had a sensitivity of 29% and a positive predictive value of 76%. The code for systolic heart failure was used more frequently over time with sensitivity increasing from 16% to 37% but at the expense of the positive predictive value which decreased from 80% to 74%. The overall area under the receiver operating curve for the relationship between LVEF and the systolic heart failure code was 0.71. Using a LVEF > 50% to define diastolic heart failure, led to a sensitivity of 29% for a diastolic heart failure code with a positive predictive value of 78%. In multivariate analysis, a systolic heart failure code had an odds ratio for 1-year mortality of 1.1 (95% CI 1.03-1.17) compared to not having a systolic heart failure code.CONCLUSION: Coding for systolic and diastolic heart failure is associated with LVEF but the accuracy is too poor to substitute for the documented LVEF in performance measurement.

  View details for PubMedID 30743043

• Discharge Heart Rate After Hospitalization for Myocardial Infarction and Long-Term Mortality in 2 US Registries. Journal of the American Heart Association Alapati, V., Tang, F., Charlap, E., Chan, P. S., Heidenreich, P. A., Jones, P. G., Spertus, J. A., Srinivas, V., Kizer, J. R. 2019; 8 (3): e010855

  Abstract

  Background Although admission heart rate predicts higher mortality after acute myocardial infarction ( AMI ), less is known about discharge heart rate. We tested the hypothesis that higher discharge heart rate after AMI is related to increased long-term mortality independent of admission heart rate, and assessed whether beta blockers modify this relationship. Methods and Results In 2 prospective US multicenter registries of AMI , we evaluated the associations of discharge and admission heart rate with 3-year mortality using Cox models. Among 6576 patients with AMI , discharge heart rate was modestly associated with initial heart rate ( r=0.28), comorbidities, and infarct severity. In this cohort, 10.7% did not receive beta blockers at discharge. After full adjustment for demographic, psychosocial, and clinical covariates, discharge heart rate (hazard ratio [HR]=1.14 per 10beats per minute [bpm]; 95% CI =1.07-1.21 per 10 bpm) was more strongly associated with risk of death than admission heart rate (HR=1.05 per 10bpm; 95% CI=1.02-1.09 per 10 bpm) when both were entered in the same model ( P=0.043 for comparison). There was a significant interaction between discharge heart rate and beta-blocker use ( P=0.004) on mortality, wherein risk of death was markedly higher among those with high discharge heart rate and not on beta blockers (HR=1.35 per 10bpm; 95% CI=1.19-1.53 per 10 bpm) versus those with a high discharge heart rate and on beta blockers at discharge (HR=1.10 per 10 bpm; 95% CI=1.03-1.17 per 10 bpm). Conclusions Higher discharge heart rate after AMI was more strongly associated with 3-year mortality than admission heart rate, and the risk associated with higher discharge heart rate was modified by beta blockers at discharge. These findings highlight opportunities for risk stratification and intervention that will require further investigation.

  View details for DOI 10.1161/JAHA.118.010855

  View details for PubMedID 30691334

• Relationship Between Hospital Characteristics and Early Adoption of Angiotensin-Receptor/Neprilysin Inhibitor Among Eligible Patients Hospitalized for Heart Failure JOURNAL OF THE AMERICAN HEART ASSOCIATION Luo, N., Lippmann, S. J., Mentz, R. J., Greiner, M. A., Hammill, B. G., Hardy, N., Laskey, W. K., Heidenreich, P. A., Chang, C., Hernandez, A. F., Curtis, L. H., Peterson, P. N., Fonarow, G. C., O'Brien, E. C. 2019; 8 (3): e010484

  Abstract

  Background The angiotensin-receptor/neprilysin inhibitor ( ARNI ) sacubitril/valsartan reduces hospitalization and mortality for patients with heart failure with reduced ejection fraction. However, adoption of ARNI into clinical practice has been slow. Factors influencing use of ARNI have not been fully elucidated. Using data from the Get With The Guidelines-Heart Failure registry, Hospital Compare, Dartmouth Atlas, and the American Hospital Association Survey, we sought to identify hospital characteristics associated with patient-level receipt of an ARNI prescription. Methods and Results We analyzed patients with heart failure with reduced ejection fraction who were eligible for ARNI prescription (ejection fraction≤40%, no contraindications) and hospitalized from October 1, 2015 through December 31, 2016. We used logistic regression to estimate the associations between hospital characteristics and patient ARNI prescription at hospital discharge, accounting for clustering of patients within hospitals using generalized estimating equation methods and adjusting for patient-level covariates. Of 16 674 eligible hospitalizations from 210 hospitals, 1020 patients (6.1%) were prescribed ARNI at discharge. The median hospital-level proportion of patients prescribed ARNI was 3.3% (Q1, Q3: 0%, 12.6%). After adjustment for patient-level covariates, for-profit hospitals had significantly higher odds of ARNI prescription compared with not-for-profit hospitals (odds ratio, 2.53; 95% CI , 1.05-6.10; P=0.04), and hospitals located in the Western United States had lower odds of ARNI prescription compared with those in the Northeast (odds ratio, 0.33; 95% CI , 0.13-0.84; P=0.02). Conclusions Relatively few hospital characteristics were associated with ARNI prescription at hospital discharge, in contrast to what has been observed in early adoption in other disease areas. Additional evaluation of barriers to implementing new evidence into heart failure practice is needed.

  View details for DOI 10.1161/JAHA.118.010484

  View details for Web of Science ID 000460106400007

  View details for PubMedID 30712431

  View details for PubMedCentralID PMC6405590

• Comparison of Outpatient Satisfaction Survey Scores for Asian Physicians and Non-Hispanic White Physicians JAMA NETWORK OPEN Garcia, L. C., Chung, S., Liao, L., Altamirano, J., Fassiotto, M., Maldonado, B., Heidenreich, P., Palaniappan, L. 2019; 2 (2)

  View details for DOI 10.1001/jamanetworkopen.2019.0027

  View details for Web of Science ID 000465423800022

• Secular trends in success rate of catheter ablation for atrial fibrillation: The SMASH-AF cohort AMERICAN HEART JOURNAL Perino, A. C., Leef, G. C., Cluckey, A., Yunus, F. N., Askari, M., Heidenreich, P. A., Narayan, S. M., Wang, P. J., Turakhia, M. P. 2019; 208: 110–19

  View details for DOI 10.1016/j.ahj.2018.10.006

  View details for Web of Science ID 000459125900013

• Efficacy of Ablation Lesion Sets in Addition to Pulmonary Vein Isolation for Paroxysmal Atrial Fibrillation: Findings From the SMASH-AF Meta-Analysis Study Cohort JOURNAL OF THE AMERICAN HEART ASSOCIATION Cluckey, A., Perino, A. C., Yunus, F. N., Leef, G. C., Askari, M., Heidenreich, P. A., Narayan, S. M., Wang, P. J., Turakhia, M. P. 2019; 8 (1)

  View details for DOI 10.1161/JAHA.118.009976

  View details for Web of Science ID 000455185000012

• Efficacy of Ablation Lesion Sets in Addition to Pulmonary Vein Isolation for Paroxysmal Atrial Fibrillation: Findings From the SMASH - AF Meta-Analysis Study Cohort. Journal of the American Heart Association Cluckey, A., Perino, A. C., Yunus, F. N., Leef, G. C., Askari, M., Heidenreich, P. A., Narayan, S. M., Wang, P. J., Turakhia, M. P. 2019; 8 (1): e009976

  Abstract

  Background The objective was to explore the efficacy of ablation lesion sets in addition to pulmonary vein isolation ( PVI ) for paroxysmal atrial fibrillation. The optimal strategy for catheter ablation of paroxysmal atrial fibrillation is debated. Methods and Results The SMASH-AF (Systematic Review and Meta-analysis of Ablation Strategy Heterogeneity in Atrial Fibrillation) study cohort includes trials and observational studies identified in PubMed, Scopus, and Cochrane databases from January 1 1990, to August 1, 2016. We included studies reporting single procedure paroxysmal atrial fibrillation ablation success rates. Exclusion criteria included insufficient reporting of outcomes, ablation strategies that were not prespecified and uniform, and a sample size of fewer than 40 patients. We analyzed lesion sets performed in addition to PVI ( PVI plus) using multivariable random-effects meta-regression to control for patient, study, and procedure characteristics. The analysis included 145 total studies with 23263 patients ( PVI- only cohort: 115 studies, 148 treatment arms, 16500 patients; PVI plus cohort: 39 studies; 46 treatment arms, 6763 patients). PVI plus studies, as compared with PVI -only studies, included younger patients (56.7years versus 58.8years, P=0.001), fewer women (27.2% versus 32.0% women, P=0.002), and were more methodologically rigorous with longer follow-up (29.5 versus 17.1months, P 0.004) and more randomization (19.4% versus 11.8%, P<0.001). In multivariable meta-regression, PVI plus studies were associated with improved success (7.6% absolute improvement [95% CI, 2.6-12.5%]; P<0.01, I2=88%), specifically superior vena cava isolation (4 studies, 4 treatment arms, 1392 patients; 15.1% absolute improvement [95%CI, 2.3-27.9%]; P 0.02, I2=87%). However, residual heterogeneity was large. Conclusions Across the paroxysmal atrial fibrillation ablation literature, PVI plus ablation strategies were associated with incremental improvements in success rate. However, large residual heterogeneity complicates evidence synthesis.

  View details for PubMedID 30587059

• Comparison of Outpatient Satisfaction Survey Scores for Asian Physicians and Non-Hispanic White Physicians. JAMA network open Garcia, L. C., Chung, S. n., Liao, L. n., Altamirano, J. n., Fassiotto, M. n., Maldonado, B. n., Heidenreich, P. n., Palaniappan, L. n. 2019; 2 (2): e190027

  Abstract

  Patient satisfaction scores are used to inform decisions about physician compensation, and there remains a lack of consensus regarding the need to adjust scores for patient race/ethnicity. Previous research suggests that patients prefer physicians of the same race/ethnicity as themselves and that Asian patients provide lower satisfaction scores than non-Hispanic white patients.To examine whether Asian physicians receive less favorable patient satisfaction scores relative to non-Hispanic white physicians.This population-based survey study used data from Press Ganey Outpatient Medical Practice Surveys collected from December 1, 2010, to November 30, 2014, which included 149 775 patient survey responses for 962 physicians. Every month, 5 patients per physician were randomly selected to complete a satisfaction survey after an outpatient visit. Hierarchical multivariable logistic regression was used to examine the association between Asian race/ethnicity of the physician and racial/ethnic concordance of the patient with the probability of receiving the highest score on the survey item rating the likelihood to recommend the physician. Statistical analysis was performed from April 2 to August 27, 2018.Physician characteristics included race/ethnicity, sex, years in practice, and proportion of Asian patient responders. Patient characteristics included race/ethnicity, sex, age, and language spoken.The highest score (a score of 5 on a 1-5 Likert scale, where 1 indicates very poor and 5 indicates very good) on the survey item rating the likelihood to recommend the physician on the Press Ganey Outpatient Medical Practice Survey.Of the 962 physicians in this study, 515 (53.5%) were women; physicians had a mean (SD) of 19.9 (9.1) years of experience since graduating medical school; 573 (59.6%) were white, and 350 (36.4%) were Asian. In unadjusted analyses, the odds of receiving the highest score on the survey item rating the likelihood to recommend the physician were lower for Asian physicians compared with non-Hispanic white physicians (odds ratio, 0.78; 95% CI, 0.72-0.84; P < .001). This association was not significant after adjusting for patient characteristics, including patient race/ethnicity. However, Asian patients were less likely to give the highest scores relative to non-Hispanic white patients (odds ratio, 0.56; 95% CI, 0.54-0.58; P < .001), regardless of physician race/ethnicity.This study suggests that Asian physicians may be more likely to receive lower patient satisfaction scores because they serve a greater proportion of Asian patients. Patient satisfaction scores should be adjusted for patient race/ethnicity.

  View details for PubMedID 30794297

• Patient vs provider perspectives of 30-day hospital readmissions BMJ OPEN QUALITY Smeraglio, A., Heidenreich, P. A., Krishnan, G., Hopkins, J., Chen, J., Shieh, L. 2019; 8 (1)

  View details for DOI 10.1136/bmjoq-2017-000264

  View details for Web of Science ID 000672549000003

• Site Variation and Outcomes for Antithrombotic Therapy in Atrial Fibrillation Patients After Percutaneous Coronary Intervention. Circulation. Cardiovascular interventions Olivier, C. B., Fan, J. n., Askari, M. n., Mahaffey, K. W., Heidenreich, P. A., Perino, A. C., Leef, G. C., Ho, P. M., Harrington, R. A., Turakhia, M. P. 2019; 12 (8): e007604

  Abstract

  Patients with atrial fibrillation (AF) treated with percutaneous coronary intervention (PCI) require multiple antithrombotic therapies. The optimal strategy is debated suggesting increased treatment variation. This study sought to characterize site-level variation in antithrombotic therapies in AF patients after PCI and determine the association with outcomes.Using the retrospective TREAT-AF study (The Retrospective Evaluation and Assessment of Therapies in AF) from the Veterans Health Administration, patients with newly diagnosed, nonvalvular AF between 2004 and 2015 followed by a PCI with a P2Y12-antagonist prescription were identified. Patients were grouped according to the therapy dispensed 7 days before until 30 days after the PCI: oral anticoagulation plus platelet inhibition (OAC+PI) or platelet inhibition only. A combined outcome of death, myocardial infarction, stroke, or major bleeding was assessed 1 year after PCI and Cox regression was performed to estimate hazard ratios.Of 230 762 patients with newly diagnosed AF, 4042 (1.8%) underwent PCI and received a P2Y12-antagonist during the observation period (age, 67±9 years; CHA2DS2-VASc, 2.7±1.7; HAS-BLED, 2.6±1.2). Among these, 47% were prescribed OAC+PI, and 53% platelet inhibition only 7 days before until 30 days after the PCI. Across 63 sites, the use of OAC+PI ranged from 19% to 66%. Prescription of OAC+PI was independently associated with a reduction in the combined outcome of death, myocardial infarction, stroke, or major bleeding compared with platelet inhibition only (adjusted hazard ratio, 0.85; 95% CI, 0.73-0.99; P=0.033).In patients with established AF undergoing PCI, the use of OAC+PI varied substantially across sites in the 30 days post-PCI. Anticoagulation appeared to be underutilized but was associated with improved outcomes. Strategies to promote OAC+PI and minimize site variation may be useful, particularly in light of recent randomized trials.

  View details for DOI 10.1161/CIRCINTERVENTIONS.118.007604

  View details for PubMedID 31416357

• Eligibility of sodium-glucose co-transporter-2 inhibitors among patients with diabetes mellitus admitted for heart failure. ESC heart failure Sharma, A. n., Wu, J. n., Ezekowitz, J. A., Felker, G. M., Udell, J. A., Heidenreich, P. A., Fonarow, G. C., Mahaffey, K. W., Hernandez, A. F., DeVore, A. D. 2019

  Abstract

  Sodium-glucose co-transporter (SGLT)-2 inhibitors have been shown to reduce the risk of cardiovascular death and heart failure (HF) hospitalization in patients with type 2 diabetes mellitus (DM) and high cardiovascular risk in two large clinical outcome trials: empagliflozin in EMPA-REG OUTCOME and canagliflozin in CANVAS. The scope of eligibility for SGLT-2 inhibitors (empagliflozin and canagliflozin) among patients with type 2 DM and HF, based on clinical trial criteria and current US Food and Drug Administration (FDA) labelling criteria, remains unknown.Using data from the US Get With The Guidelines (GWTG)-Heart Failure registry, we evaluated the proportion of patients with DM and HF eligible for SGLT-2 inhibitor therapy based on the clinical trial criteria and the US FDA labelling criteria. The GWTG-HF registry is a quality improvement registry of patients admitted in hospital with HF in the USA. We included GWTG-HF registry participants meeting eligibility criteria hospitalized between August 2014 and 30 June 2017 from sites fully participating in the registry. The initial inclusion time point reflects when both drugs had FDA approval. Among the 139 317 patients (out of 407 317) with DM hospitalized with HF (in 460 hospitals; 2014 to 2017), the median age was 71 years, 47% (n = 65 685) were female, and 43% (n = 59 973) had HF with reduced ejection fraction. Overall, 43% (n = 59 943) were eligible for the EMPA-REG OUTCOME trial, 45% (n = 62 818) were eligible for the CANVAS trial, and 34% (n = 47 747) of patients were eligible for either SGLT-2 inhibitors based on the FDA labelling criteria. Among the FDA-eligible patients, 91.5% (n = 43 708) were eligible for either the EMPA-REG OUTCOME trial or the CANVAS trial. Patients who were FDA eligible, compared with those who were not, were younger (70.0 vs. 72.0 years of age), more likely to be male (57.7 vs. 50.3%), and had less burden of co-morbidities.The majority of patients with DM who are hospitalized with HF are not eligible for SGLT-2 inhibitor therapies. Ongoing studies evaluating the safety and efficacy of SGLT-2 inhibitors among patients with HF may potentially broaden the population that may benefit from these therapies.

  View details for DOI 10.1002/ehf2.12528

  View details for PubMedID 31747132

• Association of Left Ventricular Ejection Fraction and Symptoms With Mortality After Elective Noncardiac Surgery Among Patients With Heart Failure JAMA Lerman, B. J., Popat, R. A., Assimes, T., Heidenreich, P., Wren, S. M. 2019; 321 (6): 572-579

  View details for DOI 10.1001/jama.2019.0156

• Improving risk stratification in heart failure with preserved ejection fraction by combining two validated risk scores. Open heart Boralkar, K. A., Kobayashi, Y., Moneghetti, K. J., Pargaonkar, V. S., Tuzovic, M., Krishnan, G., Wheeler, M. T., Banerjee, D., Kuznetsova, T., Horne, B. D., Knowlton, K. U., Heidenreich, P. A., Haddad, F. 2019; 6 (1): e000961

  Abstract

  Introduction: The Intermountain Risk Score (IMRS) was developed and validated to predict short-term and long-term mortality in hospitalised patients using demographics and commonly available laboratory data. In this study, we sought to determine whether the IMRS also predicts all-cause mortality in patients hospitalised with heart failure with preserved ejection fraction (HFpEF) and whether it is complementary to the Get with the Guidelines Heart Failure (GWTG-HF) risk score or N-terminal pro-B-type natriuretic peptide (NT-proBNP).Methods and results: We used the Stanford Translational Research Integrated Database Environment to identify 3847 adult patients with a diagnosis of HFpEF between January 1998 and December 2016. Of these, 580 were hospitalised with a primary diagnosis of acute HFpEF. Mean age was 76±16 years, the majority being female (58%), with a high prevalence of diabetes mellitus (36%) and a history of coronary artery disease (60%). Over a median follow-up of 2.0 years, 140 (24%) patients died. On multivariable analysis, the IMRS and GWTG-HF risk score were independently associated with all-cause mortality (standardised HRs IMRS (1.55 (95% CI 1.27 to 1.93)); GWTG-HF (1.60 (95% CI 1.27 to 2.01))). Combining the two scores, improved the net reclassification over GWTG-HF alone by 36.2%. In patients with available NT-proBNP (n=341), NT-proBNP improved the net reclassification of each score by 46.2% (IMRS) and 36.3% (GWTG-HF).Conclusion: IMRS and GWTG-HF risk scores, along with NT-proBNP, play a complementary role in predicting outcome in patients hospitalised with HFpEF.

  View details for DOI 10.1136/openhrt-2018-000961

  View details for PubMedID 31217994

• Strict Versus Lenient Versus Poor Rate Control Among Patients With Atrial Fibrillation and Heart Failure (from the Get With The Guidelines - Heart Failure Program). The American journal of cardiology Hess, P. L., Sheng, S. n., Matsouaka, R. n., DeVore, A. D., Heidenreich, P. A., Yancy, C. W., Bhatt, D. L., Allen, L. A., Peterson, P. N., Ho, P. M., Lewis, W. R., Hernandez, A. F., Fonarow, G. C., Piccini, J. P. 2019

  Abstract

  Randomized data suggest lenient rate control (resting heart rate <110 beats/min) is noninferior to strict rate control (resting heart rate <80 beats/min) in patients with atrial fibrillation (AF). However, the optimal rate control strategy in patients with AF and heart failure (HF) remains unknown. Accordingly, we performed an observational analysis using data from the Get With The Guidelines-HF Program linked with Medicare data from July 1, 2011, to September 30, 2014. Of 13,981 patients with AF and HF, 9,100 (65.0%) had strict rate control, 4,617 (33.0%) had lenient rate control, and 264 (1.9%) had poor rate control by resting heart rate on the day of discharge. After multivariable adjustment, compared with strict rate control, lenient rate control was associated with higher adjusted risks of death (hazard ratio [HR] 1.21, 95% confidence interval [CI] 1.11 to 1.33, p <0.001), all-cause readmission (HR 1.09, 95% CI 1.03 to 1.15, p <0.002), death or all-cause readmission (HR 1.11, 95% CI 1.05 to 1.18, p <0.001), but not cardiovascular readmission (HR1.08, 95% CI 1.00 to 1.16, p = 0.051) at 90 days. Associations were comparable in patients with poor rate control and with heart rate modeled as a continuous variable. The presence or absence of reduced ejection fraction did not impact the magnitude of most observed associations. In conclusion, in patients with HF and AF, 2 of 3 patients had a heart rate that met strict-control goals at discharge. Heart rates >80 beats/min were associated with adverse outcomes irrespective of left ventricular ejection fraction.

  View details for DOI 10.1016/j.amjcard.2019.12.025

  View details for PubMedID 31980141

• Comparing the Barriers and Facilitators of Heart Failure Management as Perceived by Patients, Caregivers, and Clinical Providers. The Journal of cardiovascular nursing Trivedi, R. B., Slightam, C. n., Nevedal, A. n., Guetterman, T. C., Fan, V. S., Nelson, K. M., Rosland, A. M., Heidenreich, P. A., Timko, C. n., Asch, S. M., Piette, J. D. 2019

  Abstract

  Heart failure (HF) management requires the participation of patients, their significant others, and clinical providers. Each group may face barriers to HF management that may be unique or may overlap.The aim of this study was to compare the barriers and facilitators of HF management as perceived by patients, significant others, and clinical providers.Participants were recruited from a Veterans Health Administration facility. Eligible patients had a diagnosis of HF (ICD9 code 428.XX), 1 or more HF-related visit in the previous year, and a significant other who was their primary caregiver. Significant others were adults with no history of cognitive impairments caring for patients with HF. Providers were eligible if they cared for patients with HF. All participants completed semistructured interviews designed to elicit barriers to managing HF and strategies that they used to overcome these barriers. Interviews were transcribed and analyzed using latent thematic analysis, and recruitment continued until thematic saturation was attained.A total of 17 couples and 12 providers were recruited. All 3 groups identified poor communication as a key barrier to HF management, including communication between patients and their significant other, between couples and providers, and providers with each other. Significant others noted that the lack of direct communication with clinical providers hindered their efforts to care for the patient. All 3 groups emphasized the importance of family members in optimizing adherence to HF self-management recommendations.Providers, patients, and significant others all play important and distinct roles in the management of HF. Tools to enhance communication and collaboration for all 3 and supporting the needs of significant others are missing components of current HF care.

  View details for DOI 10.1097/JCN.0000000000000591

  View details for PubMedID 31365440

• Value of Neutrophil to Lymphocyte Ratio and Its Trajectory in Patients Hospitalized With Acute Heart Failure and Preserved Ejection Fraction. The American journal of cardiology Boralkar, K. A., Kobayashi, Y. n., Amsallem, M. n., Ataam, J. A., Moneghetti, K. J., Cauwenberghs, N. n., Horne, B. D., Knowlton, K. U., Maecker, H. n., Kuznetsova, T. n., Heidenreich, P. A., Haddad, F. n. 2019

  Abstract

  The neutrophil to lymphocyte ratio (NLR) has been proposed as a simple and routinely obtained marker of inflammation. This study sought to determine whether the NLR on admission as well as NLR trajectory would be complementary to the Get with the Guidelines Heart Failure (GWTG-HF) risk score in patients hospitalized with acute heart failure with preserved ejection fraction (HFpEF).Using the Stanford Translational Research Database, we identified 443 patients between January 2002 and December 2013 hospitalized with acute HFpEF and with complete data of NLR both on admission and at discharge. The primary endpoint was all-cause mortality. Mean age was 77 ± 16 years, 58% were female, with a high prevalence of diabetes mellitus (35.4%), coronary artery disease (58.2%), systemic hypertension (96.6%) and history of atrial fibrillation (57.5%). Over a median follow-up of 2.2 years, 121 (27.3%) patients died. The median NLR on admission was 6.5 (IQR 3.6 - 11.1); a majority of patients decreased their NLR during the course of hospitalization. On multivariable Cox modeling, both NLR on admission (HR 1.18 95% CI (1.00 - .38), p = 0.04) and absolute NLR trajectory (HR 1.26 95% CI (1.10 - 1.45), p = 0.001) were shown to be incremental to GWTG-HF risk score (p < 0.05) for outcome prediction. Adding the NLR or absolute NLR trajectory to the GWTG-HF risk score significantly improved the area under the operator-receiver curve and the reclassification up to 3 years after admission.This simple, readily available marker of inflammation may be useful when stratifying the risk of patients hospitalized with HFpEF.

  View details for DOI 10.1016/j.amjcard.2019.10.020

  View details for PubMedID 31753313

• Patient vs provider perspectives of 30-day hospital readmissions. BMJ open quality Smeraglio, A., Heidenreich, P. A., Krishnan, G., Hopkins, J., Chen, J., Shieh, L. 2019; 8 (1): e000264

  Abstract

  Objective: To compare patients' and providers' views on contributors to 30-day hospital readmissions.Design: Analysis of a qualitative interview survey between 18 May-30 June 2015.Setting: Interviews were conducted during the 30-day readmission hospitalisation at a single tertiary care academic hospital.Participants: We conducted 178 interviews of readmitted patients.Measures: We queried opinions of what factors patients believed contributed to their rehospitalisation and compared this with the perspective of the index admission provider. The primary outcome was the view that the readmission was preventable. A review by a RN (nurse) case manager also provided an assessment based on patient report, provider report and chart review.Results: Patients were more likely to view a readmission as preventable compared with physicians (p<0.0001). Patients identified system issues (defined as factors controlled by the hospital discharge process) as contributors to their readmission in 58% (103/178) of cases while providers identified system issues as the contributor to a patients' readmission in 2% (2/101) of cases. Patients with poor functional status were more likely to feel the cause of their readmission was due to system issues than patients with better functional status (p=0.03). A RN case manager review determined that in 48% (86/178) of cases the system had some amount of contribution to a patient's readmission. There was no significant difference in belief that the readmission was preventable between the RN case manager and the patient (p=0.47).Conclusions: Readmitted patients often feel that the hospital system contributed to their readmission. Providers did not recognise patient and RN case manager identified issues as contributors to hospital readmissions.

  View details for PubMedID 30687798

• Comparison of the change in heart failure readmission and mortality rates between hospitals subject to hospital readmission reduction program penalties and critical access hospitals. American heart journal Sandhu, A. T., Heidenreich, P. A. 2018; 209: 63–67

  Abstract

  BACKGROUND: The Hospital Readmission Reduction Program (HRRP), announced in 2010, penalizes hospitals with high readmissions for multiple conditions including heart failure.METHODS: We compared heart failure readmission and mortality rates in hospitals exposed to HRRP financial penalties with critical access hospitals (CAHs) not subject to the penalty between 2005 and 2016 using 3-year moving averages from Hospital Compare.RESULTS: After HRRP introduction, CAHs experienced a 0.60% annual decrease (95% CI: -0.61 to -0.59%) in heart failure readmissions. HRRP-exposed hospitals experienced an additional 0.13% annual decrease (95% CI: -0.14 to -0.12%) compared with CAHs. The association between HRRP penalties and mortality varied with model specifications.CONCLUSIONS: Using CAHs as a control group, we found the introduction of financial penalties was only associated with modest reductions in readmissions and an uncertain association with mortality. Cluster-randomized rollouts of health care policy interventions will allow us to better evaluate the impact of our interventions.

  View details for PubMedID 30685676

• Glycated Hemoglobin and Outcomes of Heart Failure (from Get With the Guidelines-Heart Failure). The American journal of cardiology Echouffo-Tcheugui, J. B., Sheng, S., DeVore, A. D., Matsouaka, R. A., Hernandez, A. F., Yancy, C. W., Heidenreich, P. A., Bhatt, D. L., Fonarow, G. C. 2018

  Abstract

  Glycated hemoglobin (HbA1C) is a risk factor for new onset heart failure (HF). There is however a paucity of data evaluating its association with outcomes in patients with established HF. We assessed the relation of HbA1C with outcomes among hospitalized HF patients. Among 41,776 HF patients from 263 hospitals participating to the Get with the Guidelines-HF registry between January 2009 and March 2016, we related HbA1C to outcomes (in-hospital mortality, length of hospital stay, discharge to home, 30-day mortality, 30-day readmission, and 1-year mortality), using generalized estimating equation to account for within-hospital clustering and potential confounders. There were 68% of HF patients with diabetes and median HbA1C was 7.1%. Each percent change in HbA1C was associated with higher odds of discharge to home for HbA1C levels <6.5% (covariate-adjusted odds ratio [OR] 1.13 [95% confidence interval 1.04 to 1.12]) or ≥6.5% (OR 1.05 [1.02 to 1.07]). After stratification by diabetes status, this association remained significant only among patients with diabetes (ORs for HbA1C levels <6.5%: 1.17 [1.07 to 1.27]; and ≥6.5%: 1.06 [1.03 to 1.09]). Compared with the lowest HbA1C tertile (HbA1C ≤6.1%), patients in the highest HbA1C tertile (HbA1C 7.3% to 19%) were more likely to have a length of hospital stay >4 days (OR 1.10 [1.02 to 1.18]) and to be discharged home (OR 1.23 [1.14 to 1.33]). There were no significant association between HbA1C and the following outcomes: in-hospital mortality, 30-day mortality, 30-day readmission, and 1-year mortality. In conclusion, among hospitalized HF patients, HbA1C was associated with prolonged hospital stay and home discharge, but not with readmission, short-term, or intermediate-term mortality.

  View details for PubMedID 30553509

• Predictive models for identifying risk of readmission after index hospitalization for heart failure: A systematic review. European journal of cardiovascular nursing : journal of the Working Group on Cardiovascular Nursing of the European Society of Cardiology Mahajan, S. M., Heidenreich, P., Abbott, B., Newton, A., Ward, D. 2018; 17 (8): 675–89

  Abstract

  AIMS:: Readmission rates for patients with heart failure have consistently remained high over the past two decades. As more electronic data, computing power, and newer statistical techniques become available, data-driven care could be achieved by creating predictive models for adverse outcomes such as readmissions. We therefore aimed to review models for predicting risk of readmission for patients admitted for heart failure. We also aimed to analyze and possibly group the predictors used across the models.METHODS:: Major electronic databases were searched to identify studies that examined correlation between readmission for heart failure and risk factors using multivariate models. We rigorously followed the review process using PRISMA methodology and other established criteria for quality assessment of the studies.RESULTS:: We did a detailed review of 334 papers and found 25 multivariate predictive models built using data from either health system or trials. A majority of models was built using multiple logistic regression followed by Cox proportional hazards regression. Some newer studies ventured into non-parametric and machine learning methods. Overall predictive accuracy with C-statistics ranged from 0.59 to 0.84. We examined significant predictors across the studies using clinical, administrative, and psychosocial groups.CONCLUSIONS:: Complex disease management and correspondingly increasing costs for heart failure are driving innovations in building risk prediction models for readmission. Large volumes of diverse electronic data and new statistical methods have improved the predictive power of the models over the past two decades. More work is needed for calibration, external validation, and deployment of such models for clinical use.

  View details for PubMedID 30189748

• Predictive models for identifying risk of readmission after index hospitalization for heart failure: A systematic review EUROPEAN JOURNAL OF CARDIOVASCULAR NURSING Mahajan, S. M., Heidenreich, P., Abbott, B., Newton, A., Ward, D. 2018; 17 (8): 675–89

  View details for DOI 10.1177/1474515118799059

  View details for Web of Science ID 000512308600002

• Response by Kumbhani et al to Letters Regarding Article, "Association Between Hospital Volume, Processes of Care, and Outcomes in Patients Admitted With Heart Failure: Insights From Get With The Guidelines-Heart Failure" CIRCULATION Kumbhani, D. J., Fonarow, G. C., Heidenreich, P. A., Schulte, P. J., Lu, D., Hernandez, A., Yancy, C., Bhatt, D. L. 2018; 138 (20): 2306–7

  View details for DOI 10.1161/CIRCULATIONAHA.118.036250

  View details for Web of Science ID 000452171400024

• CHA2DS2VASC and HAS-BLED Scores Predict Frailty in Non-Valvular Atrial Fibrillation Pundi, K., Perino, A., Fan Jun, Askari, M., Heidenreich, P., Turakhia, M. LIPPINCOTT WILLIAMS & WILKINS. 2018

  View details for Web of Science ID 000528619406362

• Estimation of Stroke Outcomes in Atrial Fibrillation Using Continuous Clinical and Implantable Device Data From the Treat-AF Study: A Comparison With CHA2DS2-VASc Score Bentley, J. P., Askari, M., Fan Jun, Heidenreich, P. A., Mahaffey, K. W., Desai, M., Scheinker, D., Turakhia, M. P. LIPPINCOTT WILLIAMS & WILKINS. 2018

  View details for Web of Science ID 000528619404424

• Ischemic Heart Disease and Change in Left Ventricular Ejection Fraction Over Time Among Patients With Heart Failure. Patel, J. M., Heidenreich, P. A. LIPPINCOTT WILLIAMS & WILKINS. 2018

  View details for Web of Science ID 000528619401145

• Managing the Economic Challenges in the Treatment of Heart Failure PROGRESS IN CARDIOVASCULAR DISEASES Pina, I. L., Desai, N. R., Allen, L. A., Heidenreich, P. 2018; 61 (5-6): 476–83

  View details for DOI 10.1016/j.pcad.2018.10.002

  View details for Web of Science ID 000454671100011

• Managing the Economic Challenges in the Treatment of Heart Failure. Progress in cardiovascular diseases Pina, I. L., Desai, N. R., Allen, L. A., Heidenreich, P. 2018; 61 (5-6): 476–83

  Abstract

  The economics of heart failure (HF) touches all patients with HF, their families, and the physicians and health systems that care for them. HF is specifically targeted by cost-reduction and care quality initiatives from the Centers for Medicare and Medicaid Services (CMS). The changing quality assessment and payment landscape is, and will continue to be, challenging for hospitals and HF specialists as they provide care for patients with this debilitating disease. Quality-based payment systems with evolving performance metrics are replacing traditional volume-based fee-for-service models. A critical objective of quality-based models is to improve care and reduce cost, but there are few data to support decision-making on how to improve. CMS payment programs and their implications for health systems treating HF were reviewed at a symposium at the Heart Failure Society of America conference in Nashville, Tennessee on September 15, 2018. This article constitutes the proceedings from that symposium.

  View details for PubMedID 30565564

• Secular trends in success rate of catheter ablation for atrial fibrillation: The SMASH-AF cohort. American heart journal Perino, A. C., Leef, G. C., Cluckey, A., Yunus, F. N., Askari, M., Heidenreich, P. A., Narayan, S. M., Wang, P. J., Turakhia, M. P. 2018

  Abstract

  BACKGROUND: Approaches, tools, and technologies for atrial fibrillation (AF) ablation have evolved significantly since its inception. We sought to characterize secular trends in AF ablation success rates.METHODS: We performed a systematic review and meta-analysis of AF ablation from January 1, 1990, to August 1, 2016, searching PubMed, Scopus, and Cochrane databases. Major exclusion criteria were insufficient outcome reporting and ablation strategies that were not prespecified and uniform. We stratified treatment arms by AF type (paroxysmal AF; nonparoxysmal AF) and analyzed single-procedure outcomes. Multivariate meta-regressions analyzed effects of study, patient, and procedure characteristics on success rate trends. Registered in PROSPERO (CRD42016036549).RESULTS: A total of 180 trials and observational studies with 28,118 patients met inclusion. For paroxysmal AF ablation studies, unadjusted success rate summary estimates ranged from 73.1% in 2003 to 77.1% in 2016, increasing by 0.9%/year (95% CI 0.4%-1.4%; P = .001; I2 = 90%). After controlling for study design and patient demographics, rate of improvement in success rate summary estimate increased (1.6%/year; 95% CI 0.9%-2.2%; P = .001; I2 = 87%). For nonparoxysmal AF ablation studies, unadjusted success rate summary estimates ranged from 70.0% in 2010 to 64.3% in 2016 (1.1%/year; 95% CI -1.3% to 3.5%; P = .37; I2 = 85%), with no improvement in multivariate analyses.CONCLUSIONS: Despite substantial research investment and health care expenditure, improvements in AF ablation success rates have been incremental. Meaningful improvements may require major paradigm or technology changes, and evaluation of clinical outcomes such as mortality and quality of life may prove to be important going forward.

  View details for PubMedID 30502925

• The American Heart Association Heart Failure Summit, Bethesda, April 12, 2017 Proceedings and Calls to Action CIRCULATION-HEART FAILURE Peterson, P. N., Allen, L. A., Heidenreich, P. A., Albert, N. M., Pina, I. L., Amer Heart Assoc 2018; 11 (10): e004957

  Abstract

  The American Heart Association convened a meeting to summarize the changing landscape of heart failure (HF), anticipate upcoming challenges and opportunities to achieve coordinated identification and treatment, and to recommend areas in need of focused efforts. The conference involved representatives from clinical care organizations, governmental agencies, researchers, patient advocacy groups, and public and private healthcare partners, demonstrating the breadth of stakeholders interested in improving care and outcomes for patients with HF. The main purposes of this meeting were to foster dialog and brainstorm actions to close gaps in identifying people with or at risk for HF and reduce HF-related morbidity, mortality, and hospitalizations. This report highlights the key topics covered during the meeting, including (1) identification of patients with or at risk for HF, (2) tracking patients once diagnosed, (3) application of population health approaches to HF, (4) improved strategies for reducing HF hospitalization (not just rehospitalization), and (5) promoting HF self-management.

  View details for PubMedID 30354400

• Trends in Hospice Discharge and Relative Outcomes Among Medicare Patients in the Get With The Guidelines Heart Failure Registry JAMA CARDIOLOGY Warraich, H. J., Xu, H., DeVore, A. D., Matsouaka, R., Heidenreich, P. A., Bhatt, D. L., Hernandez, A. F., Yancy, C. W., Fonarow, G. C., Allen, L. A. 2018; 3 (10): 917–26

  Abstract

  While 1 in 10 older patients hospitalized with heart failure (HF) die within 30 days, end-of-life care for this population is not well described.To assess rates of discharge to hospice, readmission after hospice, and survival in hospice in patients following hospital discharge.In this observational cohort analysis of patients in the multicenter American Heart Association Get With The Guidelines (GWTG)-HF registry linked to Medicare fee-for-service claims data, we analyzed patients 65 years and older discharged alive from the hospital between 2005 and 2014. We compared 4588 patients discharged to hospice with 4357 patients with advanced HF (ejection fraction ≤25% and any of the following: inpatient inotrope use, serum sodium level ≤130 mEq/L, blood urea nitrogen level ≥45 mg/dL [to convert to micromoles per liter, multiply by 0.357], systolic blood pressure ≤90 mm Hg, or comfort measures during hospitalization) not discharged to hospice and with 113 045 other patients with HF in the GWTG-HF registry. Data were analyzed from October 2017 to June 2018.Discharge to hospice, rehospitalization, and mortality.Of the 4588 patients discharged to hospice, 2556 (55.7%) were female and 4047 (88.2%) were white, and they had a median (interquartile range) age of 86 (80-90) years. Hospice accounted for 4588 of 121 990 discharges (3.8%), of which 2424 (52.8%) were discharges to home hospice and 2164 (47.2%) were to a hospice facility. Hospice discharges increased from 2.0% (109 of 5528) in 2005 to 4.9% (968 of 19 590) in 2014. Patients discharged to hospice were older, white, and more symptomatic compared with patients with advanced HF (n = 4357) and other patients in the GWTG-HF registry (n = 113 045). The median (interquartile range) postdischarge survival time in patients discharged to hospice was 11 (3-63) days compared with 318 (78-1105) days in patients with advanced HF and 754 (221-1868) days in other patients in the GWTG-HF registry. A total of 739 patients (34.1%) discharged to hospice facilities died in less than 72 hours, while 295 (12.2%) discharged to home hospice died in less than 72 hours; 690 patients (15.0%) discharged from hospice lived for 6 months or more. Among hospitals with more than 25 hospice discharges, the median (interquartile range) hospice discharge rate was 3.5% (2.0%-5.7%). Readmission at 30 days was lower in patients discharged to hospice (189 [4.1%]) compared with patients with advanced HF (1185 [27.2%]) and others in the GWTG-HF registry (25 022 [22.2%]). Nonwhite race and younger age were the strongest predictors of readmission from hospice.Hospice use has grown to about 4.9% of Medicare HF hospital discharges, with significant hospital-level variation. Almost a quarter of patients discharged to hospice die within 3 days of discharge, and about 4.1% of patients are readmitted to the hospital within 30 days.

  View details for PubMedID 30167645

• Association of Healthcare Plan with atrial fibrillation prescription patterns CLINICAL CARDIOLOGY Chang, A., Askari, M., Fan, J., Heidenreich, P. A., Ho, P., Mahaffey, K. W., Ullal, A., Perino, A., Turakhia, M. P. 2018; 41 (9): 1136–43

  View details for DOI 10.1002/clc.23042

  View details for Web of Science ID 000446429700004

• Association Between Offering Limited Left Ventricular Ejection Fraction Echocardiograms and Overall Use of Echocardiography JAMA INTERNAL MEDICINE Sandhu, A. T., Parizo, J., Moradi-Ragheb, N., Heidenreich, P. A. 2018; 178 (9): 1270-+

  View details for DOI 10.1001/jamainternmed.2018.3317

  View details for Web of Science ID 000443911200032

• Frequency of Statin Use in Patients With Low-Density Lipoprotein Cholesterol >= 190 mg/dl from the Veterans Affairs Health System AMERICAN JOURNAL OF CARDIOLOGY Rodriguez, F., Knowles, J. W., Maron, D. J., Virani, S. S., Heidenreich, P. A. 2018; 122 (5): 756–61

  View details for DOI 10.1016/j.amjcard.2018.05.008

  View details for Web of Science ID 000447960500008

• Validity of Performance and Outcome Measures for Heart Failure CIRCULATION-HEART FAILURE Patel, J., Sandhu, A., Parizo, J., Moayedi, Y., Fonarow, G. C., Heidenreich, P. A. 2018; 11 (9)

  View details for DOI 10.1161/CIRCHEARTFAILURE.118.005035

  View details for Web of Science ID 000453590600006

• Dual Healthcare System Use During Episodes of Acute Care Heart Failure Associated With Higher Healthcare Utilization and Mortality Risk JOURNAL OF THE AMERICAN HEART ASSOCIATION Axon, R., Gebregziabher, M., Everett, C. J., Heidenreich, P., Hunt, K. J. 2018; 7 (15)

  View details for DOI 10.1161/JAHA.118.009054

  View details for Web of Science ID 000452701900019

• Dual Healthcare System Use During Episodes of Acute Care Heart Failure Associated With Higher Healthcare Utilization and Mortality Risk. Journal of the American Heart Association Axon, R. N., Gebregziabher, M., Everett, C. J., Heidenreich, P., Hunt, K. J. 2018; 7 (15): e009054

  Abstract

  Background Individuals receiving cross-system care (dual users) have higher rates of healthcare utilization and worse outcomes for heart failure ( HF ) and other conditions. Individuals can be dual users or single-system users at different times, though, and little is known about utilization and mortality within discrete episodes of care. Methods and Results A retrospective cohort of 3439 patients with 5231 discrete episodes of HF exacerbation were identified between 2007 and 2011. Episodes encompassed the period from 2weeks before an initial HF emergency department ( ED ) visit or hospitalization, included any acute care visits within 30days after initial visit, and ended 30days after the last acute care visit in the episode chain. All-cause and HF -specific ED visits and hospitalization within 30days of index visit were analyzed using generalized estimating equations with robust variance. Hazard for death within episodes of acute illness was analyzed using Cox proportional hazards models. In adjusted analyses, dual use acute HF episodes were associated with higher odds of all-cause ED visits (odds ratio 1.61, 95% confidence interval [ CI ], 1.33, 1.95), HF -specific ED visits, (odds ratio 1.54, 95% CI , 1.12, 2.13), all-cause hospitalization (odds ratio 1.89, 95% CI , 1.50, 2.38), and HF -specific hospitalization (odds ratio 1.62, 95% CI , 1.15-2.30) as compared with Veterans Health Administration-only episodes of acute HF care. Dual use episodes of care were associated with higher hazard for mortality (hazard ratio=1.52, 95% CI 1.07, 2.16) as compared with all-Veterans Health Administration episodes of care. Conclusions Episodes of acute HF care spanning across healthcare systems appear to be associated with higher risk of subsequent ED visits, hospitalization, and mortality.

  View details for PubMedID 30371248

• Discharge home health services referral and 30-day all-cause readmission in older adults with heart failure ARCHIVES OF MEDICAL SCIENCE Arundel, C., Sheriff, H., Bearden, D. M., Morgan, C. J., Heidenreich, P. A., Fonarow, G. C., Butler, J., Allman, R. M., Ahmed, A. 2018; 14 (5): 995–1002

  View details for DOI 10.5114/aoms.2018.77562

  View details for Web of Science ID 000441438300006

• Discharge home health services referral and 30-day all-cause readmission in older adults with heart failure. Archives of medical science : AMS Arundel, C., Sheriff, H., Bearden, D. M., Morgan, C. J., Heidenreich, P. A., Fonarow, G. C., Butler, J., Allman, R. M., Ahmed, A. 2018; 14 (5): 995-1002

  Abstract

  Heart failure (HF) is the leading cause of hospital readmission. Medicare home health services provide intermittent skilled nursing care to homebound Medicare beneficiaries. We examined whether discharge home health referral is associated with a lower risk of 30-day all-cause readmission in HF.Of the 8049 Medicare beneficiaries hospitalized for acute HF and discharged alive from 106 Alabama hospitals, 6406 (76%) patients were not admitted from nursing homes and were discharged home without discharge hospice referrals. Of these, 1369 (21%) received a discharge home health referral. Using propensity scores for home health referral, we assembled a matched cohort of 1253 pairs of patients receiving and not receiving home health referrals, balanced on 33 baseline characteristics.The 2506 matched patients had a mean age of 78 years, 61% were women, and 27% were African American. Thirty-day all-cause readmission occurred in 28% and 19% of matched patients receiving and not receiving home health referrals, respectively (hazard ratio (HR) = 1.52; 95% confidence interval (CI): 1.29-1.80; p < 0.001). Home health referral was also associated with a higher risk of 30-day all-cause mortality (HR = 2.32; 95% CI: 1.58-3.41; p < 0.001) but not with 30-day HF readmission (HR = 1.28; 95% CI: 0.99-1.64; p = 0.056). HRs (95% CIs) for 1-year all-cause readmission, all-cause mortality, and HF readmission are 1.24 (1.13-1.36; p < 0.001), 1.37 (1.20-1.57; p < 0.001) and 1.09 (0.95-1.24; p = 0.216), respectively.Hospitalized HF patients who received discharge home health services referral had a higher risk of 30-day and 1-year all-cause readmission and all-cause mortality, but not of HF readmission.

  View details for DOI 10.5114/aoms.2018.77562

  View details for PubMedID 30154880

  View details for PubMedCentralID PMC6111362

• Diabetes is Associated with Worse In-Hospital and 30-Day Post-Discharge Morbidity in Patients with Heart Failure with Preserved Ejection Fraction: Findings from the Get With The Guidelines Heart Failure Registry McHugh, K., Wu, J., Matsouaka, R. A., DeVore, A. D., Fonarow, G. C., Heidenreich, P. A., Yancy, C. W., Green, J. B., Altman, N., Hernandez, A. F. CHURCHILL LIVINGSTONE INC MEDICAL PUBLISHERS. 2018: S92

  View details for DOI 10.1016/j.cardfail.2018.07.358

  View details for Web of Science ID 000445715800236

• US Department of Justice Investigations of Implantable Cardioverter-Defibrillators and Quality Improvement in Health Care. JAMA Heidenreich, P. A. 2018; 320 (1): 40–42

  View details for PubMedID 29971380

• US Department of Justice Investigations of Implantable Cardioverter-Defibrillators and Quality Improvement in Health Care JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Heidenreich, P. A. 2018; 320 (1): 40–42

  View details for DOI 10.1001/jama.2018.8514

  View details for Web of Science ID 000437219400015

• Association of the Affordable Care Act's Medicaid Expansion With Care Quality and Outcomes for Low-Income Patients Hospitalized With Heart Failure CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES Wadhera, R. K., Maddox, K., Fonarow, G. C., Zhao, X., Heidenreich, P. A., DeVore, A. D., Matsouaka, R. A., Hernandez, A. F., Yancy, C. W., Bhatt, D. L. 2018; 11 (7): e004729

  Abstract

  Heart failure (HF) is the leading cause of morbidity and mortality in the United States. Despite advancement in the management of HF, outcomes remain suboptimal, particularly among the uninsured. In 2014, the Affordable Care Act expanded Medicaid eligibility, and millions of low-income adults gained insurance. Little is known about Medicaid expansion's effect on inpatient HF care.We used the American Heart Association's Get With The Guidelines-Heart Failure registry to assess changes in inpatient care quality and outcomes among low-income patients (<65 years old) hospitalized for HF after Medicaid expansion, in expansion, and nonexpansion states. Patients were classified as low-income if covered by Medicaid, uninsured, or missing insurance. Expansion states were those that implemented expansion in 2014. Piecewise logistic multivariable regression models were constructed to track quarterly trends of quality and outcome measures in the pre (January 1, 2010-December 31, 2013) and postexpansion (January 1, 2014-June 30, 2017) periods. These measures were compared between expansion versus nonexpansion states during the postexpansion period. The cohort included 58 804 patients hospitalized across 391 sites. In states that expanded Medicaid, uninsured HF hospitalizations declined from 7.9% to 4.4%, and Medicaid HF hospitalizations increased from 18.3% to 34.6%. Defect-free HF care was increasing during the preexpansion period (adjusted odds ratio/quarter, 1.06; 95% confidence interval, 1.03-1.08) but did not change after expansion (adjusted odds ratio, 0.99; 95% confidence interval, 0.97-1.02). Patterns were similar for other quality measures. There were no quality measures for which the rate of improvement sped up after expansion. In-hospital mortality rates remained similar during the preexpansion (adjusted odds ratio, 0.99; 95% confidence interval, 0.96-1.02) and postexpansion periods (adjusted odds ratio, 1.00; 95% confidence interval, 0.97-1.03). Among nonexpansion states, uninsured HF hospitalizations increased (11.6% to 16.7%) as did Medicaid HF hospitalizations (17.9% to 26.6%), and no quarterly improvement was observed for most quality measures in the post compared with preexpansion period. During the postexpansion period, defect-free care and mortality did not differ between expansion and nonexpansion states.Medicaid expansion was associated with a significant decline in uninsured HF hospitalizations but not improvements in quality of care or in-hospital mortality among sites participating in a national quality improvement initiative. Efforts beyond insurance expansion are needed to improve in-hospital outcomes for low-income patients with HF.

  View details for PubMedID 29946015

• In Pursuit of Better Measures of Quality of Care JAMA CARDIOLOGY Heidenreich, P. A. 2018; 3 (7): 553-554

  View details for DOI 10.1001/jamacardio.2018.1204

  View details for Web of Science ID 000439158800002

  View details for PubMedID 29799972

• Lean-Based Redesign of Multidisciplinary Rounds on General Medicine Service JOURNAL OF HOSPITAL MEDICINE Kane, M., Rohatgi, N., Heidenreich, P. A., Thakur, A., Winget, M., Shum, K., Hereford, J., Shieh, L., Lew, T., Hom, J., Chi, J., Weinacker, A., Seay-Morrison, T., Ahuja, N. 2018; 13 (7): 482–85

  View details for DOI 10.12788/jhm.2908

  View details for Web of Science ID 000437294500006

• Diabetes and long-term outcomes of ischaemic stroke: findings from Get With The Guidelines-Stroke EUROPEAN HEART JOURNAL Echouffo-Tcheugui, J. B., Xu, H., Matsouaka, R. A., Xian, Y., Schwamm, L. H., Smith, E. E., Bhatt, D. L., Hernandez, A. F., Heidenreich, P. A., Fonarow, G. C. 2018; 39 (25): 2376–86

  Abstract

  There is a paucity of data on the influence of diabetes on long-term outcomes after ischaemic stroke (IS). We assessed whether outcomes after IS differ between patients with and without diabetes.Patients aged ≥65 years (n = 409 060) in Get With The Guidelines-Stroke (nationwide registry of stroke patients from 1690 sites in the USA) were followed for 3 years post-discharge. The outcomes of interest were mortality, cardiovascular and non-cardiovascular hospitalizations, heart failure (HF), and recurrence of IS/transient ischaemic attack (TIA). Patients with diabetes (29.6%) were younger and had more comorbidities. At 3 years post-discharge after IS, diabetes was associated with higher risks of adverse outcomes: all-cause mortality [cumulative incidence 46.0% vs. 44.2%, absolute difference (AD) 1.8%; adjusted hazard ratio (aHR) 1.24, 95% confidence interval 1.23-1.25], all-cause readmission (71.3% vs. 63.7%, AD 7.6%; aHR 1.22, 1.21-1.23), composite of mortality and all-cause readmission (84.1% vs. 79.3%, AD 4.8%; aHR 1.21, 1.20-1.22), composite of mortality and cardiovascular readmission (69.5% vs. 64.3%, AD 5.2%; aHR 1.19, 1.18-1.20), IS/TIA readmission (15.9% vs. 13.3%, AD 2.6%; aHR 1.18, 1.16-1.20), HF readmission (10.3% vs. 6.4%, AD 3.9%; aHR 1.60, 1.56-1.64), non-cardiovascular readmission (58.3% vs. 50.3%, AD 8.0%; aHR 1.28, 1.26-1.29), and non-IS/TIA readmission (67.6% vs. 59.7%, AD 7.9%; aHR 1.23, 1.22-1.25). Accounting for the initial severity of stroke using the National Institute of Health Stroke Scale as well as using propensity score matching method as a sensitivity analysis, did not modify the results.Among older IS patients diabetes was associated with increased risks of death, cardiovascular and non-cardiovascular hospitalizations, HF, and IS/TIA recurrence.

  View details for PubMedID 29438515

  View details for PubMedCentralID PMC6031049

• Racial Differences in Quality of Care and Outcomes After Acute Coronary Syndrome AMERICAN JOURNAL OF CARDIOLOGY Yong, C. M., Ungar, L., Abnousi, F., Asch, S. M., Heidenreich, P. A. 2018; 121 (12): 1489–95

  View details for DOI 10.1016/j.amjcard.2018.02.036

  View details for Web of Science ID 000436383200007

• 2016 ACC/AHA Clinical Performance and Quality Measures for Adults With Atrial Fibrillation or Atrial Flutter: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures (vol 68, pg 525, 2016) JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Heidenreich, P. A., Solis, P., Estes, N. M., Fonarow, G. C., Jurgens, C. Y., Marine, J. E., McManus, D. D., McNamara, R. L. 2018; 71 (23): 2713-2716

  View details for DOI 10.1016/j.jacc.2018.01.029

  View details for Web of Science ID 000434924500022

• Home-Time After Discharge Among Patients Hospitalized With Heart Failure JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Greene, S. J., O'Brien, E. C., Mentz, R. J., Luo, N., Hardy, N., Laskey, W. K., Heidenreich, P. A., Chang, C., Turner, S. J., Yancy, C. W., Hernandez, A. F., Curtis, L. H., Peterson, P. N., Fonarow, G. C., Hammill, B. G. 2018; 71 (23): 2643-2652

  Abstract

  Surveys of patients with cardiovascular disease have suggested that "home-time"-being alive and out of any health care institution-is a prioritized outcome. This novel measure has not been studied among patients with heart failure (HF).This study sought to characterize home-time following hospitalization for HF and assess its relationship with patient characteristics and traditionally reported clinical outcomes.Using GWTG-HF (Get With The Guidelines-Heart Failure) registry data, patients discharged alive from an HF hospitalization between 2011 and 2014 and ≥65 years of age were identified. Using Medicare claims, post-discharge home-time over 30-day and 1-year follow-up was calculated for each patient as the number of days alive and spent outside of a hospital, skilled nursing facility (SNF), or rehabilitation facility.Among 59,736 patients, 57,992 (97.1%) and 42,153 (70.6%) had complete follow-up for home-time calculation through 30 days and 1 year, respectively. The mean home-time was 21.6 ± 11.7 days at 30 days and 243.9 ± 137.6 days at 1 year. Contributions to reduced home-time varied by follow-up period, with days spent in SNF being the largest contributor though 30 days and death being the largest contributor through 1 year. Over 1 year, 2,044 (4.8%) patients had no home-time following index hospitalization discharge, whereas 8,194 (19.4%) had 365 days of home-time. In regression models, several conditions were associated with substantially reduced home-time, including chronic obstructive pulmonary disease, renal insufficiency, and dementia. Through 1 year, home-time was highly correlated with time-to-event endpoints of death (tau = 0.72) and the composite of death or HF readmission (tau = 0.59).Home-time, which can be readily calculated from administrative claims data, is substantially reduced for many patients following hospitalization for HF and is highly correlated with traditional time-to-event mortality and hospitalization outcomes. Home-time represents a novel, easily measured, patient-centered endpoint that may reflect effectiveness of interventions in future HF studies.

  View details for DOI 10.1016/j.jacc.2018.03.517

  View details for Web of Science ID 000434924500007

  View details for PubMedID 29880124

  View details for PubMedCentralID PMC6742493

• Frequency of Statin Use in Patients With Low-Density Lipoprotein Cholesterol ≥190 mg/dl from the Veterans Affairs Health System. The American journal of cardiology Rodriguez, F., Knowles, J. W., Maron, D. J., Virani, S. S., Heidenreich, P. A. 2018

  Abstract

  Patients with low-density lipoprotein cholesterol (LDL-C) ≥190 mg/dl have severe hypercholesterolemia and are at markedly increased risk for adverse cardiovascular events. This study sought to examine the prevalence and treatment of patients with uncontrolled severe hypercholesterolemia in the Veterans Affairs (VA) Health System. The study population was comprised of VA outpatients ≥21 years of age without atherosclerotic disease or diabetes mellitus and an index LDL-C ≥190 mg/dl during April 2011 to March 2014. Patients needed to have filled medications at the VA within the past 6 months. Patient and facility-level predictors of statin use, high-intensity statin use, and statin intensification were analyzed using multivariate logistic regressions. There were a total of 63,576 patients meeting inclusion criteria, including 8,553 (13.5%) women and 26,879 (29.0%) nonwhite patients. The mean (±S.D.) age was 55 (±13) years and the mean of the most recent LDL-C values was 207 ± 22 mg/dl. Only 52% of all eligible patients were on any statin therapy and 9.7% received high-intensity statin therapy. High-intensity statin use increased from 8.6% in 2011 to 13.6% in 2014 (p < 0.001). In adjusted analysis, patients <35 or >75 years of age were less likely to be on a statin (p < 0.001). Women were less likely to be treated than men, odds ratio = 0.88; 95% confidence interval (0.83, 0.92). Similar patterns were observed for predictors of high-intensity statin use and statin intensification. In conclusion, only half of high-risk VA patients with uncontrolled severe hypercholesterolemia were treated with statins and a small minority was on high-intensity statin therapy.

  View details for PubMedID 30055758

• A Hospital Level Analysis of 30-Day Readmission Performance for Heart Failure Patients and Long-Term Survival: Findings from Get With The Guidelines-Heart Failure AMERICAN HEART JOURNAL Jalnapurkar, S., Zhao, X., Heidenreich, P. A., Bhatt, D. L., Smith, E. E., DeVore, A. D., Hernandez, A. F., Matsouaka, R., Yancy, C. W., Fonarow, G. C. 2018; 200: 127–33

  Abstract

  Medicare utilizes 30-day risk-standardized readmission rates (RSRR) as a measure of hospital quality and applies penalties based on this measure. The objective of this study was to identify the relationship between hospital performance on 30-day RSRR in heart failure (HF) patients and long-term patient survival.Data were collected from Get With The Guidelines (GWTG)-HF and linked with Medicare data. Based on hospital performance for 30-day RSRR, hospitals were grouped into performance quartiles: top 25% (N=11,181), 25-50% (N=10,367), 50-75% (N=8729), and bottom 25% (N=7180). The primary outcome was mortality at 3 years applying Cox proportional hazards regression adjusted for patient and hospital characteristics.The overall 30-day readmission rate was 19.8% and the 3-year mortality rates were 61.8%, 61.0%, 62.6%, and 59.9% for top 25%, 25-50%, 50-75%, and bottom 25% hospitals for 30-day RSRR performance, respectively. Compared to bottom 25% performing hospitals, adjusted hazard ratios (HR) for 3-year mortality were HR 0.96 (95% confidence interval [CI] 0.90-1.01), HR 0.89 (95% CI 0.84-0.94), HR 1.01 (95% CI 0.95-1.06) for the top 25%, 25-50% and 50-75% hospitals respectively. Median survival time was highest for the bottom 25% hospitals on the 30-day RSRR metric.Hospital performance on 30-day readmissions in HF has no or little association with risk adjusted 3-year mortality or median survival. There is a compelling need to utilize more meaningful and patient-centered outcome measures for reporting and incentivizing quality care for HF.

  View details for PubMedID 29898841

• Early impact of guideline publication on angiotensin-receptor neprilysin inhibitor use among patients hospitalized for heart failure AMERICAN HEART JOURNAL Luo, N., Ballew, N. G., O'Brien, E. C., Greiner, M. A., Peterson, P. N., Hammill, B. G., Hardy, N., Laskey, W. K., Heidenreich, P. A., Chang, C., Hernandez, A. F., Curtis, L. H., Mentz, R. J., Fonarow, G. C. 2018; 200: 134-140

  Abstract

  On May 20, 2016, US professional organizations in cardiology published joint treatment guidelines recommending the use of angiotensin-receptor neprilysin inhibitor (ARNI) for eligible patients with heart failure with reduced ejection fraction (HFrEF). Using data from the Get With The Guidelines-Heart Failure registry, we evaluated the early impact of this update on temporal trends in ARNI prescription.We analyzed patients with HFrEF who were eligible for ARNI prescription (EF ≤40%, no contraindications) and hospitalized from February 20, 2016, through August 19, 2016-allowing for 13weeks before and after guideline publication. We quantified trends in ARNI use associated with guidelines publication with an interrupted time-series design using logistic regression and accounting for correlations within hospitals using general estimating equation methods.Of 7,200 eligible patient hospitalizations, 51.9% were discharged in the period directly preceding publication of the guidelines, and 48.1% were discharged after. Odds ratios of ARNI prescription at discharge were significantly higher in the postguideline period compared with the preguideline period in adjusted models (adjusted odds ratio 1.29, 95% CI 1.06-1.57, P=.01). However, there was no significant interaction between observed and expected ARNI use after guideline publication (Pinteraction=.14). Results were consistent using a 6-month before and after time frame.The model suggested a small increase in ARNI use in HF patients being discharged from the hospital immediately after guideline release. However, the publication of national guidelines recommending ARNI use seemed to have little influence on the adoption of this evidence-based medication in the first 3 to 6months.

  View details for DOI 10.1016/j.ahj.2018.01.009

  View details for Web of Science ID 000434948300020

  View details for PubMedID 29898842

• Association of Hospital Performance Based on 30-Day Risk-Standardized Mortality Rate With Long-term Survival After Heart Failure Hospitalization An Analysis of the Get With The Guidelines-Heart Failure Registry JAMA CARDIOLOGY Pandey, A., Patel, K., Liang, L., DeVore, A. D., Matsouaka, R., Bhatt, D. L., Yancy, C. W., Hernandez, A. F., Heidenreich, P. A., de Lemos, J. A., Fonarow, G. C. 2018; 3 (6): 489–97

  Abstract

  Among patients hospitalized with heart failure (HF), the long-term clinical implications of hospitalization at hospitals based on 30-day risk-standardized mortality rates (RSMRs) is not known.To evaluate the association of hospital-specific 30-day RSMR with long-term survival among patients hospitalized with HF in the American Heart Association Get With The Guidelines-HF registry.The longitudinal observational study included 106 304 patients with HF who were admitted to 317 centers participating in the Get With The Guidelines-HF registry from January 1, 2005, to December 31, 2013, and had Medicare-linked follow-up data. Hospital-specific 30-day RSMR was calculated using a hierarchical logistic regression model. In the model, 30-day mortality rate was a binary outcome, patient baseline characteristics were included as covariates, and the hospitals were treated as random effects. The association of 30-day RSMR-based hospital groups (low to high 30-day RSMR: quartile 1 [Q1] to Q4) with long-term (1-year, 3-year, and 5-year) mortality was assessed using adjusted Cox models. Data analysis took place from June 29, 2017, to February 19, 2018.Thirty-day RSMR for participating hospitals.One-year, 3-year, and 5-year mortality rates.Of the 106 304 patients included in the analysis, 57 552 (54.1%) were women and 84 595 (79.6%) were white, and the median (interquartile range) age was 81 (74-87) years. The 30-day RSMR ranged from 8.6% (Q1) to 10.7% (Q4). Hospitals in the low 30-day RSMR group had greater availability of advanced HF therapies, cardiac surgery, and percutaneous coronary interventions. In the primary landmarked analyses among 30-day survivors, there was a graded inverse association between 30-day RSMR and long-term mortality (Q1 vs Q4: 5-year mortality, 73.7% vs 76.8%). In adjusted analysis, patients admitted to hospitals in the high 30-day RSMR group had 14% (95% CI, 10-18) higher relative hazards of 5-year mortality compared with those admitted to hospitals in the low 30-day RSMR group. Similar findings were observed in analyses of survival from admission, with 22% (95% CI, 18-26) higher relative hazards of 5-year mortality for patients admitted to Q4 vs Q1 hospitals.Lower hospital-level 30-day RSMR is associated with greater 1-year, 3-year, and 5-year survival for patients with HF. These differences in 30-day survival continued to accrue beyond 30 days and persisted long term, suggesting that 30-day RSMR may be a useful HF performance metric to incentivize quality care and improve long-term outcomes.

  View details for PubMedID 29532056

  View details for PubMedCentralID PMC5875302

• Trends in Noncardiovascular Comorbidities Among Patients Hospitalized for Heart Failure Insights From the Get With The Guidelines-Heart Failure Registry CIRCULATION-HEART FAILURE Sharma, A., Zhao, X., Hammill, B. G., Hernandez, A. F., Fonarow, G. C., Felker, G., Yancy, C. W., Heidenreich, P. A., Ezekowitz, J. A., DeVore, A. D. 2018; 11 (6): e004646

  Abstract

  The increase in medical complexity among patients hospitalized with heart failure (HF) may be reflected by an increase in concomitant noncardiovascular comorbidities. Among patients hospitalized with HF, the temporal trends in the prevalence of noncardiovascular comorbidities have not been well described.We used data from 207 984 patients in the Get With The Guidelines-Heart Failure registry (from 2005 to 2014) to evaluate the prevalence and trends of noncardiovascular comorbidities (chronic obstructive pulmonary disorder/asthma, anemia, diabetes mellitus, obesity [body mass index ≥30 kg/m2], and renal impairment) among patients hospitalized with HF. Medicare beneficiaries aged ≥65 years were used to assess 30-day mortality. The prevalence of 0, 1, 2, and ≥3 noncardiovascular comorbidities was 18%, 30%, 27%, 25%, respectively. From 2005 to 2014, there was a decline in patients with 0 noncardiovascular comorbidities (22%-16%; P<0.0001) and an increase in patients with ≥3 noncardiovascular comorbidities (18%-29%; P<0.0001). Among Medicare beneficiaries, there was an increased 30-day adjusted mortality risk among patients with 1 noncardiovascular comorbidity (hazard ratio, 1.16; 95% confidence interval, 1.09-1.24; P<0.0001), 2 noncardiovascular comorbidities (hazard ratio, 1.34; 95% confidence interval, 1.25-1.44; P<0.0001), and ≥3 noncardiovascular comorbidities (hazard ratio, 1.63; 95% confidence interval, 1.51-1.75; P<0.0001). Similar trends were seen for in-hospital mortality.Patients admitted in hospital for HF have an increasing number of noncardiovascular comorbidities over time, which are associated with worse outcomes. Strategies addressing the growing burden of noncardiovascular comorbidities may represent an avenue to improve outcomes and should be included in the delivery of in-hospital HF care.

  View details for PubMedID 29793934

• Geographic and racial representation and reported success rates of studies of catheter ablation for atrial fibrillation: Findings from the SMASH-AF meta-analysis study cohort JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY Leef, G. C., Perino, A. C., Cluckey, A., Yunus, F. N., Askari, M., Heidenreich, P. A., Narayan, S. M., Wang, P. J., Turakhia, M. P. 2018; 29 (5): 747–55

  View details for DOI 10.1111/jce.13439

  View details for Web of Science ID 000433580000013

• Medicare Expenditures by Race/Ethnicity After Hospitalization for Heart Failure With Preserved Ejection Fraction JACC-HEART FAILURE Ziaeian, B., Heidenreich, P. A., Xu, H., DeVore, A. D., Matsouaka, R. A., Hernandez, A. F., Bhatt, D. L., Yancy, C. W., Fonarow, G. C. 2018; 6 (5): 388-397

  Abstract

  The purpose of this study was to analyze cumulative Medicare expenditures at index admission and after discharge by race or ethnicity.Heart failure with preserved ejection fraction (HFpEF) is a growing proportion of heart failure (HF) admissions. Research on health care expenditures for patients with HFpEF is limited.Records of patients discharged from the Get With The Guidelines-Heart Failure registry between 2006 and 2014 were linked to Medicare data. The primary outcome was unadjusted payments for acute care services. Comparisons between race/ethnic groups were made using generalized linear mixed models. Cost ratios were reported by race/ethnicity, and adjustments were made sequentially for patient characteristics, hospital factors, and regional socioeconomic status.Median Medicare costs for index hospitalizations were $7,241 for the entire cohort, $7,049 for whites, $8,269 for blacks, $8,808 for Hispanics, $8,477 for Asians, and $8,963 for other races. Median costs at 30 days for readmitted patients were $9,803 and $17,456 for the entire cohort at 1-year. No significant differences were seen in index admission cost ratios by race/ethnicity. At 30 days among readmitted patients, costs were 9% higher (95% confidence interval [CI]: 1% to 17%; p = 0.020) for blacks in the fully adjusted model than whites. At 1 year, costs were 14% higher (95% CI: 9% to 18%; p < 0.001) for blacks, 7% higher (95% CI: 0% to 14%; p = 0.041) for Hispanics, and 24% higher (95% CI: 8% to 42%; p = 0.003) for patients of other races. No significant differences between white and Asian expenditures were noted.Minority patients with HFpEF have greater acute care service costs. Further research of improving care delivery is needed to reduce acute care use for vulnerable populations.

  View details for DOI 10.1016/j.jchf.2017.12.007

  View details for Web of Science ID 000432098700005

  View details for PubMedID 29655830

  View details for PubMedCentralID PMC8312702

• Clinical Implications of Ablation of Drivers for Atrial Fibrillation A Systematic Review and Meta-Analysis CIRCULATION-ARRHYTHMIA AND ELECTROPHYSIOLOGY Baykaner, T., Rogers, A. J., Meckler, G. L., Zaman, J., Navara, R., Rodrigo, M., Alhusseini, M., Kowalewski, C. B., Viswanathan, M. N., Narayan, S. M., Clopton, P., Wang, P. J., Heidenreich, P. A. 2018; 11 (5)

  View details for DOI 10.1161/CIRCEP.117.006119

  View details for Web of Science ID 000439150300011

• Association Between Hospital Volume, Processes of Care, and Outcomes in Patients Admitted With Heart Failure Insights From Get With The Guidelines-Heart Failure CIRCULATION Kumbhani, D. J., Fonarow, G. C., Heidenreich, P. A., Schulte, P. J., Lu, D., Hernandez, A., Yancy, C., Bhatt, D. L. 2018; 137 (16): 1661-+

  Abstract

  Hospital volume is frequently used as a structural metric for assessing quality of care, but its utility in patients admitted with acute heart failure (HF) is not well characterized. Accordingly, we sought to determine the relationship between admission volume, process-of-care metrics, and short- and long-term outcomes in patients admitted with acute HF.Patients enrolled in the Get With The Guidelines-HF registry with linked Medicare inpatient data at 342 hospitals were assessed. Volume was assessed both as a continuous variable, and quartiles based on the admitting hospital annual HF case volume, as well: 5 to 38 (quartile 1), 39 to 77 (quartile 2), 78 to 122 (quartile 3), 123 to 457 (quartile 4). The main outcome measures were (1) process measures at discharge (achievement of HF achievement, quality, reporting, and composite metrics); (2) 30-day mortality and hospital readmission; and (3) 6-month mortality and hospital readmission. Adjusted logistic and Cox proportional hazards models were used to study these associations with hospital volume.A total of 125 595 patients with HF were included. Patients admitted to high-volume hospitals had a higher burden of comorbidities. On multivariable modeling, lower-volume hospitals were significantly less likely to be adherent to HF process measures than higher-volume hospitals. Higher hospital volume was not associated with a difference in in-hospital (odds ratio, 0.99; 95% confidence interval [CI], 0.94-1.05; P=0.78) or 30-day mortality (hazard ratio, 0.99; 95% CI, 0.97-1.01; P=0.26), or 30-day readmissions (hazard ratio, 0.99; 95% CI, 0.97-1.00; P=0.10). There was a weak association of higher volumes with lower 6-month mortality (hazard ratio, 0.98; 95% CI, 0.97-0.99; P=0.001) and lower 6-month all-cause readmissions (hazard ratio, 0.98; 95%, CI 0.97-1.00; P=0.025).Our analysis of a large contemporary prospective national quality improvement registry of older patients with HF indicates that hospital volume as a structural metric correlates with process measures, but not with 30-day outcomes, and only marginally with outcomes up to 6 months of follow-up. Hospital profiling should focus on participation in systems of care, adherence to process metrics, and risk-standardized outcomes rather than on hospital volume itself.

  View details for PubMedID 29378692

• Association of Electronic Health Record Use With Quality of Care and Outcomes in Heart Failure: An Analysis of Get With The GuidelinesHeart Failure JOURNAL OF THE AMERICAN HEART ASSOCIATION Selvaraj, S., Fonarow, G. C., Sheng, S., Matsouaka, R. A., DeVore, A. D., Heidenreich, P. A., Hernandez, A. F., Yancy, C. W., Bhatt, D. L. 2018; 7 (7)

  Abstract

  Adoption of electronic health record (EHR) systems has increased significantly across the nation. Whether EHR use has translated into improved quality of care and outcomes in heart failure (HF) is not well studied.We examined participants from the Get With The Guidelines-HF registry who were admitted with HF in 2008 (N=21 222), using various degrees of EHR implementation (no EHR, partial EHR, and full EHR). We performed multivariable logistic regression to determine the relation between EHR status and several in-hospital quality metrics and outcomes. In a substudy of Medicare participants (N=8421), we assessed the relation between EHR status and rates of 30-day mortality, readmission, and a composite outcome. In the cohort, the mean age was 71±15 years, 49% were women, and 64% were white. The mean ejection fraction was 39±17%. Participants were admitted to hospitals with no EHR (N=1484), partial EHR (N=13 473), and full EHR (N=6265). There was no association between EHR status and several quality metrics (aside from β blocker at discharge) or in-hospital outcomes on multivariable adjusted logistic regression (P>0.05 for all comparisons). In the Medicare cohort, there was no association between EHR status and 30-day mortality, readmission, or the combined outcome.In a large registry of hospitalized patients with HF, there was no association between degrees of EHR implementation and several quality metrics and 30-day postdischarge death or readmission. Our results suggest that EHR may not be sufficient to improve HF quality or related outcomes.

  View details for PubMedID 29602768

• Government continues to have an important role in promoting cardiovascular health AMERICAN HEART JOURNAL Tomaselli, G., Roach, W. H., Pina, I. L., Oster, M. E., Dietz, W. H., Horton, K., Borden, W. B., Brownell, K., Gibbons, R. J., Otten, J. J., Lee, C. S., Hill, C., Heidenreich, P. A., Siscovick, D. S., Whitsel, L. P. 2018; 198: 160–65

  View details for PubMedID 29653638

• National Trends of Hospital Performance in Acute Myocardial Infarction Care Department of Veterans Affairs, 2011-2014 CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES Hess, P. L., Gunzburger, E. C., Kini, V., Liu, C., Jones, J., Matlock, D., Heidenreich, P. A., Levy, C. R., Maddox, T. M., Grunwald, G. K., Ho, P. 2018; 11 (4): e004282

  View details for DOI 10.1161/CIRCOUTCOMES.117.004282

  View details for Web of Science ID 000436414100006

  View details for PubMedID 29650717

• Heart failure management with ambulatory pulmonary artery pressure monitoring TRENDS IN CARDIOVASCULAR MEDICINE Sandhu, A. T., Heidenreich, P. A. 2018; 28 (3): 212–19

  View details for DOI 10.1016/j.tcm.2017.09.002

  View details for Web of Science ID 000429487800009

• Early Ambulation Among Hospitalized Heart Failure Patients Is Associated With Reduced Length of Stay and 30-Day Readmissions. Circulation. Heart failure Fleming, L. M., Zhao, X., DeVore, A. D., Heidenreich, P. A., Yancy, C. W., Fonarow, G. C., Hernandez, A. F., Kociol, R. D. 2018; 11 (4): e004634

  Abstract

  BACKGROUND: Early ambulation (EA) is associated with improved outcomes for mechanically ventilated and stroke patients. Whether the same association exists for patients hospitalized with acute heart failure is unknown. We sought to determine whether EA among patients hospitalized with heart failure is associated with length of stay, discharge disposition, 30-day post discharge readmissions, and mortality.METHODS AND RESULTS: The study population included 369 hospitals and 285653 patients with heart failure enrolled in the Get With The Guidelines-Heart Failure registry. We used multivariate logistic regression with generalized estimating equations at the hospital level to identify predictors of EA and determine the association between EA and outcomes. Sixty-five percent of patients ambulated by day 2 of the hospital admission. Patient-level predictors of EA included younger age, male sex, and hospitalization outside of the Northeast (P<0.01 for all). Hospital size and academic status were not predictive. Hospital-level analysis revealed that those hospitals with EA rates in the top 25% were less likely to have a long length of stay (defined as >4 days) compared with those in the bottom 25% (odds ratio, 0.83; confidence interval, 0.73-0.94; P=0.004). Among a subgroup of fee-for-service Medicare beneficiaries, we found that hospitals in the highest quartile of rates of EA demonstrated a statistically significant 24% lower 30-day readmission rates (P<0.0001). Both end points demonstrated a dose-response association and statistically significant P for trend test.CONCLUSIONS: Multivariable-adjusted hospital-level analysis suggests an association between EA and both shorter length of stay and lower 30-day readmissions. Further prospective studies are needed to validate these findings.

  View details for DOI 10.1161/CIRCHEARTFAILURE.117.004634

  View details for PubMedID 29643066

• Racial Differences in Quality of Care and Outcomes After Acute Coronary Syndrome. The American journal of cardiology Yong, C. M., Ungar, L., Abnousi, F., Asch, S. M., Heidenreich, P. A. 2018

  Abstract

  Guideline adherence and variation in acute coronary syndrome (ACS) outcomes by race in the modern era of drug-eluting stents (DES) are not well understood. Previous studies also fail to capture rapidly growing minority populations, such as Asians. A retrospective analysis of 689,238 hospitalizations for ACS across all insurance types from 2008 to 2011 from the Healthcare Cost and Utilization Project database was performed to determine whether quality of ACS care and mortality differ by race (white, black, Asian, Hispanic, or Native American), with adjustment for patient clinical and demographic characteristics and clustering by hospital. We found that black patients had the lowest in-hospital mortality rates (5% vs 6% to 7% for other races, p<0.0001, odds ratio [OR] 1.02, 95% confidence interval [CI] 0.97 to 1.07), despite low rates of timely angiography in ST-elevation myocardial infarction and non-ST-elevation myocardial infarction, and lower use of DES (30% vs 38% to 40% for other races, p<0.0001). In contrast, Asian patients had the highest in-hospital mortality rates (7% vs 5% to 7% for other races, p<0.0001, odds ratio 1.13, 95% CI 1.08 to 1.20, relative to white patients), despite higher rates of timely angiography in ST-elevation myocardial infarction and non-ST-elevation myocardial infarction, and the highest use of DES (74% vs 63% to 68% for other races, p<0.0001). Asian patients had the worst in-hospital mortality outcomes after ACS, despite high use of early invasive treatments. Black patients had better in-hospital outcomes despite receiving less guideline-driven care.

  View details for PubMedID 29655881

• THE COMPLEMENTARY VALUE OF THE GET WITH THE GUIDELINES: HEART FAILURE RISK SCORE AND LABORATORY MARKERS AT DISCHARGE IN PREDICTING MORTALITY IN PATIENTS HOSPITALIZED WITH HEART FAILURE WITH PRESERVED EJECTION FRACTION Boralkar, K., Kobayashi, Y., Pargaonkar, V., Moneghetti, K., Tuzovic, M., Krishnan, G., Amsallem, M., Kouznetsova, T., Horne, B., Knowlton, K., Heidenreich, P., Haddad, F. ELSEVIER SCIENCE INC. 2018: 839

  View details for DOI 10.1016/S0735-1097(18)31380-9

  View details for Web of Science ID 000429659702089

• EARLY IMPACT OF GUIDELINE PUBLICATION ON ANGIOTENSIN-RECEPTOR NEPRILYSIN INHIBITOR USE AMONG PATIENTS HOSPITALIZED FOR HEART FAILURE Luo, N., Ballew, N. G., O'Brien, E., Greiner, M., Peterson, P., Hammill, B., Hardy, N., Laskey, W., Heidenreich, P., Chang, C., Hernandez, A., Curtis, L., Mentz, R., Fonarow, G. C. ELSEVIER SCIENCE INC. 2018: 791

  View details for DOI 10.1016/S0735-1097(18)31332-9

  View details for Web of Science ID 000429659702041

• APPLYING NATURAL LANGUAGE PROCESSING OF ECHOCARDIOGRAPHY REPORTS TO DESCRIBE EPIDEMIOLOGY OF HEART FAILURE Tisdale, R., Heidenreich, P. ELSEVIER SCIENCE INC. 2018: 712

  View details for DOI 10.1016/S0735-1097(18)31253-1

  View details for Web of Science ID 000429659701562

• Relationship between Hospital 30-Day Mortality Rates for Heart Failure and Patterns of Early Inpatient Comfort Care JOURNAL OF HOSPITAL MEDICINE Chen, L. M., Levine, D. A., Hayward, R., Cox, M., Schulte, P. J., DeVore, A. D., Hernandez, A., Heidenreich, P. A., Yancy, C., Fonarow, G. C. 2018; 13 (3): 170-176

  Abstract

  The Centers for Medicare & Medicaid Services rewards hospitals that have low 30-day riskstandardized mortality rates (RSMR) for heart failure (HF).To describe the use of early comfort care for patients with HF, and whether hospitals that more commonly initiate comfort care have higher 30-day mortality rates.A retrospective, observational study.Acute care hospitals in the United States.A total of 93,920 fee-for-service Medicare beneficiaries admitted with HF from January 2008 to December 2014 to 272 hospitals participating in the Get With The Guidelines-Heart Failure registry.Early comfort care (defined as comfort care within 48 hours of hospitalization) rate.A 30-day RSMR.Hospitals' early comfort care rates were low for patients admitted for HF, with no change over time (2.5% to 2.6%, from 2008 to 2014, P = .56). Rates varied widely (0% to 40%), with 14.3% of hospitals not initiating comfort care for any patients during the first 2 days of hospitalization. Risk-standardized early comfort care rates were not correlated with RSMR (median RSMR = 10.9%, 25th to 75th percentile = 10.1% to 12.0%; Spearman's rank correlation = 0.13; P = .66).Hospital use of early comfort care for HF varies, has not increased over time, and on average, is not correlated with 30-day RSMR. This suggests that current efforts to lower mortality rates have not had unintended consequences for hospitals that institute early comfort care more commonly than their peers.

  View details for DOI 10.12788/jhm.2862

  View details for Web of Science ID 000426374100005

  View details for PubMedID 29505624

• Geographic and racial representation and reported success rates of studies of catheter ablation for atrial fibrillation: Findings from the SMASH-AF meta-analysis study cohort. Journal of cardiovascular electrophysiology Leef, G. C., Perino, A. C., Cluckey, A., Yunus, F. N., Askari, M., Heidenreich, P. A., Narayan, S. M., Wang, P. J., Turakhia, M. P. 2018

  Abstract

  INTRODUCTION: We performed a systematic review and meta-analysis of geographic and racial representation and reported success rates of studies of catheter ablation for atrial fibrillation (AF).METHODS AND RESULTS: We searched PubMed, Scopus, and Cochrane databases from 1/1/1990 to 8/1/2016 for trials and observational studies reporting AF ablation outcomes. Major exclusion criteria were insufficient reporting of outcomes, non-English language articles, and ablation strategies that were not prespecified and uniform. We described geographic and racial representation and single-procedure ablation success rates by country, controlling for patient demographics and study design characteristics. The analysis cohort included 306 studies (49,227 patients) from 28 countries. Over half of the paroxysmal (PAF) and nonparoxysmal AF (NPAF) treatment arms were conducted in 5 and 3 countries, respectively. Reporting of race or ethnicity demographics and outcomes were rare (1 study, 0.3%) and nonexistent, respectively. Unadjusted success rates by country ranged from 63.5% to 83.0% for PAF studies and 52.7% to 71.6% for NPAF studies, with substantial variation in patient demographics and study design. After controlling for covariates, South Korea and the United States had higher PAF ablation success rates, with large residual heterogeneity. NPAF ablation success rates were statistically similar by country.CONCLUSIONS: Studies of AF ablation have substantial variation in patient demographics, study design, and reported outcomes by country. There is limited geographic representation of trials and observational studies of AF ablation and a paucity of race- or ethnicity-stratified results. Future AF ablation studies and registries should aim to have broad representation by race, geography, and ethnicity to ensure generalizability.

  View details for PubMedID 29364570

• The interaction between rural/urban status and dual use status among veterans with heart failure RURAL AND REMOTE HEALTH Hunt, K. J., Gebregziahber, M., Everett, C. J., Heidenreich, P. A., Axon, R. 2018; 18 (2): 4495

  Abstract

  Dual healthcare system use is associated with higher rates of healthcare utilization, but the influence of rurality on this phenomenon is unclear. This study aimed to determine the extent to which rurality in the USA modifies the likelihood for acute healthcare use among veterans with heart failure (HF).Using merged Veterans Affairs (VA), Medicare, and state-level administrative data, a retrospective cohort study of 4985 veterans with HF was performed. Negative binomial regression with interaction term for dual use and geographic location was used to estimate and compare the associations between dual use (as compared to VA-only use) and emergency department (ED) visits, hospitalizations, and 30-day hospital readmissions in rural/highly rural veterans versus urban veterans.The association between dual use compared to VA-only use and ED visits was stronger in rural/highly rural veterans (RR=1.28 (95%CI: 1.21,1.35)) than in urban veterans (rate ratio (RR)=1.17 (95% confidence interval (CI): 1.11,1.22)) (interaction p-value=0.0109), while the association between dual use and all-cause hospitalizations was similar in rural/highly rural veterans (RR=2.00 (95%CI: 1.87, 2.14)) and in urban veterans (RR=1.87 (95%CI: 1.77,1.98)). The association between dual use and all-cause 30-day hospital readmission was also similar in rural/highly rural versus urban veterans.Rurality significantly modifies the likelihood of ED visits for HF, although this effect was not observed for hospitalizations or hospital readmissions. While other patient- or system-level factors may more heavily influence hospitalization and readmission in this population, dual use appears to be a marker for higher healthcare utilization and worse outcomes for both urban and rural veterans.

  View details for PubMedID 29742355

• Longitudinal Outcomes of Medicare Beneficiaries With Transient Ischemic Attack: a GWTG-Stroke Study Shah, S., Liang, L., Smith, E. E., Bhatt, D. L., Fonarow, G. C., Heidenreich, P. A., Peterson, E. D., Bettger, J. P. LIPPINCOTT WILLIAMS & WILKINS. 2018

  View details for Web of Science ID 000429728400160

• Association of Healthcare Plan with Atrial Fibrillation Prescription Patterns. Clinical cardiology Chang, A. Y., Askari, M. n., Fan, J. n., Heidenreich, P. A., Ho, P. M., Mahaffey, K. W., Ullal, A. J., Perino, A. C., Turakhia, M. P. 2018

  Abstract

  Atrial fibrillation (AF) is treated by many types of physician specialists, including primary care physicians (PCPs). Health plans have different policies for how patients encounter these providers, and these may affect selection of AF treatment strategy.We hypothesized that healthcare plans with PCP-gatekeeping to specialist access may be associated with different pharmacologic treatments for AF.We performed a retrospective cohort study using a commercial pharmaceutical claims database. We utilized logistic regression models to compare odds of prescription of oral anticoagulant (OAC), non-vitamin K-dependent oral anticoagulant (NOAC), rate control, and rhythm control medications used to treat AF between patients with PCP-gated healthcare plans (e.g. HMO, EPO, POS) and patients with non-PCP-gated healthcare plans (e.g. PPO, CHDP, HDHP, Comprehensive) between 2007 and 2012. We also calculated median time to receipt of therapy within 90 days of index AF diagnosis.We found similar odds of OAC prescription at 90 days following new AF diagnosis in patients with PCP-gated plans compared to those with non-PCP-gated plans (OR: OAC 1.01, p=0.84; warfarin 1.05, p=0.08). Relative odds were similar for rate control (1.17, p<0.01) and rhythm control agents (0.93, p=0.03). However, PCP-gated plan patients had slightly lower likelihood of being prescribed NOACs (0.82, p=0.001) than non-gated plan patients. Elapsed time until receipt of medication was similar between PCP-gated and non-gated groups across drug classes.Pharmaceutical claims data do not suggest that PCP-gatekeeping by healthcare plans is a structural barrier to AF therapy, although it was associated with lower use of NOACs.

  View details for PubMedID 30098034

• Patient and facility variation in costs of catheter ablation for atrial fibrillation. Journal of cardiovascular electrophysiology Perino, A. C., Fan, J. n., Schmitt, S. n., Kaiser, D. W., Heidenreich, P. A., Narayan, S. M., Wang, P. J., Chang, A. Y., Turakhia, M. P. 2018

  Abstract

  Cost-effectiveness or value of cardiovascular therapies may be undermined by unwarranted cost variation, particularly for heterogeneous procedures such as catheter ablation for atrial fibrillation (AF). We sought to characterize cost variation of AF ablation in the U.S. health care system and the relationship between cost and outcomes.We performed a retrospective cohort study using data from the MarketScan® commercial claims and Medicare supplemental databases including patients who received an AF ablation from 2007 through 2011. We aggregated encounter cost, reflecting total payments received for the encounter, to the facility level to calculate median facility cost. We classified procedures as outpatient or inpatient and assessed for association between cost and 30-day and one-year outcomes. The analysis cohort included 9,415 AF ablations (59±11 years; 28% female; 52% outpatient) occurring at 327 facilities, with large cost variation across facilities (median: $25,100; 25th percentile: $18,900, 75th percentile: $35,600, 95th percentile: $57,800). Among outpatient procedures, there was reduced health care utilization in higher cost quintiles with reductions in rehospitalization at 30-days (Quintile 1: 16.1%, Quintile 5: 8.8%, p < 0.001) and one-year (Quintile 1: 34.8%, Quintile 5: 25.6%, p < 0.001), which remained significant in multivariate analysis.Although median costs of AF ablation are below amounts used in prior cost-effectiveness studies that demonstrated good value, large facility variation in cost suggests opportunities for cost reduction. However, for outpatient encounters, association of cost to modestly improved outcomes suggests cost containment strategies could have variable effects. This article is protected by copyright. All rights reserved.

  View details for PubMedID 29864193

• Automating Quality Measures for Heart Failure Using Natural Language Processing: A Descriptive Study in the Department of Veterans Affairs JMIR MEDICAL INFORMATICS Garvin, J., Kim, Y., Gobbel, G., Matheny, M. E., Redd, A., Bray, B. E., Heidenreich, P., Bolton, D., Heavirland, J., Kelly, N., Reeves, R., Kalsy, M., Goldstein, M., Meystre, S. M. 2018; 6 (1): e5

  Abstract

  We developed an accurate, stakeholder-informed, automated, natural language processing (NLP) system to measure the quality of heart failure (HF) inpatient care, and explored the potential for adoption of this system within an integrated health care system.To accurately automate a United States Department of Veterans Affairs (VA) quality measure for inpatients with HF.We automated the HF quality measure Congestive Heart Failure Inpatient Measure 19 (CHI19) that identifies whether a given patient has left ventricular ejection fraction (LVEF) <40%, and if so, whether an angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker was prescribed at discharge if there were no contraindications. We used documents from 1083 unique inpatients from eight VA medical centers to develop a reference standard (RS) to train (n=314) and test (n=769) the Congestive Heart Failure Information Extraction Framework (CHIEF). We also conducted semi-structured interviews (n=15) for stakeholder feedback on implementation of the CHIEF.The CHIEF classified each hospitalization in the test set with a sensitivity (SN) of 98.9% and positive predictive value of 98.7%, compared with an RS and SN of 98.5% for available External Peer Review Program assessments. Of the 1083 patients available for the NLP system, the CHIEF evaluated and classified 100% of cases. Stakeholders identified potential implementation facilitators and clinical uses of the CHIEF.The CHIEF provided complete data for all patients in the cohort and could potentially improve the efficiency, timeliness, and utility of HF quality measurements.

  View details for PubMedID 29335238

• Heart failure management with ambulatory pulmonary artery pressure monitoring. Trends in cardiovascular medicine Sandhu, A. T., Heidenreich, P. A. 2018; 28 (3): 212–19

  Abstract

  Remote monitoring strategies have been developed to improve ambulatory care of heart failure patients and reduce heart failure hospitalizations. This article evaluates the CardioMEMS device, an implantable wireless pulmonary artery pressure monitor. We provide a historical review of remote monitoring in heart failure along with an in-depth analysis of the rationale, evidence, and limitations of the CardioMEMS device.

  View details for PubMedID 28988604

• Association of the Hospital Readmissions Reduction Program Implementation With Readmission and Mortality Outcomes in Heart Failure JAMA CARDIOLOGY Gupta, A., Allen, L. A., Bhatt, D. L., Cox, M., DeVore, A. D., Heidenreich, P. A., Hernandez, A. F., Peterson, E. D., Matsouaka, R. A., Yancy, C. W., Fonarow, G. C. 2018; 3 (1): 44–53

  Abstract

  Public reporting of hospitals' 30-day risk-standardized readmission rates following heart failure hospitalization and the financial penalization of hospitals with higher rates have been associated with a reduction in 30-day readmissions but have raised concerns regarding the potential for unintended consequences.To examine the association of the Hospital Readmissions Reduction Program (HRRP) with readmission and mortality outcomes among patients hospitalized with heart failure within a prospective clinical registry that allows for detailed risk adjustment.Interrupted time-series and survival analyses of index heart failure hospitalizations were conducted from January 1, 2006, to December 31, 2014. This study included 115 245 fee-for-service Medicare beneficiaries across 416 US hospital sites participating in the American Heart Association Get With The Guidelines-Heart Failure registry. Data analysis took place from January 1, 2017, to June 8, 2017.Time intervals related to the HRRP were before the HRRP implementation (January 1, 2006, to March 31, 2010), during the HRRP implementation (April 1, 2010, to September 30, 2012), and after the HRRP penalties went into effect (October 1, 2012, to December 31, 2014).Risk-adjusted 30-day and 1-year all-cause readmission and mortality rates.The mean (SD) age of the study population (n = 115 245) was 80.5 (8.4) years, 62 927 (54.6%) were women, and 91 996 (81.3%) were white and 11 037 (9.7%) were black. The 30-day risk-adjusted readmission rate declined from 20.0% before the HRRP implementation to 18.4% in the HRRP penalties phase (hazard ratio (HR) after vs before the HRRP implementation, 0.91; 95% CI, 0.87-0.95; P < .001). In contrast, the 30-day risk-adjusted mortality rate increased from 7.2% before the HRRP implementation to 8.6% in the HRRP penalties phase (HR after vs before the HRRP implementation, 1.18; 95% CI, 1.10-1.27; P < .001). The 1-year risk-adjusted readmission and mortality rates followed a similar pattern as the 30-day outcomes. The 1-year risk-adjusted readmission rate declined from 57.2% to 56.3% (HR, 0.92; 95% CI, 0.89-0.96; P < .001), and the 1-year risk-adjusted mortality rate increased from 31.3% to 36.3% (HR, 1.10; 95% CI, 1.06-1.14; P < .001) after vs before the HRRP implementation.Among fee-for-service Medicare beneficiaries discharged after heart failure hospitalizations, implementation of the HRRP was temporally associated with a reduction in 30-day and 1-year readmissions but an increase in 30-day and 1-year mortality. If confirmed, this finding may require reconsideration of the HRRP in heart failure.

  View details for PubMedID 29128869

  View details for PubMedCentralID PMC5833526

• Lean-Based Redesign of Multidisciplinary Rounds on General Medicine Service. Journal of hospital medicine Kane, M. n., Rohatgi, N. n., Heidenreich, P. n., Thakur, A. n., Winget, M. n., Shum, K. n., Hereford, J. n., Shieh, L. n., Lew, T. n., Horn, J. n., Chi, J. n., Weinacker, A. n., Seay-Morrison, T. n., Ahuja, N. n. 2018

  Abstract

  Multidisciplinary rounds (MDR) facilitate timely communication amongst the care team and with patients. We used Lean techniques to redesign MDR on the teaching general medicine service.To examine if our Lean-based new model of MDR was associated with change in the primary outcome of length of stay (LOS) and secondary outcomes of discharges before noon, documentation of estimated discharge date (EDD), and patient satisfaction.This is a pre-post study. The preperiod (in which the old model of MDR was followed) comprised 4000 patients discharged between September 1, 2013, and October 22, 2014. The postperiod (in which the new model of MDR was followed) comprised 2085 patients between October 23, 2014, and April 30, 2015.Lean-based redesign of MDR.LOS, discharges before noon, EDD, and patient satisfaction.There was no change in the mean LOS. Discharges before noon increased from 6.9% to 10.7% (P < .001). Recording of EDD increased from 31.4% to 41.3% (P < .001). There was no change in patient satisfaction.Lean-based redesign of MDR was associated with an increase in discharges before noon and in recording of EDD.

  View details for PubMedID 29394300

• Clinical Implications of Ablation of Drivers for Atrial Fibrillation: A Systematic Review and Meta-Analysis. Circulation. Arrhythmia and electrophysiology Baykaner, T. n., Rogers, A. J., Meckler, G. L., Zaman, J. n., Navara, R. n., Rodrigo, M. n., Alhusseini, M. n., Kowalewski, C. A., Viswanathan, M. N., Narayan, S. M., Clopton, P. n., Wang, P. J., Heidenreich, P. A. 2018; 11 (5): e006119

  Abstract

  The outcomes from pulmonary vein isolation (PVI) for atrial fibrillation (AF) are suboptimal, but the benefits of additional lesion sets remain unproven. Recent studies propose ablation of AF drivers improves outcomes over PVI, yet with conflicting reports in the literature. We undertook a systematic literature review and meta-analysis to determine outcomes from ablation of AF drivers in addition to PVI or as a stand-alone procedure.Database search was done using the terms atrial fibrillation and ablation or catheter ablation and driver or rotor or focal impulse or FIRM (Focal Impulse and Rotor Modulation). We pooled data using random effects model and assessed heterogeneity with I2 statistic.Seventeen studies met inclusion criteria, in a cohort size of 3294 patients. Adding AF driver ablation to PVI reported freedom from AF of 72.5% (confidence interval [CI], 62.1%-81.8%; P<0.01) and from all arrhythmias of 57.8% (CI, 47.5%-67.7%; P<0.01). AF driver ablation when added to PVI or as stand-alone procedure compared with controls produced an odds ratio of 3.1 (CI, 1.3-7.7; P=0.02) for freedom from AF and an odds ratio of 1.8 (CI, 1.2-2.7; P<0.01) for freedom from all arrhythmias in 4 controlled studies. AF termination rate was 40.5% (CI, 30.6%-50.9%) and predicted favorable outcome from ablation(P<0.05).In controlled studies, the addition of AF driver ablation to PVI supports the possible benefit of a combined approach of AF driver ablation and PVI in improving single-procedure freedom from all arrhythmias. However, most studies are uncontrolled and are limited by substantial heterogeneity in outcomes. Large multicenter randomized trials are needed to precisely define the benefits of adding driver ablation to PVI.

  View details for PubMedID 29743170

• Use of Mineralocorticoid Receptor Antagonists in Patients With Heart Failure and Comorbid Diabetes Mellitus or Chronic Kidney Disease JOURNAL OF THE AMERICAN HEART ASSOCIATION Cooper, L. B., Lippmann, S. J., Greiner, M. A., Sharma, A., Kelly, J. P., Fonarow, G. C., Yancy, C. W., Heidenreich, P. A., Hernandez, A. F. 2017; 6 (12)

  Abstract

  Perceived risks of hyperkalemia and acute renal insufficiency may limit use of mineralocorticoid receptor antagonist (MRA) therapy in patients with heart failure, especially those with diabetes mellitus or chronic kidney disease.Using clinical registry data linked to Medicare claims, we analyzed patients hospitalized with heart failure between 2005 and 2013 with a history of diabetes mellitus or chronic kidney disease. We stratified patients by MRA use at discharge. We used inverse probability-weighted proportional hazards models to assess associations between MRA therapy and 30-day, 1-year, and 3-year mortality, all-cause readmission, and readmission for heart failure, hyperkalemia, and acute renal insufficiency. We performed interaction analyses for differential effects on 3-year outcomes for reduced, borderline, and preserved ejection fraction. Of 16 848 patients, 12.3% received MRA therapy at discharge. Higher serum creatinine was associated with lower odds of MRA use (odds ratio, 0.66; 95% confidence interval, 0.61-0.71); serum potassium was not (odds ratio, 1.00; 95% confidence interval, 0.90-1.11). There was no mortality difference between groups. MRA therapy was associated with greater risks of readmission for hyperkalemia and acute renal insufficiency and lower risks of long-term all-cause readmission. Patients on MRA therapy with borderline or preserved ejection fraction had greater risks of readmission for hyperkalemia (P=0.02) and acute renal insufficiency (P<0.001); patients with reduced ejection fraction did not.Among patients with heart failure and diabetes mellitus or chronic kidney disease, MRA use was associated with lower risk of all-cause readmission despite greater risk of hyperkalemia and acute renal insufficiency.

  View details for DOI 10.1161/JAHA.117.006540

  View details for Web of Science ID 000418951100016

  View details for PubMedID 29275368

  View details for PubMedCentralID PMC5779000

• Heart Failure With Preserved, Borderline, and Reduced Ejection Fraction 5-Year Outcomes JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Shah, K. S., Xu, H., Matsouaka, R. A., Bhatt, D. L., Heidenreich, P. A., Hernandez, A. F., Devore, A. D., Yancy, C. W., Fonarow, G. C. 2017; 70 (20): 2476–86

  Abstract

  Patients with heart failure (HF) have a poor prognosis and are categorized by ejection fraction (EF).This study sought to characterize differences in outcomes in patients hospitalized with heart failure with preserved ejection fraction (HFpEF) (EF ≥50%), heart failure with borderline ejection fraction (HFbEF) (EF 41% to 49%), and heart failure with reduced ejection fraction (HFrEF) (EF ≤40%).Data from GWTG-HF (Get With The Guidelines-Heart Failure) were linked to Medicare data for longitudinal follow-up. Multivariable models were constructed to examine 5-year outcomes and to compare survival to median survival of the U.S.A total of 39,982 patients from 254 hospitals who were admitted for HF between 2005 and 2009 were included: 18,299 (46%) had HFpEF, 3,285 (8.2%) had HFbEF, and 18,398 (46%) had HFrEF. Overall, median survival was 2.1 years. In risk-adjusted survival analysis, all 3 groups had similar 5-year mortality (HFrEF 75.3% vs. HFpEF 75.7%; hazard ratio: 0.99 [95% confidence interval: 0.958 to 1.022]; HFbEF 75.7% vs. HFpEF 75.7%; hazard ratio: 0.99 [95% confidence interval: 0.947 to 1.046]). In risk-adjusted analyses, the composite of mortality and rehospitalization was similar for all subgroups. Cardiovascular and HF readmission rates were higher in those with HFrEF and HFbEF compared with those with HFpEF. When compared with the U.S. population, HF patients across all age and EF groups had markedly lower median survival.Among patients hospitalized with HF, patients across the EF spectrum have a similarly poor 5-year survival with an elevated risk for cardiovascular and HF admission. These findings underscore the need to improve treatment of patients with HF.

  View details for PubMedID 29141781

• Association Between Dual Healthcare System Use for Medications and Heart Failure Outcomes: A VA Facility-Level Analysis Sandhu, A. T., Heidenreich, P. A. LIPPINCOTT WILLIAMS & WILKINS. 2017

  View details for Web of Science ID 000437035905372

• Home-Time as a Novel Post-Discharge Outcome for Patients Hospitalized With Heart Failure Greene, S., Luo, N., Mentz, R. J., Hardy, C., Laskey, W. K., Heidenreich, P. A., Yancy, C. W., Hernandez, A., Curtis, L., Peterson, P. N., Chang, C., Turner, S., O'Brien, E. C., Fonarow, G. C., Hammill, B. G. LIPPINCOTT WILLIAMS & WILKINS. 2017

  View details for Web of Science ID 000437035902330

• Oral Anticoagulation Prescription Practices in Response to Cardiac Implanted Device Detected Subclinical Atrial Fibrillation Perino, A. C., Fan, J., Askari, M., Schmitt, S., Heidenreich, P. A., Turakhia, M. P. LIPPINCOTT WILLIAMS & WILKINS. 2017

  View details for Web of Science ID 000437035905134

• Complementary Value of Heart Failure Risk Scores on Long-term Mortality in Patients Hospitalized With Acute Heart Failure Preserved Ejection Fraction Boralkar, K. A., Kobayashi, Y., Pargaonkar, V. S., Moneghetti, K. J., Tuzovic, M., Krishnan, G., Bouajila, S., Wheeler, M., Banerjee, D., Horne, B. D., Knowlton, K. U., Heidenreich, P. A., Haddad, F. LIPPINCOTT WILLIAMS & WILKINS. 2017

  View details for Web of Science ID 000437035904494

• Patient Centered Outcomes Research Priorities for Heart Failure and Kawasaki Disease: An Online Consensus Panel of Patients, Clinicians, and Researchers Kim, K. K., Khodyakov, D., Heidenreich, P. A., Ong, M. K., Burns, J. C. LIPPINCOTT WILLIAMS & WILKINS. 2017

  View details for Web of Science ID 000437035905168

• Five-Year Outcomes in Patients Hospitalized With Heart Failure With Preserved, Borderline, and Reduced Ejection Fraction in the Medicare Population Shah, K. S., Xu, H., Matsouaka, R. A., Bhatt, D. L., Heidenreich, P. A., Hernandez, A. F., Devore, A. D., Yancy, C. W., Fonarow, G. C. LIPPINCOTT WILLIAMS & WILKINS. 2017

  View details for Web of Science ID 000437035901029

• Implementation of the Hospital Readmissions Reduction Program, Readmissions, and Mortality in Heart Failure Gupta, A., Allen, L. A., Bhatt, D. L., Cox, M., DeVore, A. D., Heidenreich, P. A., Hernandez, A. F., Peterson, E. D., Matsouaka, R. A., Yancy, C. W., Fonarow, G. C. LIPPINCOTT WILLIAMS & WILKINS. 2017

  View details for Web of Science ID 000437035902041

• Antiarrhythmic Drug Use and Success Rates After Catheter Ablation for Atrial Fibrillation: Findings From the SMASH-AF Meta-Analysis Study Cohort Cluckey, A., Yunus, F. N., Leef, G. C., Askari, M., Heidenreich, P., Turakhia, M. P., Perino, A. C. LIPPINCOTT WILLIAMS & WILKINS. 2017

  View details for Web of Science ID 000437035901166

• Women Suffer Higher In-Hospital Mortality After Transcatheter Aortic Valve Replacement Despite Lower Burden of Comorbidities Yong, C. M., Shah, S., Fearon, W. F., Heidenreich, P. LIPPINCOTT WILLIAMS & WILKINS. 2017

  View details for Web of Science ID 000437035904382

• Age Differences in Hospital Mortality for Acute Myocardial Infarction: Implications for Hospital Profiling ANNALS OF INTERNAL MEDICINE Dharmarajan, K., McNamara, R. L., Wang, Y., Masoudi, F. A., Ross, J. S., Spatz, E. E., Desai, N. R., de Lemos, J. A., Fonarow, G. C., Heidenreich, P. A., Bhatt, D. L., Bernheim, S. M., Slattery, L. E., Khan, Y. M., Curtis, J. P. 2017; 167 (8): 555-+

  Abstract

  Publicly reported hospital risk-standardized mortality rates (RSMRs) for acute myocardial infarction (AMI) are calculated for Medicare beneficiaries. Outcomes for older patients with AMI may not reflect general outcomes.To examine the relationship between hospital 30-day RSMRs for older patients (aged ≥65 years) and those for younger patients (aged 18 to 64 years) and all patients (aged ≥18 years) with AMI.Retrospective cohort study.986 hospitals in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry-Get With the Guidelines.Adults hospitalized for AMI from 1 October 2010 to 30 September 2014.Hospital 30-day RSMRs were calculated for older, younger, and all patients using an electronic health record measure of AMI mortality endorsed by the National Quality Forum. Hospitals were ranked by their 30-day RSMRs for these 3 age groups, and agreement in rankings was plotted. The correlation in hospital AMI achievement scores for each age group was also calculated using the Hospital Value-Based Purchasing (HVBP) Program method computed with the electronic health record measure.267 763 and 276 031 AMI hospitalizations among older and younger patients, respectively, were identified. Median hospital 30-day RSMRs were 9.4%, 3.0%, and 6.2% for older, younger, and all patients, respectively. Most top- and bottom-performing hospitals for older patients were neither top nor bottom performers for younger patients. In contrast, most top and bottom performers for older patients were also top and bottom performers for all patients. Similarly, HVBP achievement scores for older patients correlated weakly with those for younger patients (R = 0.30) and strongly with those for all patients (R = 0.92).Minority of U.S. hospitals.Hospital mortality rankings for older patients with AMI inconsistently reflect rankings for younger patients. Incorporation of younger patients into assessment of hospital outcomes would permit further examination of the presence and effect of age-related quality differences.American College of Cardiology.

  View details for PubMedID 28973634

• 2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non-ST-Elevation Myocardial Infarction A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Jneid, H., Addison, D., Bhatt, D. L., Fonarow, G. C., Gokak, S., Grady, K. L., Green, L. A., Heidenreich, P. A., Ho, P., Jurgens, C. Y., King, M. L., Kumbhani, D. J., Pancholy, S. 2017; 70 (16): 2048-2090

  View details for DOI 10.1016/j.jacc.2017.06.032

  View details for Web of Science ID 000412547300012

  View details for PubMedID 28943066

• 2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non-ST-Elevation Myocardial Infarction A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES Jneid, H., Addison, D., Bhatt, D. L., Fonarow, G. C., Gokak, S., Grady, K. L., Green, L. A., Heidenreich, P. A., Ho, P., Jurgens, C. Y., King, M. L., Kumbhani, D. J., Pancholy, S., Albert, N. M., Barnes, G. D., Chan, P. S., Curtis, L. H., Gilstrap, L., Gurvitz, M., O'Brien, S., Olin, J., Randolph, T., Russo, A. M., Thomas, R. J., Varosy, P. D., Yeh, R., Zaheeruddin, S., Amer Coll Cardiology, Amer Heart Assoc Task Force Perfom, Writing Comm Members 2017; 10 (10)

  View details for DOI 10.1161/HCQ.0000000000000032

  View details for Web of Science ID 000415113800001

• A Randomized Trial of Reminders of Past High BNP to Increase Measurement of LVEF JACC-CARDIOVASCULAR IMAGING Heidenreich, P. A., Gholami, P., Lin, S., Sahay, A. 2017; 10 (10): 1203-+

  View details for DOI 10.1016/j.jcmg.2016.09.026

  View details for Web of Science ID 000411953200018

  View details for PubMedID 28109923

• Using 30-Day Mortality to Measure Quality of Heart Failure Care JACC-HEART FAILURE Heidenreich, P. 2017; 5 (10): 753–55

  View details for DOI 10.1016/j.jchf.2017.08.016

  View details for Web of Science ID 000411610300009

  View details for PubMedID 28958350

• Clinical Effectiveness of Hydralazine-Isosorbide Dinitrate in African-American Patients With Heart Failure JACC-HEART FAILURE Ziaeian, B., Fonarow, G. C., Heidenreich, P. A. 2017; 5 (9): 632–39

  Abstract

  This study sought to evaluate the effectiveness of hydralazine-isosorbide dinitrate (H-ISDN) in African Americans with heart failure (HF) with reduced ejection fraction (HFrEF).Among African-American patients with HFrEF, H-ISDN was found to improve quality of life and lower HF-related hospitalization and mortality rates in the A-HEFT (African-American Heart Failure Trial). Few studies have evaluated the effectiveness of this therapy in clinical practice.Veterans Affairs patients with a hospital admission for HF between 2007 and 2013 were screened. Inclusion criteria included African-American race, left ventricular ejection fraction <40%, and receipt of Veterans Affairs medications. Exclusions were documented contraindications to H-ISDN, creatinine >2.0 mg/dl, or intolerance to angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Adjusted hazard ratios were calculated for patients who received H-ISDN 6-months before admission compared with patients who did not receive H-ISDN, by using inverse probability weighting of propensity scores and a time to death analysis for 18 months of follow-up. Propensity scores were generated using patients' characteristics, left ventricular ejection fraction, laboratory values, and hospital characteristics.The final cohort included 5,168 African-American patients with HF (mean age 65.2 years), with 15.2% treated with H-ISDN before index admission. After 18 months, there were 1,275 reported deaths (24.7%). The adjusted mortality rate at 18 months was 22.1% for patients receiving H-ISDN treatment and 25.2% for untreated patients (p = 0.009); adjusted hazard ratio: 0.85 (95% confidence interval: 0.73 to 1.00; p = 0.057).H-ISDN remains underused in African-American patients with HFrEF. In this cohort, the study found that H-ISDN use was associated with lower mortality rates in African-American patients with HFrEF when controlling for patient selection by using an inverse probability weighting of propensity scores.

  View details for DOI 10.1016/j.jchf.2017.04.008

  View details for Web of Science ID 000408585700003

  View details for PubMedID 28711446

  View details for PubMedCentralID PMC5581201

• Are Drug Eluting Stents Worth Triple Therapy? Journal of the American Heart Association Heidenreich, P. 2017; 6 (8)

  View details for DOI 10.1161/JAHA.117.006983

  View details for PubMedID 28862966

• Correlation of diastolic dysfunction echocardiogram with mortality and morbidity in heart failure with preserved left ventricular ejection fraction Bahrami, H., Heidenreich, P. OXFORD UNIV PRESS. 2017: 130

  View details for Web of Science ID 000440509300393

• Health Informatics Improves Heart Failure Data Capture for Quality Measures, Research and Decision Support in VA Garvin, J. H., Kim, Y., Heidenreich, P., Nativi-Nicolau, J., Inampudi, C., Zeng-Treitler, Q., Gobbel, G. T., Meystre, S. M. CHURCHILL LIVINGSTONE INC MEDICAL PUBLISHERS. 2017: S113

  View details for DOI 10.1016/j.cardfail.2017.07.332

  View details for Web of Science ID 000408403100313

• Treating Specialty and Outcomes in Newly Diagnosed Atrial Fibrillation From the TREAT-AF Study JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Perino, A. C., Fan, J., Schmitt, S. K., Askari, M., Kaiser, D. W., Deshmukh, A., Heidenreich, P. A., Swan, C., Narayan, S. M., Wang, P. J., Turakhia, M. P. 2017; 70 (1): 78–86

  Abstract

  Atrial fibrillation (AF) occurs in many clinical contexts and is diagnosed and treated by clinicians across many specialties. This approach has resulted in treatment variations.The goal of this study was to evaluate the association between treating specialty and AF outcomes among patients newly diagnosed with AF.Using data from the TREAT-AF (Retrospective Evaluation and Assessment of Therapies in AF) study from the Veterans Health Administration, patients with newly diagnosed, nonvalvular AF between 2004 and 2012 were identified who had at least 1 outpatient encounter with primary care or cardiology within 90 days of the AF diagnosis. Cox proportional hazards regression was used to evaluate the association between treating specialty and AF outcomes.Among 184,161 patients with newly diagnosed AF (age 70 ± 11 years; 1.7% women; CHA2DS2-VASc score 2.6 ± 1.7), 40% received cardiology care and 60% received primary care only. After adjustment for covariates, cardiology care was associated with reductions in stroke (hazard ratio [HR]: 0.91; 95% confidence interval [CI]: 0.86 to 0.96; p < 0.001) and death (HR: 0.89; 95% CI: 0.88 to 0.91; p < 0.0001) and increases in hospitalizations for AF/supraventricular tachycardia (HR: 1.38; 95% CI: 1.35 to 1.42; p < 0.0001) and myocardial infarction (HR: 1.03; 95% CI: 1.00 to 1.05; p < 0.04). The propensity-matched cohort had similar results. In mediation analysis, oral anticoagulation prescription within 90 days of diagnosis may have mediated reductions in stroke but did not mediate reductions in survival.In patients with newly diagnosed AF, cardiology care was associated with improved outcomes, potentially mediated by early prescription of oral anticoagulation therapy. Although hypothesis-generating, these data warrant serious consideration and study of health care system interventions at the time of new AF diagnosis.

  View details for PubMedID 28662810

• Association Between Previous Use of Antiplatelet Therapy and Intracerebral Hemorrhage Outcomes STROKE Khan, N. I., Siddiqui, F. M., Goldstein, J. N., Cox, M., Xian, Y., Matsouaka, R. A., Heidenreich, P. A., Peterson, E. D., Bhatt, D. L., Fonarow, G. C., Schwamm, L. H., Smith, E. E. 2017; 48 (7): 1810-+

  Abstract

  Although the use of antiplatelet therapy (APT) is associated with the risk of intracerebral hemorrhage (ICH), there are limited data on prestroke APT and outcomes, particularly among patients on combination APT (CAPT). We hypothesized that the previous use of antiplatelet agents is associated with increased mortality in ICH.We analyzed data of 82 576 patients with ICH who were not on oral anticoagulant therapy from 1574 Get with the Guidelines-Stroke hospitals between October 2012 and March 2016. Patients were categorized as not on APT, on single-APT (SAPT), and CAPT before hospital presentation with ICH. We described baseline characteristics, comorbidities, hospital characteristics and outcomes, overall and stratified by APT use.Before the diagnosis of ICH, 65.8% patients were not on APT, 29.5% patients were on SAPT, and 4.8% patients were on CAPT. There was an overall modest increased in-hospital mortality in the APT group versus no APT group (24% versus 23%; adjusted odds ratio, 1.05; 95% confidence interval, 1.01-1.10). Although patients on SAPT and CAPT were older and had higher risk profiles in terms of comorbidities, there was no significant difference in the in-hospital mortality among patients on SAPT versus those not on any APT (23% versus 23%; adjusted odds ratio, 1.01; 95% confidence interval, 0.97-1.05). However, in-hospital mortality was higher among those on CAPT versus those not on APT (30% versus 23%; adjusted odds ratio, 1.50; 95% confidence interval, 1.39-1.63).Our study suggests that among patients with ICH, previous use of CAPT, but not SAPT, was associated with higher risk for in-hospital mortality.

  View details for PubMedID 28596454

• Warfarin utilisation and anticoagulation control in patients with atrial fibrillation and chronic kidney disease HEART Yang, F., Hellyer, J. A., Than, C., Ullal, A. J., Kaiser, D. W., Heidenreich, P. A., Hoang, D. D., Winkelmayer, W. C., Schmitt, S., Frayne, S. M., Phibbs, C. S., Turakhia, M. P. 2017; 103 (11): 818-826

  Abstract

  To evaluate warfarin prescription, quality of international normalised ratio (INR) monitoring and of INR control in patients with atrial fibrillation (AF) and chronic kidney disease (CKD).We performed a retrospective cohort study of patients with newly diagnosed AF in the Veterans Administration (VA) healthcare system. We evaluated anticoagulation prescription, INR monitoring intensity and time in and outside INR therapeutic range (TTR) stratified by CKD.Of 123 188 patients with newly diagnosed AF, use of warfarin decreased with increasing severity of CKD (57.2%-46.4%), although it was higher among patients on dialysis (62.3%). Although INR monitoring intensity was similar across CKD strata, the proportion with TTR≥60% decreased with CKD severity, with only 21% of patients on dialysis achieving TTR≥60%. After multivariate adjustment, the magnitude of TTR reduction increased with CKD severity. Patients on dialysis had the highest time markedly out of range with INR <1.5 or >3.5 (30%); 12% of INR time was >3.5, and low TTR persisted for up to 3 years.There is a wide variation in anticoagulation prescription based on CKD severity. Patients with moderate-to-severe CKD, including dialysis, have substantially reduced TTR, despite comparable INR monitoring intensity. These findings have implications for more intensive warfarin management strategies in CKD or alternative therapies such as direct oral anticoagulants.

  View details for DOI 10.1136/heartjnl-2016-309266

  View details for Web of Science ID 000401028400006

• Patient Ratings of Veterans Affairs and Affiliated Hospitals AMERICAN JOURNAL OF MANAGED CARE Heidenreich, P. A., Zapata, A., Shieh, L., Oliva, N., Sahay, A. 2017; 23 (6): 382-+

  Abstract

  Hospital Compare, a website maintained by CMS, allows comparisons of outcomes and processes of care but not of patient satisfaction for hospitals within the Veteran Affairs (VA) Healthcare System. Therefore, we sought to compare online hospital ratings between VA hospitals and their local affiliated hospitals.Observational analysis.We identified 39 VA hospitals and a non-VA affiliated hospital with at least 2 online Yelp ratings. We determined the difference in the mean rating (VA-affiliate rating) with weighting by the number of ratings for each hospital. We used multivariate regression to compare mean Yelp ratings between VA and non-VA affiliate hospitals, adjusting for hospital characteristics (bed size, teaching status, and accreditation).The mean patient rating for VA hospitals (± standard deviation) was higher (3.64 ± 1.0) than the rating for affiliated hospitals (3.09 ± 0.8; P = .0036). There was no significant correlation in rating between a VA hospital and its affiliate (r = 0.07; P = .59). After adjustment for hospital characteristics, the adjusted rating difference (VA-affiliate hospitals) was 0.65 (95% confidence interval, 0.18-1.12).VA hospitals had higher patient ratings than their non-VA affiliated hospitals, a finding not explained by bed size or teaching status.

  View details for Web of Science ID 000405277900010

  View details for PubMedID 28817300

• Scope of Sacubitril/Valsartan Eligibility After Heart Failure Hospitalization Findings From the GWTG-HF Registry (Get With The Guidelines-Heart Failure) CIRCULATION Parikh, K. S., Lippmann, S. J., Greiner, M., Heidenreich, P. A., Yancy, C. W., Fonarow, G. C., Hernandez, A. F. 2017; 135 (21): 2077–80

  View details for PubMedID 28533321

  View details for PubMedCentralID PMC5475261

• Race/Ethnic Differences in Outcomes Among Hospitalized Medicare Patients With Heart Failure and Preserved Ejection Fraction. JACC. Heart failure Ziaeian, B., Heidenreich, P. A., Xu, H., DeVore, A. D., Matsouaka, R. A., Hernandez, A. F., Bhatt, D. L., Yancy, C. W., Fonarow, G. C. 2017

  Abstract

  This study analyzed HFpEF patient characteristics and clinical outcomes according to race/ethnicity and adjusted for patient and hospital characteristics along with socioeconomic status (SES).The proportion of hospitalizations for heart failure with preserved ejection fraction (HFpEF) has increased over the last decade. Whether the short- and long-term outcomes differ between racial/ethnic groups is not well described.The Get With The Guidelines-Heart Failure registry was linked to Medicare administrative data to identify hospitalized patients with HFpEF ≥65 years of age with left ventricular ejection fraction ≥50% between 2006 and 2014. Cox proportional hazards models were used to report hazard ratios (HRs) for 30-day and 1-year readmission and mortality rates with sequential adjustments for patient characteristics, hospital characteristics, and SES.The final cohort included 53,065 patients with HFpEF. Overall 30-day mortality was 5.87%; at 1 year, it was 33.1%. The 30-day all-cause readmission rate was 22.2%, and it was 67.0% at 1 year. After adjusting for patient characteristics, hospital characteristics, and SES, 30-day mortality was lower for black patients (HR: 0.84; 95% confidence interval [CI]: 0.71 to 0.98; p = 0.031) and Hispanic patients (HR: 0.78; 95% CI: 0.64 to 0.96; p = 0.017) compared with white patients. One-year mortality was lower for black patients (HR: 0.93; 95% CI: 0.87 to 0.99; p = 0.031), Hispanic patients (HR: 0.83; 95% CI: 0.75 to 0.91; p < 0.001), and Asian patients (HR: 0.76; 95% CI: 0.66 to 0.88; p < 0.001) compared with white patients. Black patients had a higher risk of readmission at 30 days (HR: 1.09; 95% CI: 1.02 to 1.16; p = 0.012) and 1 year (HR: 1.14; 95% CI: 1.09 to 1.20; p < 0.001) compared with white patients.Black, Hispanic, and Asian patients had a lower mortality risk after a hospitalization for HFpEF compared with white patients; black patients had higher readmission rates. These differences in mortality and readmission risk according to race/ethnicity persisted after adjusting for patient characteristics, SES, and hospital factors.

  View details for DOI 10.1016/j.jchf.2017.02.012

  View details for PubMedID 28501527

• Estimation of Eligibility for PCSK9 Inhibitors and Associated Costs Based on the FOURIER Trial: Insights from the Department of Veterans Affairs. Circulation Virani, S. S., Akeroyd, J. M., Nambi, V., Heidenreich, P. A., Morris, P. B., Nasir, K., Michos, E. D., Bittner, V. A., Petersen, L. A., Ballantyne, C. M. 2017

  View details for DOI 10.1161/CIRCULATIONAHA.117.028503

  View details for PubMedID 28465286

• Impact of Current Versus Previous Cardiac Resynchronization Therapy Guidelines on the Proportion of Patients With Heart Failure Eligible for Therapy JACC-HEART FAILURE Lyons, K. J., Ezekowitz, J. A., Liang, L., Heidenreich, P. A., Yancy, C. W., DeVore, A. D., Hernandez, A. F., Fonarow, G. C. 2017; 5 (5): 388-392

  Abstract

  This study sought to ascertain the impact of heart failure (HF) guideline change on the number of patients eligible to undergo cardiac resynchronization therapy (CRT).The 2013 HF guideline of the American College of Cardiology Foundation and American Heart Association (ACCF/AHA) narrowed the recommendations for CRT. The impact of this guideline change on the number of eligible patients for CRT has not been described.Using data from Get With The Guidelines-Heart Failure between 2012 and 2015, this study evaluated the proportion of hospitalized patients with HF who were eligible for CRT on the basis of historical and current guideline recommendations. The authors identified 25,102 hospitalizations for HF that included patients with a left ventricular ejection fraction (LVEF) ≤35% from 283 hospitals. Patients with a medical, system-related, or patient-related reason for not undergoing CRT were excluded.Overall, 49.1% (n = 12,336) of patients with HF, an LVEF ≤35%, and no documented contraindication were eligible for CRT on the basis of historical guidelines, and 33.1% (n = 8,299) of patients were eligible for CRT on the basis of current guidelines, a 16.1% absolute reduction in eligibility (p < 0.0001). Patients eligible for CRT on the basis of current guidelines were more likely to have CRT with an implantable cardioverter-defibrillator or CRT with pacing only placed or prescribed at discharge (57.8% vs. 54.9%; p < 0.0001) compared with patients eligible for CRT on the basis of historical guidelines.In this population of patients with HF, an LVEF ≤35%, and no documented contraindication for CRT, the current ACCF/AHA HF guidelines reduce the proportion of patients eligible for CRT by approximately 15%.

  View details for DOI 10.1016/Hchf.2017.02.018

  View details for Web of Science ID 000400634100012

  View details for PubMedID 28449799

• The changing non-cardiovascular comorbidity profile of patients hospitalized with heart failure: Insights from the Get With The Guidelines-Heart Failure registry Sharma, A., Zhao, X., Hammill, B. G., Hernandez, A. F., Fonarow, G. C., Felker, G. M., Yancy, C., Heidenreich, P. A., Ezekowitz, J. A., Devore, A. D. WILEY. 2017: 196

  View details for Web of Science ID 000401005300543

• Intensity of Statin Treatment and Mortality-Reply. JAMA cardiology Rodriguez, F., Maron, D. J., Heidenreich, P. A. 2017

  View details for DOI 10.1001/jamacardio.2017.0549

  View details for PubMedID 28445560

• Cost-Effectiveness of Sacubitril-Valsartan in Patients Who Have Heart Failure With Reduced Ejection Fraction. Annals of internal medicine Sandhu, A. T., Ollendorf, D. A., Chapman, R. H., Pearson, S. D., Heidenreich, P. A. 2017; 166 (8): 607-608

  View details for DOI 10.7326/L17-0044

  View details for PubMedID 28418550

• Early Adoption of Sacubitril/Valsartan for Patients With Heart Failure With Reduced Ejection Fraction Insights From Get With the Guidelines-Heart Failure (GWTG-HF) JACC-HEART FAILURE Luo, N., Fonarow, G. C., Lippmann, S. J., Mi, X., Heidenreich, P. A., Yancy, C. W., Greiner, M. A., Hammill, B. G., Hardy, N. C., Turner, S. J., Laskey, W. K., Curtis, L. H., Hernandez, A. F., Mentz, R. J., O'Brien, E. C. 2017; 5 (4): 305-309

  Abstract

  The aim of this study was to assess the prevalence and variation in angiotensin receptor/neprilysin inhibitor (ARNI) prescription among a real-world population with heart failure with reduced ejection fraction (HFrEF).The U.S. Food and Drug Administration approved sacubitril/valsartan for patients with HFrEF in July 2015. Little is known about the early patterns of use of this novel therapy.The study included patients discharged alive from hospitals in Get With the Guidelines-Heart Failure (GWTG-HF), a registry of hospitalized patients with heart failure, between July 2015 and June 2016 who had documentation of whether ARNIs were prescribed at discharge. Patient and hospital characteristics were compared among patients with HFrEF (ejection fraction ≤40%) with and without ARNI prescription at discharge, excluding those with documented contraindications to ARNIs. To evaluate hospital variation, hospitals with at least 10 eligible hospitalizations during the study period were assessed.Of 21,078 patients hospitalized with HFrEF during the study period, 495 (2.3%) were prescribed ARNIs at discharge. Patients prescribed ARNIs were younger (median age 65 years vs. 70 years; p < 0.001), had lower ejection fractions (median 23% vs. 25%; p < 0.001), and had higher use of aldosterone antagonists (45% vs. 31%; p < 0.001) at discharge. At the 241 participating hospitals with 10 or more eligible admissions, 125 (52%) reported no discharge prescriptions of ARNIs.Approximately 2.3% of patients hospitalized for HFrEF in a national registry were prescribed ARNI therapy in the first 12 months following Food and Drug Administration approval. Further study is needed to identify and overcome barriers to implementing new evidence into practice, such as ARNI use among eligible patients with HFrEF.

  View details for DOI 10.1016/j.jchf.2016.12.018

  View details for Web of Science ID 000398335800010

  View details for PubMedID 28359417

• RACIAL DIFFERENCES IN QUALITY OF CARE AND OUTCOMES AFTER ACUTE CORONARY SYNDROME Yong, C. M., Ungar, L., Abnousi, F., Bibbins-Domingo, K., Knight, S., Asch, S., Heidenreich, P. ELSEVIER SCIENCE INC. 2017: 2569

  View details for Web of Science ID 000397342303491

• THE IMPACT OF THE CURRENT VERSUS PRIOR CARDIAC RESYNCHRONIZATION GUIDELINES ON THE PROPORTION OF HOSPITALIZED HEART FAILURE PATIENTS ELIGIBLE FOR THERAPY Lyons, K. J., Ezekowitz, J., Liang, L., Heidenreich, P., Yancy, C., DeVore, A., Hernandez, A. F., Fonarow, G. ELSEVIER SCIENCE INC. 2017: 784

  View details for Web of Science ID 000397342301306

• A HOSPITAL LEVEL ANALYSIS OF 30-DAY READMISSION RATES FOR HEART FAILURE PATIENTS AND LONG-TERM SURVIVAL AMONG HIGHEST AND LOWEST PERFORMING HOSPITALS, FINDINGS FROM GET WITH THE GUIDELINES-HEART FAILURE Jalnapurkar, S., Zhao, X., Heidenreich, P., Bhatt, D., Smith, E., DeVore, A., Hernandez, A., Matsouaka, R., Yancy, C., Fonarow, G. ELSEVIER SCIENCE INC. 2017: 2565

  View details for Web of Science ID 000397342303487

• SUCCESS RATES BY ABLATION LESION SET OF CATHETER ABLATION FOR PAROXYSMAL ATRIAL FIBRILLATION: FINDINGS FROM THE SMASH-AF META-ANALYSIS STUDY COHORT Cluckey, A., Yunus, F., Leef, G., Askari, M., Schuit, E., Heidenreich, P., Turakhia, M., Perino, A. ELSEVIER SCIENCE INC. 2017: 370

  View details for Web of Science ID 000397342300371

• INCLUSION OF WOMEN IN STUDIES OF CATHETER ABLATION FOR ATRIAL FIBRILLATION: FINDINGS FROM THE SMASH-AF META-ANALYSIS STUDY COHORT Yunus, F., Leef, G., Cluckey, A., Askari, M., Schuit, E., Heidenreich, P., Turakhia, M., Perino, A. ELSEVIER SCIENCE INC. 2017: 537

  View details for Web of Science ID 000397342301059

• SECULAR TRENDS IN REPORTED SUCCESS RATES OF CATHETER ABLATION FOR NON-PAROXYSMAL ATRIAL FIBRILLATION: FINDINGS FROM THE SMASH-AF META-ANALYSIS STUDY COHORT Leef, G., Cluckey, A., Yunus, F., Askari, M., Schuit, E., Heidenreich, P., Turakhia, M., Perino, A. ELSEVIER SCIENCE INC. 2017: 451

  View details for Web of Science ID 000397342300452

• PREDICTORS OF STATIN USE FOR PATIENTS WITH LDL CHOLESTEROL ABOVE 190MG/DL: INSIGHTS FROM THE VETERANS AFFAIRS HEALTH CARE SYSTEM Rodriguez, F., Knowles, J., Maron, D., Virani, S., Heidenreich, P. ELSEVIER SCIENCE INC. 2017: 1693

  View details for Web of Science ID 000397342302415

• Prescription of Guideline-Recommended Implantable Cardioverter Defibrillator and Cardiac Resynchronization Therapy Among Patients Hospitalized With Heart Failure and Varying Degrees of Renal Function. American journal of cardiology Pun, P. H., Sheng, S., Sanders, G., DeVore, A. D., Friedman, D., Fonarow, G. C., Heidenreich, P. A., Yancy, C. W., Hernandez, A. F., Al-Khatib, S. M. 2017; 119 (6): 886-892

  Abstract

  Implantable cardioverter defibrillators (ICD) and cardiac resynchronization therapy (CRT) reduce mortality in many patients with heart failure (HF), but the current use and effectiveness of ICD/CRT in patients with chronic kidney disease (CKD) are uncertain. We examined associations between kidney function and guideline-recommended prescription of ICD/CRT in the Get With The Guidelines-Heart Failure registry, a performance improvement program for hospitalized patients with HF. We compared differences in ICD and CRT prescription between the following categories of estimated glomerular filtration rate (eGFR; mL/min/1.73 m(2)): ≥60, 59 to 30, <30, and dialysis dependent. From 2008 through 2014, 26,286 patients were eligible for ICD or CRT, and 16,123(61%) had an eGFR <60. De novo ICD and CRT prescription in this group was low at 45% and 30.5%, respectively. Compared to patients with eGFR ≥60, patients with eGFR 30 to 59 were more likely to receive an ICD (adjusted odds ratio [aOR] 1.08, 95% confidence intervals [CI] 1.01 to 1.14), whereas dialysis patients were less likely (aOR 0.61, 95% CI 0.5 to 0.76). Worse kidney function was associated with a decreased likelihood of CRT prescription (aOR 0.97 per 10 ml/min eGFR decrease, p = 0.03). During the study period, the likelihood of both ICD and CRT prescription increased over time among patients with CKD (ICD aOR 1.12, 95% CI 1.07 to 1.18; CRT aOR 1.14, 95% CI 1.06 to 1.23, per year). Prescription of an ICT/CRT was associated with greater 1-year survival in all eGFR groups. In conclusion, there are significant CKD-based differences in prescription of ICD and CRT in HF. However, given the current state of evidence, it is unclear whether improved prescription of ICD and CRT in the CKD population will result in improvement in outcomes.

  View details for DOI 10.1016/j.amjcard.2016.11.043

  View details for PubMedID 28160975

  View details for PubMedCentralID PMC5329118

• Inflammation and Heart Failure Therapeutic or Diagnostic Opportunity? JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Heidenreich, P. 2017; 69 (10): 1286-1287

  View details for DOI 10.1016/j.jacc.2017.01.013

  View details for Web of Science ID 000396360100009

  View details for PubMedID 28279295

• Adoption of the 2013 American College of Cardiology/American Heart Association Cholesterol Management Guideline in Cardiology Practices Nationwide. JAMA cardiology Pokharel, Y., Tang, F., Jones, P. G., Nambi, V., Bittner, V. A., Hira, R. S., Nasir, K., Chan, P. S., Maddox, T. M., Oetgen, W. J., Heidenreich, P. A., Borden, W. B., Spertus, J. A., Petersen, L. A., Ballantyne, C. M., Virani, S. S. 2017

  Abstract

  The 2013 American College of Cardiology/American Heart Association (ACC/AHA) Cholesterol Management Guideline recommends moderate-intensity to high-intensity statin therapy in eligible patients.To examine adoption of the 2013 ACC/AHA guideline in US cardiology practices.Among 161 cardiology practices, trends in the use of moderate-intensity to high-intensity statin and nonstatin lipid-lowering therapy (LLT) were analyzed before (September 1, 2012, to November 1, 2013) and after (February 1, 2014, to April 1, 2015) publication of the 2013 ACC/AHA guideline among 4 mutually exclusive risk groups within the ACC Practice Innovation and Clinical Excellence Registry. Interrupted time series analysis was used to evaluate for differences in trend in use of moderate-intensity to high-intensity statin and nonstatin LLT use in hierarchical logistic regression models. Participants were a population-based sample of 1 105 356 preguideline patients (2 431 192 patient encounters) and 1 116 472 postguideline patients (2 377 219 patient encounters). Approximately 97% of patients had atherosclerotic cardiovascular disease (ASCVD).Moderate-intensity to high-intensity statin and nonstatin LLT use before and after publication of the 2013 ACC/AHA guideline.Time trend in the use of moderate-intensity to high-intensity statin and nonstatin LLT.In the study cohort, the mean (SD) age was 69.6 (12.1) years among 1 105 356 patients (40.2% female) before publication of the guideline and 70.0 (11.9) years among 1 116 472 patients (39.8% female) after publication of the guideline. Although there was a trend toward increasing use of moderate-intensity to high-intensity statins overall and in the ASCVD cohort, such a trend was already present before publication of the guideline. No significant difference in trend in the use of moderate-intensity to high-intensity statins was observed in other groups. The use of moderate-intensity to high-intensity statin therapy was 62.1% (before publication of the guideline) and 66.6% (after publication of the guideline) in the overall cohort, 62.7% (before publication) and 67.0% (after publication) in the ASCVD cohort, 50.6% (before publication) and 52.3% (after publication) in the cohort with elevated low-density lipoprotein cholesterol levels (ie, ≥190 mg/dL), 52.4% (before publication) and 55.2% (after publication) in the diabetes cohort, and 41.9% (before publication) and 46.9% (after publication) in the remaining group with 10-year ASCVD risk of 7.5% or higher. In hierarchical logistic regression models, there was a significant increase in the use of moderate-intensity to high-intensity statins in the overall cohort (4.8%) and in the ASCVD cohort (4.3%) (P < .01 for slope for both). There was no significant change for other risk cohorts. Nonstatin LLT use remained unchanged in the preguideline and postguideline periods in the hierarchical logistic regression models for all of the risk groups.Adoption of the 2013 ACC/AHA Cholesterol Management Guideline in cardiology practices was modest. Timely interventions are needed to improve guideline-concordant practice to reduce the burden of ASCVD.

  View details for DOI 10.1001/jamacardio.2016.5922

  View details for PubMedID 28249067

• Trends in Palliative Care Use in Elderly Men and Women With Severe Heart Failure in the United States Reply JAMA CARDIOLOGY Mandawat, A., Heidenreich, P. A., Bhatt, D. L. 2017; 2 (3): 344–45

  View details for PubMedID 27926749

• Extraction of left ventricular ejection fraction information from various types of clinical reports JOURNAL OF BIOMEDICAL INFORMATICS Kim, Y., Garvin, J. H., Goldstein, M. K., Hwang, T. S., Redd, A., Bolton, D., Heidenreich, P. A., Meystre, S. M. 2017; 67: 42–48

  Abstract

  Efforts to improve the treatment of congestive heart failure, a common and serious medical condition, include the use of quality measures to assess guideline-concordant care. The goal of this study is to identify left ventricular ejection fraction (LVEF) information from various types of clinical notes, and to then use this information for heart failure quality measurement. We analyzed the annotation differences between a new corpus of clinical notes from the Echocardiography, Radiology, and Text Integrated Utility package and other corpora annotated for natural language processing (NLP) research in the Department of Veterans Affairs. These reports contain varying degrees of structure. To examine whether existing LVEF extraction modules we developed in prior research improve the accuracy of LVEF information extraction from the new corpus, we created two sequence-tagging NLP modules trained with a new data set, with or without predictions from the existing LVEF extraction modules. We also conducted a set of experiments to examine the impact of training data size on information extraction accuracy. We found that less training data is needed when reports are highly structured, and that combining predictions from existing LVEF extraction modules improves information extraction when reports have less structured formats and a rich set of vocabulary.

  View details for PubMedID 28163196

  View details for PubMedCentralID PMC5575914

• Initiation, Continuation, or Withdrawal of Angiotensin-Converting Enzyme Inhibitors/Angiotensin Receptor Blockers and Outcomes in Patients Hospitalized With Heart Failure With Reduced Ejection Fraction. Journal of the American Heart Association Gilstrap, L. G., Fonarow, G. C., Desai, A. S., Liang, L., Matsouaka, R., DeVore, A. D., Smith, E. E., Heidenreich, P., Hernandez, A. F., Yancy, C. W., Bhatt, D. L. 2017; 6 (2)

  Abstract

  Guidelines recommend continuation or initiation of guideline-directed medical therapy, including angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEi/ARB), in hospitalized patients with heart failure with reduced ejection fraction.Using the Get With The Guidelines-Heart Failure Registry, we linked clinical data from 16 052 heart failure with reduced ejection fraction (ejection fraction ≤40%) patients with Medicare claims data. We divided ACEi/ARB-eligible patients into 4 categories based on admission and discharge ACEi/ARB use: continued (reference group), started, discontinued, or not started on therapy. A multivariable Cox proportional hazard model was used to determine the association between ACEi/ARB category and outcomes. Most, 90.5%, were discharged on ACEi/ARB (59.6% continued and 30.9% newly started). Of those discharged without ACEi/ARB, 1.9% were discontinued, and 7.5% were eligible but not started. Thirty-day mortality was 3.5% for patients continued and 4.1% for patients started on ACEi/ARB. In contrast, 30-day mortality was 8.8% for patients discontinued (adjusted hazard ratio [HRadj] 1.92; 95% CI 1.32-2.81; P<0.001) and 7.5% for patients not started (HRadj 1.50; 95% CI 1.12-2.00; P=0.006). The 30-day readmission rate was lowest among patients continued or started on therapy. One-year mortality was 28.2% for patients continued and 29.7% for patients started on ACEi/ARB compared to 41.6% for patients discontinued (HRadj 1.35; 95% CI 1.13-1.61; P<0.001) and 41.7% (HRadj 1.28; 95% CI 1.14-1.43; P<0.001) for patients not started on therapy.Compared with continuation, withdrawal of ACEi/ARB during heart failure hospitalization is associated with higher rates of postdischarge mortality and readmission, even after adjustment for severity of illness.

  View details for DOI 10.1161/JAHA.116.004675

  View details for PubMedID 28189999

• Factors Associated With and Prognostic Implications of Cardiac Troponin Elevation in Decompensated Heart Failure With Preserved Ejection Fraction: Findings From the American Heart Association Get With The Guidelines-Heart Failure Program. JAMA cardiology Pandey, A., Golwala, H., Sheng, S., DeVore, A. D., Hernandez, A. F., Bhatt, D. L., Heidenreich, P. A., Yancy, C. W., de Lemos, J. A., Fonarow, G. C. 2017; 2 (2): 136-145

  Abstract

  Elevated levels of cardiac troponins are associated with adverse clinical outcomes among patients with heart failure (HF) and reduced ejection fraction. However, the clinical significance of troponin elevation in the setting of decompensated HF with preserved ejection fraction (HFpEF) is not well established.To determine the clinical predictors of troponin elevation and its association with in-hospital and long-term outcomes among patients with decompensated HFpEF.Observational analysis of Get With The Guidelines-HF registry participants who were admitted for decompensated HFpEF (ejection fraction ≥50%) from January 2009 through December 2014 and who had quantitative or categorical (elevated vs normal based on institution's reference laboratory) measures of troponin level (troponin T or troponin I, as available).In-hospital outcomes (mortality, length of stay, and discharge destination) and postdischarge outcomes (30-day mortality, 30-day readmission rate, 1-year mortality).We included 34 233 patients with HFpEF from 224 sites with measured troponin levels (33.4% men; median age, 79 years): 78.6% (n = 26 896) with troponin I and 21.4% (n = 7319) with troponin T measurements. Among these, 22.6% (n = 7732) had elevation in troponin levels. In adjusted analysis, higher serum creatinine level, black race, older age, and ischemic heart disease were associated with troponin elevation. Elevated troponin was associated with higher odds of in-hospital mortality (odds ratio [OR], 2.19; 95% CI, 1.88-2.56), greater length of stay (length of stay >4 days OR, 1.38; 95% CI, 1.29-1.47), and lower likelihood of discharge to home (OR, 0.65; 95% CI, 0.61-0.71) independent of other clinical predictors and measured confounders. Presence of elevated troponin I levels was also significantly associated with increased risk of 30-day mortality (hazard ratio [HR], 1.59; 95% CI, 1.42-1.80), 30-day all-cause readmission (HR, 1.12; 95% CI, 1.01-1.25), and 1-year mortality HR, 1.35; 95% CI, 1.26-1.45).Troponin elevation among patients with acutely decompensated HFpEF is associated with worse in-hospital and postdischarge outcomes, independent of other predictive variables. Future studies are needed to determine if measurement of troponin levels among patients with decompensated HFpEF may be useful for risk stratification.

  View details for DOI 10.1001/jamacardio.2016.4726

  View details for PubMedID 28030747

• The Association of Prior Use of Antiplatelet Agents and Increased Mortality and Morbidity in Intracerebral Hemorrhage Patients Khan, N., Siddiqui, F., Goldstein, J., Xian, Y., Cox, M., Matsouaka, R., Heidenreich, P., Peterson, E., Bhatt, D. L., Fonarow, G., Schwamm, L., Smith, E. E. LIPPINCOTT WILLIAMS & WILKINS. 2017

  View details for Web of Science ID 000607147402041

• Lower Hemoglobin A1c is Associated With Higher In-Hospital Mortality in Intracerebral Hemorrhage Dandapat, S., Siddiqui, F. M., Fonarow, G. C., Bhatt, D. L., Xu, H., Matsouaka, R., Heidenreich, P., Xian, Y., Schwamm, L. H., Smith, E. E. LIPPINCOTT WILLIAMS & WILKINS. 2017

  View details for Web of Science ID 000607147402018

• 2016 AHA/ACC Clinical Performance and Quality Measures for Prevention of Sudden Cardiac Death A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES Al-Khatib, S. M., Yancy, C. W., Solis, P., Becker, L., Benjamin, E. J., Carrillo, R. G., Ezekowitz, J. A., Fonarow, G. C., Kantharia, B. K., Kleinman, M., Nichol, G., Varosy, P. D., Heidenreich, P. A., Albert, N. M., Chan, P. S., Curtis, L. H., Ferguson, T. B., Fonarow, G. C., Gurvitz, M., Jurgens, C. Y., O'Brien, S., Russo, A. M., Thomas, R. 2017; 10 (2)

  View details for DOI 10.1161/HCQ.0000000000000022

  View details for Web of Science ID 000394569400001

• Impact of an Expanded Hospital Recognition Program for Stroke Quality of Care. Journal of the American Heart Association Heidenreich, P. A., Zhao, X., Hernandez, A. F., Schwamm, L. H., Smith, E., Reeves, M., Peterson, E. D., Fonarow, G. C. 2017; 6 (1)

  Abstract

  In 2009, the Get With The Guidelines-Stroke (GWTG-Stroke) program offered additional recognition if hospitals performed well on certain stroke quality measures. We sought to determine whether quality of care for all hospitals participating in GWTG-Stroke improved with this expanded recognition program.We examined hospital-level performance on 6 quality of care (process) measures and 1 defect-free composite quality measure for stroke following expansion of the existing performance measure recognition program. Compliance with all measures improved following launch of the expanded program, and this rate increased significantly for all 9 measures. When evaluated as the relative rate of increase in use over time, process improvement slowed significantly (P<0.05) following launch of the program for 2 measures, and accelerated significantly for 1 measure. However, when evaluated as a gap in care, the decrease in the quality gap was greater following launch of the program for 5 of 6 (83%) measures. There was no evidence that other processes of stroke care suffered as the result of the increase in measures and expanded recognition program.While care for stroke continues to improve in this country, expanded hospital process performance recognition had mixed results in accelerating this improvement. However, the quality gap continues to shrink among those participating in provider performance programs.

  View details for DOI 10.1161/JAHA.116.004278

  View details for PubMedID 28110310

• Impact of Baseline Stroke Risk and Bleeding Risk on Warfarin International Normalized Ratio Control in Atrial Fibrillation (from the TREAT-AF Study) AMERICAN JOURNAL OF CARDIOLOGY Hellyer, J. A., Azarbal, F., Than, C. T., Fan, J., Schmitt, S. K., Yang, F., Frayne, S. M., Phibbs, C. S., Yong, C., Heidenreich, P. A., Turakhia, M. P. 2017; 119 (2): 268-274

  Abstract

  Warfarin prevents stroke and prolongs survival in patients with atrial fibrillation and flutter (AF, collectively) but can cause hemorrhage. The time in international normalized ratio (INR) therapeutic range (TTR) mediates stroke reduction and bleeding risk. This study sought to determine the relation between baseline stroke, bleeding risk, and TTR. Using data from The Retrospective Evaluation and Assessment of Therapies in Atrial Fibrillation (TREAT-AF) retrospective cohort study, national Veterans Health Administration records were used to identify patients with newly diagnosed AF from 2003 to 2012 and subsequent initiation of warfarin. Baseline stroke and bleeding risk was determined by calculating CHA2DS2-VASc and HAS-BLED scores, respectively. Main outcomes were first-year and long-term TTR and INR monitoring rate. In 167,190 patients, the proportion of patients with TTR (>65%) decreased across increasing strata of CHA2DS2-VASc and HAS-BLED. After covariate adjustment, odds of achieving TTR >65% were significantly associated with high CHA2DS2-VASc or HAS-BLED score. INR monitoring rate was similar across risk strata. In conclusion, increased baseline stroke and bleeding risk is associated with poor INR control, despite similar rates of INR monitoring. These findings may paradoxically limit warfarin's efficacy and safety in high-risk patients and may explain observed increased bleeding and stroke rates in this cohort.

  View details for DOI 10.1016/j.amjcard.2016.09.045

  View details for PubMedID 27836133

• Safety and Clinical Outcomes of Catheter Ablation of Atrial Fibrillation in Patients With Chronic Kidney Disease JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY Ullal, A. J., Kaiser, D. W., Fan, J., Schmitt, S. K., Than, C. T., Winkelmayer, W. C., Heidenreich, P. A., Piccini, J. P., Perez, M. V., Wang, P. J., Turakhia, M. P. 2017; 28 (1): 39-48

  Abstract

  Data regarding catheter ablation of atrial fibrillation (AF) in patients with chronic kidney disease (CKD) is limited. We therefore assessed the association of CKD with common safety and clinical outcomes in a nationwide sample of ablation recipients.Using MarketScan(®) Commercial Claims and Medicare Supplemental Databases, we evaluated 30-day safety and 1-year clinical outcomes in patients who underwent a first AF ablation procedure between 2007 and 2011. We calculated frequency of common 30-day complications and calculated frequencies, incidence rates, and Cox proportional hazards for outcomes at 1-year postablation.Of 21,091 patients included, 1,593 (7.6%) had CKD. Patients with CKD were older (64 years vs. 59 years, P < 0.001) with higher CHA2 DS2 -VASc scores (3.2 vs. 1.8, P < 0.001). At 30 days postablation, patients with CKD had similar rates of stroke/TIA (0.13% vs. 0.13%, P = 0.99), perforation/tamponade (3.2% vs. 3.1%, P = 0.83), and vascular complications (2.4% vs. 2.2%, P = 0.59) as patients without CKD, but were more likely to be hospitalized for heart failure (2.1% vs. 0.4%, P < 0.001). In multivariate analysis, there were no significant differences in hazards of AF hospitalization (adjusted HR: 1.02, 95%CI: 0.87-1.20), cardioversion (adjusted HR: 0.99, 95%CI: 0.87-1.12), or repeat AF ablation (adjusted HR: 0.89, 95%CI: 0.76-1.06) at 1 year.Among patients selected for AF ablation, those with and without CKD had similar rates of postprocedural complications although they were more likely to be re-admitted for heart failure. CKD was not independently associated with AF hospitalization, cardioversion, and repeat ablation. These findings can inform clinical decision-making in patients with AF and CKD.

  View details for DOI 10.1111/jce.13118

  View details for Web of Science ID 000393901900004

• A Validated Risk Model for 30-Day Readmission for Heart Failure Mahajan, S. M., Burman, P., Newton, A., Heidenreich, P. A., Gundlapalli, A. V., Jaulent, M. C., Zhao, D. IOS PRESS. 2017: 506–10

  Abstract

  One of the goals of the Precision Medicine Initiative launched in the United States in 2016 is to use innovative tools and sources in data science. We realized this goal by implementing a use case that identified patients with heart failure at Veterans Health Administration using data from the Electronic Health Records from multiple health domains between 2005 and 2013. We applied a regularized logistic regression model and predicted 30-day readmission risk for 1210 unique patients. Our validation cohort resulted in a C-statistic of 0.84. Our top predictors of readmission were prior diagnosis of heart failure, vascular and renal diseases, and malnutrition as comorbidities, compliance with outpatient follow-up, and low socioeconomic status. This validated risk prediction scheme delivered better performance than the published models so far (C-Statistics: 0.69). It can be used to stratify patients for readmission and to aid clinicians in delivering precise health interventions.

  View details for DOI 10.3233/978-1-61499-830-3-506

  View details for Web of Science ID 000449471200105

  View details for PubMedID 29295146

• THE COST-EFFECTIVENESS OF NEW INTERVENTIONS FOR HEART FAILURE Heidenreich, P. A. KARGER. 2017: 256

  View details for Web of Science ID 000405743600243

• A 15-year review of the Stanford Internal Medicine Residency Program: predictors of resident satisfaction and dissatisfaction ADVANCES IN MEDICAL EDUCATION AND PRACTICE Kahn, J. S., Witteles, R. M., Mahaffey, K. W., Desai, S. A., Ozdalga, E., Heidenreich, P. A. 2017; 8: 559–66

  Abstract

  Satisfaction with training and with educational experiences represents important internal medicine (IM) programmatic goals. Graduates from IM residency programs are uniquely poised to provide insights into their educational and training experiences and to assess whether these experiences were satisfactory and relevant to their current employment.We surveyed former IM residents from the training program held during the years 2000-2015 at the Department of Medicine, Stanford University. The first part of the survey reviewed the IM residency program and the second part sought identifying data regarding gender, race, ethnicity, work, relationships, and financial matters. The primary outcome was satisfaction with the residency experience.Of the 405 individuals who completed the Stanford IM residency program in the study period, we identified 384 (95%) former residents with a known email address. Two hundred and one (52%) former residents responded to the first part and 185 (48%) answered both the parts of the survey. The mean age of the respondents was 36.9 years; 44% were female and the mean time from IM residency was 6.1 (±4.3) years. Fifty-eight percent reported extreme satisfaction with their IM residency experience. Predictors associated with being less than extremely satisfied included insufficient outpatient experience, insufficient international experience, insufficient clinical research experience, and insufficient time spent with family and peers.The residents expressed an overall high satisfaction rate with their IM training. The survey results provided insights for improving satisfaction with IM residency training that includes diversifying and broadening IM training experiences.

  View details for PubMedID 28814910

• Cardiovascular Testing and Clinical Outcomes in Emergency Department Patients With Chest Pain. JAMA internal medicine Sandhu, A. T., Heidenreich, P. A., Bhattacharya, J. n., Bundorf, M. K. 2017

  Abstract

  Noninvasive testing and coronary angiography are used to evaluate patients who present to the emergency department (ED) with chest pain, but their effects on outcomes are uncertain.To determine whether cardiovascular testing-noninvasive imaging or coronary angiography-is associated with changes in the rates of coronary revascularization or acute myocardial infarction (AMI) admission in patients who present to the ED with chest pain without initial findings of ischemia.This retrospective cohort analysis used weekday (Monday-Thursday) vs weekend (Friday-Sunday) presentation as an instrument to adjust for unobserved case-mix variation (selection bias) between 2011 and 2012. National claims data (Truven MarketScan) was used. The data included a total of 926 633 privately insured patients ages 18 to 64 years who presented to the ED with chest pain without initial diagnosis consistent with acute ischemia.Noninvasive testing or coronary angiography within 2 days or 30 days of presentation.The primary end points were coronary revascularization (percutaneous coronary intervention or coronary artery bypass graft surgery) and AMI admission at 7, 30, 180, and 365 days. The secondary end points were coronary angiography and coronary artery bypass grafting in those who underwent angiography.The patients were ages 18 to 64 years with an average age of 44.4 years. A total of 536 197 patients (57.9%) were women. Patients who received testing (224 973) had increased risk at baseline and had greater risk of AMI admission than those who did not receive testing (701 660) (0.35% vs 0.14% at 30 days). Weekday patients (571 988) had similar baseline comorbidities to weekend patients (354 645) but were more likely to receive testing. After risk factor adjustment, testing within 30 days was associated with a significant increase in coronary angiography (36.5 per 1000 patients tested; 95% CI, 21.0-52.0) and revascularization (22.8 per 1000 patients tested; 95% CI, 10.6-35.0) at 1 year but no significant change in AMI admissions (7.8 per 1000 patients tested; 95% CI, -1.4 to 17.0). Testing within 2 days was also associated with a significant increase in coronary revascularization but no difference in AMI admissions.Cardiac testing in patients with chest pain was associated with increased downstream testing and treatment without a reduction in AMI admissions, suggesting that routine testing may not be warranted. Further research into whether specific high-risk subgroups benefit from testing is needed.

  View details for PubMedID 28654959

• Use of high-intensity statins for patients with atherosclerotic cardiovascular disease in the Veterans Affairs Health System: Practice impact of the new cholesterol guidelines AMERICAN HEART JOURNAL Rodriguez, F., Lin, S., Maron, D. J., Knowles, J. W., Virani, S. S., Heidenreich, P. A. 2016; 182: 97-102

  Abstract

  The November 2013 American College of Cardiology/American Heart Association cholesterol guidelines recommend the use of high-intensity statins for patients with atherosclerotic cardiovascular disease (ASCVD). We sought to determine how these guidelines are being adopted at the Veterans Affairs (VA) Health System and identify treatment gaps.We examined administrative data from the VA 12 months prior to the index dates of April 1, 2013, and after April 1, 2014, to identify patients ≤75 years of age with ≥2 codes for ASCVD. We identified those on high-intensity statin therapy (atorvastatin 40 mg or 80 mg, rosuvastatin 20 mg or 40 mg, and simvastatin 80 mg) during the 6 months after the index date.The study sample included 331,927 and 326,759 eligible adults with ASCVD before and after the release of the new guidelines, respectively. Overall, high-intensity statin use increased from 28% to 35% after guideline release. High-intensity statin use was lowest in Hispanics and Native Americans, although all groups showed an increase over time. Among those on low- or moderate-intensity statin therapy, 15.6% were intensified to a high-intensity statin after guideline release. Groups less likely to undergo statin intensification were older adults (odds ratio=0.78 for each 10-year increase, 95% CI 0.76-0.81), women (odds ratio=0.86, 95% CI 0.75-0.99), and certain minority groups. Academic teaching hospitals and hospitals on the West Coast were more likely to intensify statins after release of the new guidelines.High-intensity statin use increased in the VA following release of the American College of Cardiology/American Heart Association cholesterol treatment guidelines, although disparities persist for certain patient groups including older adults, women, and certain minority groups.

  View details for DOI 10.1016/j.ahj.2016.09.007

  View details for Web of Science ID 000389136600012

  View details for PubMedID 27914506

• Association of 30-Day Readmission Metric for Heart Failure Under the Hospital Readmissions Reduction Program With Quality of Care and Outcomes. JACC. Heart failure Pandey, A., Golwala, H., Xu, H., DeVore, A. D., Matsouaka, R., Pencina, M., Kumbhani, D. J., Hernandez, A. F., Bhatt, D. L., Heidenreich, P. A., Yancy, C. W., de Lemos, J. A., Fonarow, G. C. 2016; 4 (12): 935-946

  Abstract

  This study sought to determine whether processes of care and long-term clinical outcomes for heart failure (HF) admissions across Get With The Guidelines-Heart Failure (GWTG-HF) program participating centers differ according to HF-specific risk-adjusted 30-day readmission rates (excess readmission ratio [ERR]) as determined by the Hospital Readmission Reduction Program (HRRP).HRRP penalizes hospitals with higher than expected risk-adjusted 30-day readmission rates (ERR >1) for common conditions including HF. However, it is unclear whether the differences in this metric of hospital performance used by HRRP and related penalties are associated with measured quality of care and long-term outcomes.We analyzed data from the GWTG-HF registry linked to Medicare claims from July 2008 to June 2011. Using publically available data on HF-ERR in 2013, we stratified the participating centers into groups with low (HF-ERR ≤1) versus high (HF-ERR >1) risk-adjusted readmission rates. We compared the care quality, in-hospital, and 1-year clinical outcomes across the 2 groups in unadjusted and multivariable adjusted analysis.The analysis included 171 centers with 43,143 participants; 49% of centers had high risk-adjusted 30-day readmission rates (HF-ERR >1). There were no differences between the low and high risk-adjusted 30-day readmission groups in median adherence rate to all performance measures (95.7% vs. 96.5%; p = 0.37) or median percentage of defect-free care (90.0% vs. 91.1%; p = 0.47). The composite 1-year outcome of death or all-cause readmission rates was also not different between the 2 groups (median 62.9% vs. 65.3%; p = 0.10). The high HF-ERR group had higher 1-year all-cause readmission rates (median 59.1% vs. 54.7%; p = 0.01). However, the 1-year mortality rates were lower among high versus low HF-ERR group with a trend toward statistical significance (median 28.2% vs. 31.7%; p = 0.07).Quality of care and clinical outcomes were comparable among hospitals with high versus low risk-adjusted 30-day HF readmission rates. These findings raise questions about the validity of the HRRP performance metric in identifying and penalizing low-performance centers.

  View details for DOI 10.1016/j.jchf.2016.07.003

  View details for PubMedID 27908393

• Temporal trends and factors associated with diabetes mellitus among patients hospitalized with heart failure: Findings from Get With The Guidelines-Heart Failure registry AMERICAN HEART JOURNAL Echouffo-Tcheugui, J. B., Xu, H., DeVore, A. D., Schulte, P. J., Butler, J., Yancy, C. W., Bhatt, D. L., Hernandez, A. F., Heidenreich, P. A., Fonarow, G. C. 2016; 182: 9-20

  Abstract

  The contribution of diabetes to the burden of heart failure (HF) remains largely undescribed. Assessing diabetes temporal trends among US patients hospitalized with HF and their relation with quality measures in real-world practice can help to define this burden.Using data from the Get With the Guidelines-Heart Failure registry, we assessed temporal trends in diabetes prevalence among patients with HF and in subgroups with reduced ejection fraction (HFrEF; EF < 40%), borderline EF (HFbEF; 40%≤EF <50%), or preserved EF (HFpEF; EF ≥ 50%), hospitalized between 2005 and 2015. Logistic regression was used to assess whether in-hospital outcomes and HF quality of care were related to trends.Among 364,480 HF hospitalizations, 160,171 had diabetes (44.0% overall, 41.8% in HFrEF, 46.7% in HFbEF, 45.5% in HFpEF). There was a temporal increase in diabetes frequency in HF patients (43.2%-45.8%; Ptrend <.0001), including among those with HFrEF (42.0%-43.6%; Ptrend <.0001), HFbEF (46.0%-49.2%; Ptrend <.0001), or HFpEF (43.6%-46.8%, Ptrend <.0001). Diabetic patients had a longer hospital stay (adjusted odds ratio 1.14, 95% CI 1.12-1.16), but lower in-hospital mortality (adjusted odds ratio 0.93 [0.89-0.97]) compared with those without diabetes, with limited differences in quality measures. Temporal trends in diabetes were not associated with in-hospital mortality or length of stay. There were no temporal interactions of most HF quality measures with diabetes status.Approximately 44% of hospitalized HF patients have diabetes, and this proportion has been increasing over the past 10years, particularly among those patients with new-onset HFpEF.

  View details for DOI 10.1016/j.ahj.2016.07.025

  View details for Web of Science ID 000389136600002

  View details for PubMedID 27914505

• Association of 30-Day Readmission Metric for Heart Failure Under the Hospital Readmissions Reduction Program With Quality of Care and Outcomes JACC-HEART FAILURE Pandey, A., Golwala, H., Xu, H., DeVore, A. D., Matsouaka, R., Pencina, M., Kumbhani, D. J., Hernandez, A. F., Bhatt, D. L., Heidenreich, P. A., Yancy, C. W., de Lemos, J. A., Fonarow, G. C. 2016; 4 (12): 935-946

  Abstract

  This study sought to determine whether processes of care and long-term clinical outcomes for heart failure (HF) admissions across Get With The Guidelines-Heart Failure (GWTG-HF) program participating centers differ according to HF-specific risk-adjusted 30-day readmission rates (excess readmission ratio [ERR]) as determined by the Hospital Readmission Reduction Program (HRRP).HRRP penalizes hospitals with higher than expected risk-adjusted 30-day readmission rates (ERR >1) for common conditions including HF. However, it is unclear whether the differences in this metric of hospital performance used by HRRP and related penalties are associated with measured quality of care and long-term outcomes.We analyzed data from the GWTG-HF registry linked to Medicare claims from July 2008 to June 2011. Using publically available data on HF-ERR in 2013, we stratified the participating centers into groups with low (HF-ERR ≤1) versus high (HF-ERR >1) risk-adjusted readmission rates. We compared the care quality, in-hospital, and 1-year clinical outcomes across the 2 groups in unadjusted and multivariable adjusted analysis.The analysis included 171 centers with 43,143 participants; 49% of centers had high risk-adjusted 30-day readmission rates (HF-ERR >1). There were no differences between the low and high risk-adjusted 30-day readmission groups in median adherence rate to all performance measures (95.7% vs. 96.5%; p = 0.37) or median percentage of defect-free care (90.0% vs. 91.1%; p = 0.47). The composite 1-year outcome of death or all-cause readmission rates was also not different between the 2 groups (median 62.9% vs. 65.3%; p = 0.10). The high HF-ERR group had higher 1-year all-cause readmission rates (median 59.1% vs. 54.7%; p = 0.01). However, the 1-year mortality rates were lower among high versus low HF-ERR group with a trend toward statistical significance (median 28.2% vs. 31.7%; p = 0.07).Quality of care and clinical outcomes were comparable among hospitals with high versus low risk-adjusted 30-day HF readmission rates. These findings raise questions about the validity of the HRRP performance metric in identifying and penalizing low-performance centers.

  View details for Web of Science ID 000389561500006

• Warfarin utilisation and anticoagulation control in patients with atrial fibrillation and chronic kidney disease. Heart Yang, F., Hellyer, J. A., Than, C., Ullal, A. J., Kaiser, D. W., Heidenreich, P. A., Hoang, D. D., Winkelmayer, W. C., Schmitt, S., Frayne, S. M., Phibbs, C. S., Turakhia, M. P. 2016

  Abstract

  To evaluate warfarin prescription, quality of international normalised ratio (INR) monitoring and of INR control in patients with atrial fibrillation (AF) and chronic kidney disease (CKD).We performed a retrospective cohort study of patients with newly diagnosed AF in the Veterans Administration (VA) healthcare system. We evaluated anticoagulation prescription, INR monitoring intensity and time in and outside INR therapeutic range (TTR) stratified by CKD.Of 123 188 patients with newly diagnosed AF, use of warfarin decreased with increasing severity of CKD (57.2%-46.4%), although it was higher among patients on dialysis (62.3%). Although INR monitoring intensity was similar across CKD strata, the proportion with TTR≥60% decreased with CKD severity, with only 21% of patients on dialysis achieving TTR≥60%. After multivariate adjustment, the magnitude of TTR reduction increased with CKD severity. Patients on dialysis had the highest time markedly out of range with INR <1.5 or >3.5 (30%); 12% of INR time was >3.5, and low TTR persisted for up to 3 years.There is a wide variation in anticoagulation prescription based on CKD severity. Patients with moderate-to-severe CKD, including dialysis, have substantially reduced TTR, despite comparable INR monitoring intensity. These findings have implications for more intensive warfarin management strategies in CKD or alternative therapies such as direct oral anticoagulants.

  View details for DOI 10.1136/heartjnl-2016-309266

  View details for PubMedID 27852694

• Secular Trends in Reported Success Rates of Catheter Ablation for Paroxysmal Atrial Fibrillation: Findings From the SMASH-AF Meta-Analysis Study Cohort Perino, A. C., Leef, G. C., Cluckey, A., Yunus, F. N., Askari, M., Heidenreich, P. A., Turakhia, M. LIPPINCOTT WILLIAMS & WILKINS. 2016

  View details for Web of Science ID 000396816608100

• Association of Risk Adjusted 30 Day Heart Failure Readmission Rates Under the Hospital Readmissions Reduction Program With Quality of Care and Outcomes: Findings From the American Heart Association Get With the Guidelines-Heart Failure Program Pandey, A., Golwala, H., Xu, H., DeVore, A., Matsouaka, R., Pencina, M., Kumbhani, D., Hernandez, A., Bhatt, D., Heidenreich, P., Yancy, C., De Lemos, J., Fonarow, G. LIPPINCOTT WILLIAMS & WILKINS. 2016

  View details for Web of Science ID 000396815605005

• The Scope of Sacubitril/Valsartan Eligibility Post-Heart Failure Hospitalization: Findings From the Get With the Guidelines-Heart Failure Registry Parikh, K. S., Lippmann, S., Greiner, M., Heidenreich, P. A., Yancy, C. W., Fonarow, G. C., Hernandez, A. F. LIPPINCOTT WILLIAMS & WILKINS. 2016

  View details for Web of Science ID 000396815606090

• Clinical Predictors of Short and Long Term Mortality in Patients With Heart Failure Preserved Ejection Fraction Boralkar, K. A., Kobayashi, Y., Tuzovic, M., Moneghetti, K. J., Pargaonkar, V. S., Ouazani, N., Vrtovec, B., Wheeler, M., Banerjee, D., Heidenreich, P., Haddad, F. LIPPINCOTT WILLIAMS & WILKINS. 2016

  View details for Web of Science ID 000396815606121

• Initiation, Continuation, or Withdrawal of Angiotensin Converting Enzyme Inhibitors/Angiotensin Receptor Blockers and Outcomes in Patients Hospitalized With Heart Failure With Reduced Ejection Fraction Gilstrap, L. G., Fonawow, G. C., Li, L., DeVore, A., Smith, E. E., Heidenreich, P., Hernandez, A. F., Yancy, C. W., Bhatt, D. L. LIPPINCOTT WILLIAMS & WILKINS. 2016

  View details for Web of Science ID 000396815301055

• Mineralocorticoid Receptor Antagonist Use in Patients With Heart Failure and Co-Morbid Diabetes or Chronic Kidney Disease Cooper, L. B., Lippmann, S. J., Greiner, M. A., Kelly, J. P., Sharma, A., Fonarow, G. C., Yancy, C. W., Heidenreich, P. A., Hernandez, A. F. LIPPINCOTT WILLIAMS & WILKINS. 2016

  View details for Web of Science ID 000396815301139

• Mineralocorticoid Receptor Antagonist Use in Patients With Heart Failure and Co-Morbid Diabetes or Chronic Kidney Disease Cooper, L. B., Lippmann, S. J., Greiner, M. A., Kelly, J. P., Sharma, A., Fonarow, G. C., Yancy, C. W., Heidenreich, P. A., Hernandez, A. F. LIPPINCOTT WILLIAMS & WILKINS. 2016

  View details for Web of Science ID 000396815600095

• Initiation, Continuation, or Withdrawal of Angiotensin Converting Enzyme Inhibitors/Angiotensin Receptor Blockers and Outcomes in Patients Hospitalized With Heart Failure With Reduced Ejection Fraction Gilstrap, L. G., Fonawow, G. C., Li, L., DeVore, A., Smith, E. E., Heidenreich, P., Hernandez, A. F., Yancy, C. W., Bhatt, D. L. LIPPINCOTT WILLIAMS & WILKINS. 2016

  View details for Web of Science ID 000396815600064

• Differences in Hospital Risk-standardized Mortality Rates for Acute Myocardial Infarction by Patient Age Group: Implications for Hospital Outcome Profiling Dharmarajan, K., Wang, Y., McNamara, R., Masoudi, F., Ross, J., Desai, N., Spatz, E., de Lemos, J., Fonarow, G., Heidenreich, P., Bhatt, D., Bernheim, S., Slattery, L., Khan, Y., Curtis, J. LIPPINCOTT WILLIAMS & WILKINS. 2016

  View details for Web of Science ID 000396816605074

• Depressive Symptoms, Cardiac Disease Severity, and Functional Status in Patients With Coronary Artery Disease (from the Heart and Soul Study). American journal of cardiology Schopfer, D. W., Regan, M., Heidenreich, P. A., Whooley, M. A. 2016; 118 (9): 1287-1292

  Abstract

  Patient-reported health status is highly valued as a key measure of health care quality, yet little is known about the extent to which it is determined by subjective perception compared with objective measures of disease severity. We sought to compare the associations of depressive symptoms and objective measures of cardiac disease severity with perceived functional status in patients with stable coronary artery disease. We assessed depressive symptoms, severity of cardiovascular disease, and perceived functional status in a cross-sectional study of 1,023 patients with stable coronary artery disease. We compared the extent to which patient-reported functional status was influenced by depressive symptoms versus objective measures of disease severity. We then evaluated perceived functional status as a predictor of subsequent cardiovascular hospitalizations during 8.8 years of follow-up. Patients with depressive symptoms were more likely to report poor functional status than those without depressive symptoms (44% vs 17%; p <0.001). After adjustment for traditional risk factors and co-morbid conditions, independent predictors of poor functional status were depressive symptoms (odds ratio [OR] 2.68, 95% confidence interval [CI] 1.89 to 3.79), poor exercise capacity (OR 2.30, 95% CI 1.65 to 3.19), and history of heart failure (OR 1.61, 95% CI 1.12 to 2.29). Compared with patients who had class I functional status, those with class II functional status had a 96% greater rate (hazard ratio 1.96, 95% CI 1.15 to 3.34) and those with class III or IV functional status had a 104% greater rate (hazard ratio 2.04, 95% CI 1.12 to 3.73) of hospitalization for HF, adjusted for baseline demographic characteristics, co-morbidities, cardiac disease severity, and depressive symptoms. In conclusion, depressive symptoms and cardiac disease severity were independently associated with patient-reported functional status. This suggests that perceived functional status may be as strongly influenced by depressive symptoms as it is by cardiovascular disease severity.

  View details for DOI 10.1016/j.amjcard.2016.07.062

  View details for PubMedID 27665203

• Gender Differences in Clinical Outcomes after Catheter Ablation of Atrial Fibrillation. JACC. Clinical electrophysiology Kaiser, D. W., Fan, J., Schmitt, S., Than, C. T., Ullal, A. J., Piccini, J. P., Heidenreich, P. A., Turakhia, M. P. 2016; 2 (6): 703-710

  Abstract

  To explore gender differences in real-world outcomes after catheter ablation of atrial fibrillation (AF).Compared to men, women with AF have greater thromboembolic risk and tend to be more symptomatic. Catheter ablation is generally more effective than antiarrhythmic drug therapy alone. However, there is limited data on the influence of gender on AF ablation outcomes.We analyzed medical claims of 45 million United States patients enrolled in a variety of employee-sponsored and fee-for-service plans. We identified patients who underwent an AF ablation from 2007 to 2011 and evaluated 30-day safety and one-year effectiveness outcomes.Of the 21,091 patients who underwent an AF ablation, 7,460 (29%) were female. Women, compared to men, were older (62±11 vs. 58±11 years), had higher CHADS2 (1.2±1.1 vs. 1.0±1.0), higher CHA2DS2-VASc (2.9±1.5 vs. 1.6±1.4), and higher Charlson comorbidity index scores (1.2±1.3 vs. 1.0±1.2)(p<0.001 for all). Following ablation, women had higher risk of 30-day complications of hemorrhage (2.7 vs. 2.0%,p<0.001) and tamponade (3.8 vs. 2.9%,p<0.001). In multivariable analyses, women were more likely to have a re-hospitalization for AF (adjusted HR 1.12,p=0.009), but less likely to have repeat AF ablation (adjusted HR 0.92,p=0.04) or cardioversion (adjusted HR 0.75,p<0.001).Women have increased hospitalization rates after AF ablation and are more likely to have a procedural complication. Despite the higher rate of hospital admissions for AF after ablation, women were less likely to undergo repeat ablation or cardioversion. These data call for greater examination of barriers and facilitators to sustain rhythm control strategies in women.

  View details for DOI 10.1016/j.jacep.2016.04.014

  View details for PubMedID 29623299

  View details for PubMedCentralID PMC5881580

• Hospitalized Patients with Heart Failure and Common Bacterial Infections: A Nationwide Analysis of Concomitant Clostridium Difficile Infection Rates and In-Hospital Mortality. Journal of cardiac failure Mamic, P., Heidenreich, P. A., Hedlin, H., Tennakoon, L., Staudenmayer, K. L. 2016; 22 (11): 891-900

  Abstract

  Patients with heart failure (HF) are frequently hospitalized with common bacterial infections. It is unknown whether they experience concomitant Clostridium difficile infection (CDI) more frequently than patients without HF, and whether CDI affects their mortality.We used 2012 National Inpatient Sample data to determine the rate of CDI and associated in-hospital mortality for hospitalized patients with comorbid HF and urinary tract infection (UTI), pneumonia (PNA), or sepsis. Univariate and multivariate analyses were performed. Weighted data are presented.There were an estimated 5,851,582 patient hospitalizations with discharge diagnosis of UTI, PNA, or sepsis in 2012 in the United States. Of these, 23.4% had discharge diagnosis of HF. Patients with HF were on average older and had more comorbidities. CDI rates were higher in hospitalizations with discharge diagnosis of HF compared with those without HF (odds ratio 1.13, 95% confidence interval 1.10-1.16) after controlling for patient demographics and comorbidities and hospital characteristics. Among HF hospitalizations with UTI, PNA, or sepsis, those with concomitant CDI had a higher in-hospital mortality than those without concomitant CDI (odds ratio 1.81, 95% confidence interval 1.71-1.92) after controlling for the covariates outlined previously.HF is associated with higher CDI rates among hospitalized patients with other common bacterial infections, even when adjusting for other known risk factors for CDI. Among these patients with comorbid HF, CDI is associated with markedly higher in-hospital mortality. These findings may suggest an opportunity to improve outcomes for hospitalized patients with HF and common bacterial infections, possibly through improved Clostridium difficile screening and prophylaxis protocols.

  View details for DOI 10.1016/j.cardfail.2016.06.005

  View details for PubMedID 27317844

• Asians suffer the highest in-hospital mortality rates after acute coronary syndrome despite high use of early invasive procedures Yong, C., Abnousi, F., Asch, S., Heidenreich, P. ELSEVIER SCIENCE INC. 2016: B40

  View details for DOI 10.1016/j.jacc.2016.09.344

  View details for Web of Science ID 000397332900098

• Safety and Clinical Outcomes of Catheter Ablation of Atrial Fibrillation in Patients with Chronic Kidney Disease. Journal of cardiovascular electrophysiology Ullal, A. J., Kaiser, D. W., Fan, J., Schmitt, S., Than, C. T., Winkelmayer, W. C., Heidenreich, P. A., Piccini, J. P., Perez, M. V., Wang, P. J., Turakhia, M. P. 2016

  Abstract

  Data regarding catheter ablation of atrial fibrillation (AF) in patients with chronic kidney disease (CKD) is limited. We therefore assessed the association of CKD with common safety and clinical outcomes in a nationwide sample of ablation recipients.Using MarketScan(®) Commercial Claims and Medicare Supplemental Databases, we evaluated 30-day safety and 1-year clinical outcomes in patients who underwent a first AF ablation procedure between 2007 and 2011. We calculated frequency of common 30-day complications and calculated frequencies, incidence rates, and Cox proportional hazards for outcomes at 1-year postablation.Of 21,091 patients included, 1,593 (7.6%) had CKD. Patients with CKD were older (64 years vs. 59 years, P < 0.001) with higher CHA2 DS2 -VASc scores (3.2 vs. 1.8, P < 0.001). At 30 days postablation, patients with CKD had similar rates of stroke/TIA (0.13% vs. 0.13%, P = 0.99), perforation/tamponade (3.2% vs. 3.1%, P = 0.83), and vascular complications (2.4% vs. 2.2%, P = 0.59) as patients without CKD, but were more likely to be hospitalized for heart failure (2.1% vs. 0.4%, P < 0.001). In multivariate analysis, there were no significant differences in hazards of AF hospitalization (adjusted HR: 1.02, 95%CI: 0.87-1.20), cardioversion (adjusted HR: 0.99, 95%CI: 0.87-1.12), or repeat AF ablation (adjusted HR: 0.89, 95%CI: 0.76-1.06) at 1 year.Among patients selected for AF ablation, those with and without CKD had similar rates of postprocedural complications although they were more likely to be re-admitted for heart failure. CKD was not independently associated with AF hospitalization, cardioversion, and repeat ablation. These findings can inform clinical decision-making in patients with AF and CKD.

  View details for DOI 10.1111/jce.13118

  View details for PubMedID 27782345

• Prediction of 30-Day All-Cause Readmissions in Patients Hospitalized for Heart Failure: Comparison of Machine Learning and Other Statistical Approaches. JAMA cardiology Frizzell, J. D., Liang, L., Schulte, P. J., Yancy, C. W., Heidenreich, P. A., Hernandez, A. F., Bhatt, D. L., Fonarow, G. C., Laskey, W. K. 2016

  Abstract

  Several attempts have been made at developing models to predict 30-day readmissions in patients with heart failure, but none have sufficient discriminatory capacity for clinical use. Machine-learning (ML) algorithms represent a novel approach and may have potential advantages over traditional statistical modeling.To develop models using a ML approach to predict all-cause readmissions 30 days after discharge from a heart failure hospitalization and to compare ML model performance with models developed using "conventional" statistically based methods.Models were developed using ML algorithms, specifically, a tree-augmented naive Bayesian network, a random forest algorithm, and a gradient-boosted model and compared with traditional statistical methods using 2 independently derived logistic regression models (a de novo model and an a priori model developed using electronic health records) and a least absolute shrinkage and selection operator method. The study sample was randomly divided into training (70%) and validation (30%) sets to develop and test model performance. This was a registry-based study, and the study sample was obtained by linking patients from the Get With the Guidelines Heart Failure registry with Medicare data. After applying appropriate inclusion and exclusion criteria, 56 477 patients were included in our analysis. The study was conducted between January 4, 2005, and December 1, 2010, and analysis of the data was conducted between November 25, 2014, and June 30, 2016.C statistics were used for comparison of discriminatory capacity across models in the validation sample.The overall 30-day rehospitalization rate was 21.2% (11 959 of 56 477 patients). For the tree-augmented naive Bayesian network, random forest, gradient-boosted, logistic regression, and least absolute shrinkage and selection operator models, C statistics for the validation sets were similar: 0.618, 0.607, 0.614, 0.624, and 0.618, respectively. Applying the previously validated electronic health records model to our study sample yielded a C statistic of 0.589 for the validation set.Use of a number of ML algorithms did not improve prediction of 30-day heart failure readmissions compared with more traditional prediction models. Although there will likely be further applications of ML approaches in prognostic modeling, our study fits within the literature of limited predictive ability for heart failure readmissions.

  View details for DOI 10.1001/jamacardio.2016.3956

  View details for PubMedID 27784047

• Guideline-Appropriate Care and In-Hospital Outcomes in Patients With Heart Failure in Teaching and Nonteaching Hospitals: Findings From Get With The Guidelines-Heart Failure. Circulation. Cardiovascular quality and outcomes Patel, D. B., Shah, R. M., Bhatt, D. L., Liang, L., Schulte, P. J., DeVore, A. D., Hernandez, A. F., Heidenreich, P. A., Yancy, C. W., Fonarow, G. C. 2016

  Abstract

  Despite increasing awareness regarding evidence-based guidelines, considerable gaps exist for heart failure (HF) quality of care at teaching hospitals (TH) and nonteaching hospitals (NTH). We analyzed data from Get With The Guidelines (GWTG)-HF to compare the rates and trends of guideline-recommended care at TH and NTH for patients with HF.Baseline patient characteristics, performance measures, and in-hospital outcomes were compared between 197 187 HF patients admitted to TH and 106 924 patients admitted to NTH between 2005 and 2014. Patients treated in TH were younger and were more likely to be black and uninsured. Defect-free care (defined as 100% compliance with performance measures) was similar in both group of hospitals (crude rates: 88% at TH versus 86% at NTH, adjusted odds ratio 0.99, 95% confidence interval 0.73-1.34) as were individual performance measures: discharge instruction, documentation of ejection fraction, use of angiotensin-converting enzyme inhibitors/angiotensin receptor antagonists, use of β-blocker, and smoking cessation counseling. During the study period, there was improvement in adherence with performance measures over time, with no significant difference at TH (adjusted odds ratio 1.20, 95% confidence interval 1.11-1.30; P<0.01) and NTH (adjusted odds ratio 1.09, 95% confidence interval 1.02-1.17; P=0.01; interaction P value 0.07).Data from the GWTG-HF program suggest that there was improving and comparable adherence with HF performance measures and use of guideline-recommended therapies irrespective of hospital teaching status.

  View details for PubMedID 27780849

• Temporal Trends in Care and Outcomes of Patients Receiving Fibrinolytic Therapy Compared to Primary Percutaneous Coronary Intervention: Insights From the Get With The Guidelines Coronary Artery Disease (GWTG-CAD) Registry. Journal of the American Heart Association Hira, R. S., Bhatt, D. L., Fonarow, G. C., Heidenreich, P. A., Ju, C., Virani, S. S., Bozkurt, B., Petersen, L. A., Hernandez, A. F., Schwamm, L. H., Eapen, Z. J., Albert, M. A., Liang, L., Matsouaka, R. A., Peterson, E. D., Jneid, H. 2016; 5 (10)

  Abstract

  Timely reperfusion after ST-elevation myocardial infarction (STEMI) improves survival. Guidelines recommend primary percutaneous coronary intervention (PPCI) within 90 minutes of arrival at a PCI-capable hospital. The alternative is fibrinolysis within 30 minutes for those in those for whom timely transfer to a PCI-capable hospital is not feasible.We identified STEMI patients receiving reperfusion therapy at 229 hospitals participating in the Get With the Guidelines-Coronary Artery Disease (GWTG-CAD) database (January 1, 2003 through December 31, 2008). Temporal trends in the use of fibrinolysis and PPCI, its timeliness, and in-hospital mortality outcomes were assessed. We also assessed predictors of fibrinolysis versus PPCI and compliance with performance measures. Defect-free care was defined as 100% compliance with all performance measures. We identified 29 190 STEMI patients, of whom 2441 (8.4%) received fibrinolysis; 38.2% of these patients achieved door-to-needle times ≤30 minutes. Median door-to-needle times increased from 36 to 60 minutes (P=0.005) over the study period. Among PPCI patients, median door-to-balloon times decreased from 94 to 64 minutes (P<0.0001) over the same period. In-hospital mortality was higher with fibrinolysis than with PPCI (4.6% vs 3.3%, P=0.001) and did not change significantly over time. Patients receiving fibrinolysis were less likely to receive defect-free care compared with their PPCI counterparts.Use of fibrinolysis for STEMI has decreased over time with concomitant worsening of door-to-needle times. Over the same time period, use of PPCI increased with improvement in door-to-balloon times. In-hospital mortality was higher with fibrinolysis than with PPCI. As reperfusion for STEMI continues to shift from fibrinolysis to PPCI, it will be critical to ensure that door-to-needle times and outcomes do not worsen.

  View details for PubMedID 27792640

• Temporal Trends in Care and Outcomes of Patients Receiving Fibrinolytic Therapy Compared to Primary Percutaneous Coronary Intervention: Insights From the Get With The Guidelines Coronary Artery Disease (GWTG-CAD) Registry JOURNAL OF THE AMERICAN HEART ASSOCIATION Hira, R. S., Bhatt, D. L., Fonarow, G. C., Heidenreich, P. A., Ju, C., Virani, S. S., Bozkurt, B., Petersen, L. A., Hernandez, A. F., Schwamm, L. H., Eapen, Z. J., Albert, M. A., Liang, L., Matsouaka, R. A., Peterson, E. D., Jneid, H. 2016; 5 (10)

  View details for DOI 10.1161/JAHA.116.004113

  View details for Web of Science ID 000386748500038

• Lack of Left Ventricular Ejection Fraction Measurement Following a High B-type Natriuretic Peptide Value. Critical pathways in cardiology Heidenreich, P. A., Gholami, P., Lin, S. 2016; 15 (3): 112-113

  Abstract

  The objective of this study was to determine how often providers did not obtain a recommended measure of left ventricular ejection fraction (LVEF) following a high B-type natriuretic peptide (BNP) value when the LVEF was not known to be low (<40%). Such patients may benefit from life-prolonging treatment.We identified consecutive patients (inpatient or outpatient) with a BNP value of at least 200 pg/mL within a single VA health care system (3 inpatient facilities and 8 community clinics) during a 10-month period (September 2008-June 2009). We performed chart review to determine results of any imaging study performed (inside or outside the health system) prior to or after the high BNP value.Of the 296 patients with a high BNP, 212 were not known to have a low LVEF. Of these, 99 (47%) did not have the guideline recommended follow-up LVEF study. Among those that survived at least 6 months following BNP and a follow-up echocardiogram was indicated (no prior LVEF or prior LVEF was > 40%), mortality was 20% if an echocardiogram was performed within 6 months of the BNP and 27% if it was not performed within 6 months of BNP testing (P = 0.21).Approximately half of patients with a high BNP and an LVEF not known to be low did not have a follow-up guideline recommended LVEF study and may have unrecognized heart failure. Our findings suggest that a trial is warranted of a clinical pathway where those patients with a high BNP and without appropriate follow-up are randomized to have their physician receive a notification of the high BNP value.

  View details for DOI 10.1097/HPC.0000000000000077

  View details for PubMedID 27465007

• Heart failure medications prescribed at discharge for patients with left ventricular assist devices. American heart journal Shreibati, J. B., Sheng, S., Fonarow, G. C., DeVore, A. D., Yancy, C. W., Bhatt, D. L., Schulte, P., Peterson, E. D., Hernandez, A., Heidenreich, P. A. 2016; 179: 99-106

  Abstract

  Real-world use of traditional heart failure (HF) medications for patients with left ventricular assist devices (LVADs) is not well known.We conducted a retrospective, observational analysis of 1,887 advanced HF patients with and without LVADs from 32 LVAD hospitals participating in the Get With The Guidelines-Heart Failure registry from January 2009 to March 2015. We examined HF medication prescription at discharge, temporal trends, and predictors of prescription among patients with an in-hospital (n = 258) or prior (n = 171) LVAD implant, and those with advanced HF but no LVAD, as defined by a left ventricular ejection fraction ≤25% and in-hospital receipt of intravenous inotropes or vasopressin receptor antagonists (n = 1,458).For β-blocker and angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEI/ARB), discharge prescriptions were 58.9% and 53.5% for new LVAD patients, 53.8% and 42.9% for prior LVAD patients, and 73.4% and 63.2% for patients without LVAD support, respectively (both P < .0001). Aldosterone antagonist prescription quadrupled among LVAD patients during the study period (P < .0001), whereas ACEI/ARB use decreased nearly 20 percentage points (60.0% to 41.4%, P = .0003). In the multivariable analysis of LVAD patients, patient age was inversely associated with β-blocker, ACEI/ARB, and aldosterone antagonist prescription.Traditional HF therapies were moderately prescribed at discharge to patients with LVADs and were more frequently prescribed to patients with advanced HF without LVAD support. Moderate prescription rates suggest clinical uncertainty in the use of antiadrenergic medication in this population. Further research is needed on the optimal medical regimen for patients with LVADs.

  View details for DOI 10.1016/j.ahj.2016.06.011

  View details for PubMedID 27595684

• The Potential Impact of Expanding Cardiac Rehabilitation in Heart Failure JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Kelly, J. P., Hammill, B. G., Doll, J. A., Felker, G., Heidenreich, P. A., Bhatt, D. L., Yancy, C. W., Fonarow, G. C., Hernandez, A. F. 2016; 68 (9): 977-978

  View details for DOI 10.1016/j.jacc.2016.05.081

  View details for Web of Science ID 000382312900013

  View details for PubMedID 27561772

• Trends in the Use of Guideline-Directed Therapies Among Dialysis Patients Hospitalized With Systolic Heart Failure Findings From the American Heart Association Get With The Guidelines-Heart Failure Program JACC-HEART FAILURE Pandey, A., Golwala, H., DeVore, A. D., Lu, D., Madden, G., Bhatt, D. L., Schulte, P. J., Heidenreich, P. A., Yancy, C. W., Hernandez, A. F., Fonarow, G. C. 2016; 4 (8): 649-661

  Abstract

  The purpose of this study was to determine the temporal trends in the adherence to heart failure (HF)-related process of care measures and clinical outcomes among patients with acute decompensated HF with reduced ejection fraction (HFrEF) and end-stage renal disease (ESRD).Previous studies have demonstrated significant underuse of evidence-based HF therapies among patients with coexisting ESRD and HFrEF. However, it is unclear if the proportional use of evidence-based medical therapies and associated clinical outcomes among these patients has changed over time.Get With The Guidelines-HF study participants who were admitted for acute HFrEF between January 2005 and June 2014 were stratified into 3 groups on the basis of their admission renal function: normal renal function, renal insufficiency without dialysis, and dialysis. Temporal change in proportional adherence to the HF-related process of care measures and incidence of clinical outcomes (1-year mortality, HF hospitalization, and all-cause hospitalization) during the study period was evaluated across the 3 renal function groups.The study included 111,846 patients with HFrEF from 390 participating centers, of whom 19% had renal insufficiency but who did not require dialysis, and 3% were on dialysis. There was a significant temporal increase in adherence to evidence-based medical therapies (angiotensin-converting enzyme inhibitor/angiotensin receptor blocker: p trend <0.0001, β-blockers: p trend = 0.0089; post-discharge follow-up referral: p trend <0.0001) and defect-free composite care (p trend <0.0001) among dialysis patients. An improvement in adherence to these measures was also observed among patients with normal renal function and patients with renal insufficiency without a need for dialysis. There was no significant change in cumulative incidence of clinical outcomes over time among the HF patients on dialysis.In a large contemporary cohort of HFrEF patients with ESRD, adherence to the HF process of care measures has improved significantly over the past 10 years. Unlike patients with normal renal function, there was no significant change in 1-year clinical outcomes over time among HF patients on dialysis.

  View details for DOI 10.1016/j.jchf.2016.03.002

  View details for Web of Science ID 000383406500006

• Clinical Effectiveness of Hydralazine-Isosorbide Dinitrate in Vha Heart Failure Patients by Ethnicity Ziaeian, B., Fonarow, G. C., Heidenreich, P. CHURCHILL LIVINGSTONE INC MEDICAL PUBLISHERS. 2016: S93

  View details for DOI 10.1016/j.cardfail.2016.06.296

  View details for Web of Science ID 000381064700261

• Trends in Palliative Care Use in Veterans With Severe Heart Failure Using a Large National Cohort JAMA CARDIOLOGY Mandawat, A., Heidenreich, P. A., Mandawat, A., Bhatt, D. L. 2016; 1 (5): 616–19

  View details for PubMedID 27434266

• Automated Heart Failure Quality Measurement with Natural Language Processing Garvin, J. H., Kim, Y., Gobbel, G. T., Matheny, M. E., Redd, A., Bray, B. E., Heidenreich, P., Kalsy, M., Goldstein, M. K., Bolton, D., Nativi-Nicolau, J., Meystre, S. M. CHURCHILL LIVINGSTONE INC MEDICAL PUBLISHERS. 2016: S92

  View details for DOI 10.1016/j.cardfail.2016.06.292

  View details for Web of Science ID 000381064700257

• Trends in the Use of Guideline-Directed Therapies Among Dialysis Patients Hospitalized With Systolic Heart Failure: Findings From the American Heart Association Get With The Guidelines-Heart Failure Program. JACC. Heart failure Pandey, A., Golwala, H., DeVore, A. D., Lu, D., Madden, G., Bhatt, D. L., Schulte, P. J., Heidenreich, P. A., Yancy, C. W., Hernandez, A. F., Fonarow, G. C. 2016; 4 (8): 649-661

  Abstract

  The purpose of this study was to determine the temporal trends in the adherence to heart failure (HF)-related process of care measures and clinical outcomes among patients with acute decompensated HF with reduced ejection fraction (HFrEF) and end-stage renal disease (ESRD).Previous studies have demonstrated significant underuse of evidence-based HF therapies among patients with coexisting ESRD and HFrEF. However, it is unclear if the proportional use of evidence-based medical therapies and associated clinical outcomes among these patients has changed over time.Get With The Guidelines-HF study participants who were admitted for acute HFrEF between January 2005 and June 2014 were stratified into 3 groups on the basis of their admission renal function: normal renal function, renal insufficiency without dialysis, and dialysis. Temporal change in proportional adherence to the HF-related process of care measures and incidence of clinical outcomes (1-year mortality, HF hospitalization, and all-cause hospitalization) during the study period was evaluated across the 3 renal function groups.The study included 111,846 patients with HFrEF from 390 participating centers, of whom 19% had renal insufficiency but who did not require dialysis, and 3% were on dialysis. There was a significant temporal increase in adherence to evidence-based medical therapies (angiotensin-converting enzyme inhibitor/angiotensin receptor blocker: p trend <0.0001, β-blockers: p trend = 0.0089; post-discharge follow-up referral: p trend <0.0001) and defect-free composite care (p trend <0.0001) among dialysis patients. An improvement in adherence to these measures was also observed among patients with normal renal function and patients with renal insufficiency without a need for dialysis. There was no significant change in cumulative incidence of clinical outcomes over time among the HF patients on dialysis.In a large contemporary cohort of HFrEF patients with ESRD, adherence to the HF process of care measures has improved significantly over the past 10 years. Unlike patients with normal renal function, there was no significant change in 1-year clinical outcomes over time among HF patients on dialysis.

  View details for DOI 10.1016/j.jchf.2016.03.002

  View details for PubMedID 27179827

• Patient and Facility Variation in Costs of VA Heart Failure Patients JACC-HEART FAILURE Yoon, J., Fonarow, G. C., Groeneveld, P. W., Teerlink, J. R., Whooley, M. A., Sahay, A., Heidenreich, P. A. 2016; 4 (7): 551-558

  Abstract

  This study sought to determine the variation in annual health care costs among patients with heart failure in the Veterans Affairs (VA) system.Heart failure is associated with considerable use of health care resources, but little is known about patterns in patient characteristics related to higher costs.We obtained VA utilization and cost records for all patients with a diagnosis of heart failure in fiscal year 2010. We compared total VA costs by patient demographic factors, comorbid conditions, and facility where they were treated in bivariate analyses. We regressed total costs on patient factors alone, VA facility alone, and all factors combined to determine the relative contribution of patient factors and facility to explaining cost differences.There were 117,870 patients with heart failure, and their mean annual VA costs were $30,719 (SD 49,180) with more than one-half of their costs from inpatient care. Patients at younger ages, of Hispanic or black race/ethnicity, diagnosed with comorbid drug use disorders, or who died during the year had the highest costs (all p < 0.01). There was variation in costs by facility as mean adjusted costs ranged from approximately $15,000 to $48,000. In adjusted analyses, patient factors alone explained more of the variation in health care costs (R(2) = 0.116) compared with the facility where the patient was treated (R(2) = 0.018).A large variation in costs of heart failure patients was observed across facilities, although this was explained largely by patient factors. Improving the efficiency of VA resource utilization may require increased scrutiny of high-cost patients to determine if adequate value is being delivered to those patients.

  View details for DOI 10.1016/j.jchf.2016.01.003

  View details for Web of Science ID 000379282400005

  View details for PubMedID 26970829

• Impact of the Hospital to Home Initiative on Readmissions in the VA Health Care System. Quality management in health care Heidenreich, P. A., Sahay, A., Oliva, N., Gholami, P., Lin, S., Mittman, B. S., Rumsfeld, J. S. 2016; 25 (3): 129-133

  Abstract

  Hospital to Home (H2H) is a national quality improvement initiative sponsored by the Institute for Healthcare Improvement and the American College of Cardiology, with the goal of reducing readmission for patients hospitalized with heart disease. We sought to determine the impact of H2H within the Veterans Affairs (VA) health care system.Using a controlled interrupted time series, we determined the association of VA hospital enrollment in H2H with the primary outcome of 30-day all-cause readmission following a heart failure hospitalization. VA heart failure providers were surveyed to determine quality improvement projects initiated in response to H2H. Secondary outcomes included initiation of recommended H2H projects, follow-up within 7 days, and total hospital days at 30 days and 1 year.Sixty-five of 104 VA hospitals (66%) enrolled in the national H2H initiative. Hospital characteristic associated with H2H enrollment included provision of tertiary care, academic affiliation, and greater use of home monitoring. There was no significant difference in mean 30-day readmission rates (20.0% ± 5.0% for H2H vs 19.3% ± 5.9% for non-H2H hospitals; P = .48) The mean fraction of patients with a cardiology visit within 7 days was slightly higher for H2H hospitals (3.0% ± 2.4% for H2H vs 2.0% ± 1.9% for non-H2H hospitals; P = .05). Patients discharged from H2H hospitals had fewer mean hospitals days during the following year (7.6% ± 2.6% for H2H vs 9.2% ± 3.0 for non-H2H; P = .01) early after launch of H2H, but the effect did not persist.VA hospitals enrolling in H2H had slightly more early follow-up in cardiology clinic but no difference in 30-day readmission rates compared with hospitals not enrolling in H2H.

  View details for DOI 10.1097/QMH.0000000000000105

  View details for PubMedID 27367213

• The Heart of 25 by 25: Achieving the Goal of Reducing Global and Regional Premature Deaths From Cardiovascular Diseases and Stroke A Modeling Study From the American Heart Association and World Heart Federation CIRCULATION Sacco, R. L., Roth, G. A., Reddy, K., Arnett, D. K., Bonita, R., Gaziano, T. A., Heidenreich, P. A., Huffman, M. D., Mayosi, B. M., Mendis, S., Murray, C. L., Perel, P., Pineiro, D. J., Smith, S. C., Taubert, K. A., Wood, D. A., Zhao, D., Zoghbi, W. A. 2016; 133 (23): E674-E690

  Abstract

  In 2011, the United Nations set key targets to reach by 2025 to reduce the risk of premature noncommunicable disease death by 25% by 2025. With cardiovascular disease being the largest contributor to global mortality, accounting for nearly half of the 36 million annual noncommunicable disease deaths, achieving the 2025 goal requires that cardiovascular disease and its risk factors be aggressively addressed. The Global Cardiovascular Disease Taskforce, comprising the World Heart Federation, American Heart Association, American College of Cardiology Foundation, European Heart Network, and European Society of Cardiology, with expanded representation from Asia, Africa, and Latin America, along with global cardiovascular disease experts, disseminates information and approaches to reach the United Nations 2025 targets. The writing committee, which reflects Global Cardiovascular Disease Taskforce membership, engaged the Institute for Health Metrics and Evaluation, University of Washington, to develop region-specific estimates of premature cardiovascular mortality in 2025 based on various scenarios. Results show that >5 million premature CVD deaths among men and 2.8 million among women are projected worldwide by 2025, which can be reduced to 3.5 million and 2.2 million, respectively, if risk factor targets for blood pressure, tobacco use, diabetes mellitus, and obesity are achieved. However, global risk factor targets have various effects, depending on region. For most regions, United Nations targets for reducing systolic blood pressure and tobacco use have more substantial effects on future scenarios compared with maintaining current levels of body mass index and fasting plasma glucose. However, preventing increases in body mass index has the largest effect in some high-income countries. An approach achieving reductions in multiple risk factors has the largest impact for almost all regions. Achieving these goals can be accomplished only if countries set priorities, implement cost-effective population wide strategies, and collaborate in public-private partnerships across multiple sectors.

  View details for DOI 10.1161/CIR.0000000000000395

  View details for Web of Science ID 000377439900001

  View details for PubMedID 27162236

• Precipitating Clinical Factors, Heart Failure Characterization, and Outcomes in Patients Hospitalized With Heart Failure With Reduced, Borderline, and Preserved Ejection Fraction JACC-HEART FAILURE Kapoor, J. R., Kapoor, R., Ju, C., Heidenreich, P. A., Eapen, Z. J., Hernandez, A. F., Butler, J., Yancy, C. W., Fonarow, G. C. 2016; 4 (6): 464-472

  Abstract

  This study assessed the comparative frequency of precipitating clinical factors leading to hospitalization among heart failure (HF) patients with reduced, borderline, and preserved ejection fraction (EF) BACKGROUND: There are few data assessing the comparative frequency of clinical factors leading to HF among hospitalized among patients with reduced, borderline, and preserved EF.We analyzed the factors potentially contributing to HF hospitalization among 99,825 HF admissions from 305 hospitals in the Get With The Guidelines-HF (GWTG-HF) database between January 2005 and September 2013 and assessed their association with length of stay and in-hospital mortality.Mean patient age was 72.6 ± 14.2 years, 49% were female, and mean EF was 39.3 ± 17.2%. Common factors included pneumonia/respiratory process (28.2%), arrhythmia (21.7%), medication noncompliance (15.8%), worsening renal failure (14.7%), and uncontrolled hypertension (14.5%). In patients with borderline EF (EF 40% to 49%), pneumonia was associated with longer hospital stay, whereas dietary and medication noncompliance were associated with reduced length of stay. In patients with preserved EF (EF ≥50% or qualitative assessment of normal or mild dysfunction), pneumonia, weight gain, and worsening renal function were independently associated with longer lengths of stay. Worsening renal function and pneumonia were independently associated with higher in-hospital mortality in all HF groups, and acute pulmonary edema was associated with higher mortality in reduced EF. Dietary noncompliance (14.7%) was associated with reduced mortality for all groups but reached statistical significance in the subgroups of reduced (odds ratio [OR]: 0.65; 95% confidence interval [CI]: 0.46 to 0.91) and preserved systolic function (OR: 0.52; 95% CI: 0.33 to 0.83). Patients presenting with ischemia had a higher mortality rate (OR: 1.31; 95% CI: 1.02 to 1.69; and 1.72; 95% CI: 1.27 to 2.33, respectively, in the 2 groups).Potential precipitating factors among patients hospitalized with HF vary by EF group and are independently associated with clinical outcomes.

  View details for DOI 10.1016/j.jchf.2016.02.017

  View details for Web of Science ID 000377423900008

  View details for PubMedID 27256749

• The Heart of 25 by 25: Achieving the Goal of Reducing Global and Regional Premature Deaths From Cardiovascular Diseases and Stroke A Modeling Study From the American Heart Association and World Heart Federation GLOBAL HEART Sacco, R. L., Roth, G. A., Reddy, K., Arnett, D. K., Bonita, R., Gaziano, T. A., Heidenreich, P. A., Huffman, M. D., Mayosi, B. M., Mendis, S., Murray, C. L., Perel, P., Pineiro, D. J., Smith, S. C., Taubert, K. A., Wood, D. A., Zhao, D., Zoghbi, W. A. 2016; 11 (2): 251-264

  Abstract

  In 2011, the United Nations set key targets to reach by 2025 to reduce the risk of premature noncommunicable disease death by 25% by 2025. With cardiovascular disease being the largest contributor to global mortality, accounting for nearly half of the 36 million annual noncommunicable disease deaths, achieving the 2025 goal requires that cardiovascular disease and its risk factors be aggressively addressed. The Global Cardiovascular Disease Taskforce, comprising the World Heart Federation, American Heart Association, American College of Cardiology Foundation, European Heart Network, and European Society of Cardiology, with expanded representation from Asia, Africa, and Latin America, along with global cardiovascular disease experts, disseminates information and approaches to reach the United Nations 2025 targets. The writing committee, which reflects Global Cardiovascular Disease Taskforce membership, engaged the Institute for Health Metrics and Evaluation, University of Washington, to develop region-specific estimates of premature cardiovascular mortality in 2025 based on various scenarios. Results show that >5 million premature CVD deaths among men and 2.8 million among women are projected worldwide by 2025, which can be reduced to 3.5 million and 2.2 million, respectively, if risk factor targets for blood pressure, tobacco use, diabetes mellitus, and obesity are achieved. However, global risk factor targets have various effects, depending on region. For most regions, United Nations targets for reducing systolic blood pressure and tobacco use have more substantial effects on future scenarios compared with maintaining current levels of body mass index and fasting plasma glucose. However, preventing increases in body mass index has the largest effect in some high-income countries. An approach achieving reductions in multiple risk factors has the largest impact for almost all regions. Achieving these goals can be accomplished only if countries set priorities, implement cost-effective population wide strategies, and collaborate in public-private partnerships across multiple sectors.

  View details for DOI 10.1016/j.gheart.2016.04.002

  View details for Web of Science ID 000383550200015

  View details for PubMedID 27174522

• Response to Letter Regarding Article, "Temporal Trends and Variation in Early Scheduled Follow-up After a Hospitalization for Heart Failure: Findings from Get With The Guidelines-Heart Failure CIRCULATION-HEART FAILURE DeVore, A. D., Cox, M., Eapen, Z. J., Yancy, C. W., Bhatt, D. L., Heidenreich, P. A., Peterson, E. D., Fonarow, G. C., Hernandez, A. F. 2016; 9 (6)

  View details for PubMedID 27296399

• Cost-Effectiveness of Percutaneous Closure of the Left Atrial Appendage in Atrial Fibrillation Based on Results From PROTECT AF Versus PREVAIL CIRCULATION-ARRHYTHMIA AND ELECTROPHYSIOLOGY Freeman, J. V., Hutton, D. W., Barnes, G. D., Zhu, R. P., Owens, D. K., Garber, A. M., Go, A. S., Hlatky, M. A., Heidenreich, P. A., Wang, P. J., Al-Ahmad, A., Turakhia, M. P. 2016; 9 (6)

  View details for DOI 10.1161/CIRCEP.115.003407

  View details for Web of Science ID 000378143300006

• Cost-Effectiveness of Percutaneous Closure of the Left Atrial Appendage in Atrial Fibrillation Based on Results From PROTECT AF Versus PREVAIL CIRCULATION-ARRHYTHMIA AND ELECTROPHYSIOLOGY Freeman, J. V., Hutton, D. W., Barnes, G. D., Zhu, R. P., Owens, D. K., Garber, A. M., Go, A. S., Hlatky, M. A., Heidenreich, P. A., Wang, P. J., Al-Ahmad, A., Turakhia, M. P. 2016; 9 (6)

  Abstract

  Randomized trials of left atrial appendage (LAA) closure with the Watchman device have shown varying results, and its cost effectiveness compared with anticoagulation has not been evaluated using all available contemporary trial data.We used a Markov decision model to estimate lifetime quality-adjusted survival, costs, and cost effectiveness of LAA closure with Watchman, compared directly with warfarin and indirectly with dabigatran, using data from the long-term (mean 3.8 year) follow-up of Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation (PROTECT AF) and Prospective Randomized Evaluation of the Watchman LAA Closure Device in Patients With Atrial Fibrillation (PREVAIL) randomized trials. Using data from PROTECT AF, the incremental cost-effectiveness ratios compared with warfarin and dabigatran were $20 486 and $23 422 per quality-adjusted life year, respectively. Using data from PREVAIL, LAA closure was dominated by warfarin and dabigatran, meaning that it was less effective (8.44, 8.54, and 8.59 quality-adjusted life years, respectively) and more costly. At a willingness-to-pay threshold of $50 000 per quality-adjusted life year, LAA closure was cost effective 90% and 9% of the time under PROTECT AF and PREVAIL assumptions, respectively. These results were sensitive to the rates of ischemic stroke and intracranial hemorrhage for LAA closure and medical anticoagulation.Using data from the PROTECT AF trial, LAA closure with the Watchman device was cost effective; using PREVAIL trial data, Watchman was more costly and less effective than warfarin and dabigatran. PROTECT AF enrolled more patients and has substantially longer follow-up time, allowing greater statistical certainty with the cost-effectiveness results. However, longer-term trial results and postmarketing surveillance of major adverse events will be vital to determining the value of the Watchman in clinical practice.

  View details for DOI 10.1161/CIRCEP.115.003407

  View details for PubMedID 27307517

• Trends in 30-Day Readmission Rates for Patients Hospitalized With Heart Failure Findings From the Get With The Guidelines-Heart Failure Registry CIRCULATION-HEART FAILURE Bergethon, K. E., Ju, C., DeVore, A. D., Hardy, N. C., Fonarow, G. C., Yancy, C. W., Heidenreich, P. A., Bhatt, D. L., Peterson, E. D., Hernandez, A. F. 2016; 9 (6)

  Abstract

  Reducing hospital readmissions for patients with heart failure is a national priority, and quality improvement campaigns are targeting reductions of ≥20%. However, there are limited data on whether such targets have been met.We analyzed data from the American Heart Association's Get With The Guidelines-Heart Failure registry linked to Medicare claims between 2009 and 2012 to describe trends and relative reduction of rates of 30-day all-cause readmission among patients with heart failure. A total of 21,264 patients with heart failure were included from 70 US sites from January 2009 to October 2012. Overall hospital-level, risk-adjusted, 30-day all-cause readmission rates declined slightly, from 20.0% (SD, 1.3%) in 2009 to 19.0% (SD, 1.2%) in 2012 (P=0.001). Only 1 in 70 (1.4%) hospitals achieved the 20% relative reduction in 30-day risk-adjusted readmission rates. A multivariable linear regression model was used to determine hospital-level factors associated with relative improvements in 30-day risk-adjusted readmissions between 2009 and 2012. Teaching hospitals had higher relative readmission rates as compared with their peers, and hospitals that used postdischarge heart failure disease management programs had lower relative readmission rates.Although there has been slight improvement in 30-day all-cause readmission rates during the past 4 years in patients with heart failure, few hospitals have seen large success.

  View details for DOI 10.1161/CIRCHEARTFAILURE.115.002594

  View details for Web of Science ID 000378139000003

  View details for PubMedID 27301467

  View details for PubMedCentralID PMC4928632

• Comparison of performance on Hospital Compare process measures and patient outcomes between hospitals that do and do not participate in Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines AMERICAN HEART JOURNAL Mathews, R., Fonarow, G. C., Li, S., Peterson, E. D., Rumsfeld, J. S., Heidenreich, P. A., Roe, M. T., Oetgen, W. J., Jollis, J. G., Cannon, C. P., de Lemos, J. A., Wang, T. Y. 2016; 175: 1-8

  Abstract

  Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines (ACTION Registry-GWTG) was designed to measure and improve the treatment and outcomes of patients with acute myocardial infarction (AMI), yet it is unknown whether performance of Medicare Hospital Compare metrics and outcomes differ between hospitals participating versus those not participating in the registry.Using 2007 to 2010 Hospital Compare data, we matched participating to nonparticipating hospitals based on teaching status, size, percutaneous coronary intervention capability, and baseline (2007) Hospital Compare AMI process measure performance. We used linear mixed modeling to compare 2010 Hospital Compare process measure adherence, 30-day risk-adjusted mortality, and readmission rates. We repeated these analyses after stratification according to baseline performance level.Compared with nonparticipating hospitals, those participating were larger (median 288 vs 139 beds, P < .0001), more often teaching hospitals (18.8% vs 6.3%, P < .0001), and more likely had interventional catheterization lab capabilities (85.7% vs 34.0%, P < .0001). Among 502 matched pairs of participating and nonparticipating hospitals, we found high levels of process measure adherence in both 2007 and 2010, with minimal differences between them. Rates of 30-day mortality and readmission in 2010 were also similar between both groups. Results were consistent across strata of baseline performance level.In this observational analysis, there were no significant differences in the performance of Hospital Compare process measures or outcomes between hospitals in Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines and other hospitals not in the registry. However, baseline performance on the Hospital Compare process measures was very high in both groups, suggesting the need for new quality improvement foci to further improve patient outcomes.

  View details for DOI 10.1016/j.ahj.2016.01.008

  View details for PubMedID 27179718

• Barriers and Facilitators to Scaling Up Outpatient Palliative Care JOURNAL OF PALLIATIVE MEDICINE Bekelman, D. B., Rabin, B. A., Nowels, C. T., Sahay, A., Heidenreich, P. A., Fischer, S. M., Main, D. S. 2016; 19 (4): 456-459

  Abstract

  The Institute of Medicine recommends people with serious advanced illness have access to skilled palliative care. However, the predominant delivery model of nonhospice palliative care is inpatient, consultative care focused on the end of life, with a small specialist palliative care workforce.The study objective was to understand organizational factors that could influence the adoption and scale-up of outpatient palliative care in chronic advanced illness, using the example of heart failure.This was a cross-sectional qualitative study. Participants were 17 health care providers and local, regional, and national health system leaders from the Veterans Health Administration (VHA) who were considering whether and how to adopt and sustain outpatient palliative care. Individual interviews using semistructured questions assessed domains of the Consolidated Framework for Implementation Science.Most providers and leaders perceived outpatient palliative care as high priority in the VHA given its patient-centeredness and potential to decrease health care use and costs associated with conditions like heart failure. They also supported a collaborative care team model of outpatient palliative care delivery where a palliative care specialist collaborates with medical nurses and social workers. They reported lack of performance measures/incentives for patient-centered care processes and outcomes as a potential barrier to implementation. Features of outpatient palliative care viewed as important for successful adoption and scale-up included coordination and communication with other providers, ease of integration into existing programs, and evidence of improving quality of care while not substantially increasing overall health care costs.Incentives such as performance measures and collaboration with local VHA providers and leaders could improve adoption and scale-up of outpatient palliative care.

  View details for DOI 10.1089/jpm.2015.0280

  View details for Web of Science ID 000373237500020

• Dual health care system use is associated with higher rates of hospitalization and hospital readmission among veterans with heart failure AMERICAN HEART JOURNAL Axon, R., Gebregziabher, M., Everett, C. J., Heidenreich, P., Hunt, K. J. 2016; 174: 157–63

  Abstract

  Heart failure (HF) frequently causes hospital admission and readmission. Patients receiving care from multiple providers and facilities (dual users) may risk higher health care utilization and worse health outcomes.To determine rates of emergency department (ED) visits, hospitalizations, and hospital readmissions relative to dual use among HF patients, we analyzed a retrospective cohort of 13,977 veterans with HF hospitalized at the Veterans Affairs (VA) or non-VA facilities from 2007 to 2011; we analyzed rates of acute health care utilization using zero-inflated negative binomial regression.Compared to VA-only users and dual users, individuals receiving all of their ED and hospital care outside the VA tended to be older, more likely to be non-Hispanic white and married, and less likely to have high levels of service connected disability. Compared to VA-only users, dual users had significantly higher rates of ED visits for HF as a primary diagnosis (adjusted rate ratio 1.15, 95% CI 1.04-1.27), hospitalization for HF (adjusted rate ratio 1.4, 95% CI 1.26-1.56), hospital readmission after HF hospitalization (all cause) (1.46, 95% CI 1.30-1.65), and HF-specific hospital readmission after HF hospitalization (1.46, 95% CI 1.31-1.63). With the exception of hospitalization for any primary diagnosis, non-VA-only users had significantly lower rates of ED visits, hospitalization, and readmission compared to VA-only users.Dual use is associated with higher rates of health care utilization among patients with HF. Interventions should be devised to encourage continuity of care where possible and to improve the effectiveness and safety of dual use in instances where it is necessary or desired.

  View details for PubMedID 26995383

• Differences and Trends in DNR Among California Inpatients With Heart Failure. Journal of cardiac failure Phadke, A., Heidenreich, P. A. 2016; 22 (4): 312-315

  Abstract

  Do-not-resuscitate (DNR) orders reflect an important means of respecting patient autonomy while minimizing the risk of nonbeneficial interventions. We sought to clarify trends and differences in rates of DNR orders for patients hospitalized with heart failure.We used statewide data from California's Healthcare Cost and Utilization dataset (2007-2010) to determine trends in DNR orders within 24 hours of admission for patients with a primary discharge diagnosis of heart failure.Among 347,541 hospitalizations for heart failure, the rate of DNR order within 24 hours increased from 10.4% in 2007 to 11.3% in 2010 (P < .0001). After adjustment, DNR status correlated with older age, female gender, white race, frequent comorbidities (Charlson Score), and residence in higher income area (P < .0001). DNR use was more likely in hospitals with public or nonprofit financing or medical school affiliation, but not being a member of the Council on Teaching Hospitals (all P < .001).DNR order use among inpatients with heart failure is low but increasing slowly and varies by patient demographics and hospital characteristics.

  View details for DOI 10.1016/j.cardfail.2015.12.005

  View details for PubMedID 26700659

• Barriers and Facilitators to Scaling Up Outpatient Palliative Care. Journal of palliative medicine Bekelman, D. B., Rabin, B. A., Nowels, C. T., Sahay, A., Heidenreich, P. A., Fischer, S. M., Main, D. S. 2016; 19 (4): 456-459

  Abstract

  The Institute of Medicine recommends people with serious advanced illness have access to skilled palliative care. However, the predominant delivery model of nonhospice palliative care is inpatient, consultative care focused on the end of life, with a small specialist palliative care workforce.The study objective was to understand organizational factors that could influence the adoption and scale-up of outpatient palliative care in chronic advanced illness, using the example of heart failure.This was a cross-sectional qualitative study. Participants were 17 health care providers and local, regional, and national health system leaders from the Veterans Health Administration (VHA) who were considering whether and how to adopt and sustain outpatient palliative care. Individual interviews using semistructured questions assessed domains of the Consolidated Framework for Implementation Science.Most providers and leaders perceived outpatient palliative care as high priority in the VHA given its patient-centeredness and potential to decrease health care use and costs associated with conditions like heart failure. They also supported a collaborative care team model of outpatient palliative care delivery where a palliative care specialist collaborates with medical nurses and social workers. They reported lack of performance measures/incentives for patient-centered care processes and outcomes as a potential barrier to implementation. Features of outpatient palliative care viewed as important for successful adoption and scale-up included coordination and communication with other providers, ease of integration into existing programs, and evidence of improving quality of care while not substantially increasing overall health care costs.Incentives such as performance measures and collaboration with local VHA providers and leaders could improve adoption and scale-up of outpatient palliative care.

  View details for DOI 10.1089/jpm.2015.0280

  View details for PubMedID 26974489

• Organizational Structure for Chronic Heart Failure and Chronic Obstructive Pulmonary Disease AMERICAN JOURNAL OF MANAGED CARE Rinne, S. T., Liu, C., Wong, E. S., Hebert, P. L., Heidenreich, P., Bastian, L. A., Au, D. H. 2016; 22 (3): E82-?

  Abstract

  In contrast to chronic heart failure (CHF), measures of quality of care for chronic obstructive pulmonary disease (COPD) are poor. Our objective was to examine differences in organizational structure available to support quality of care for patients with CHF and COPD.We performed 2 nationwide surveys exploring organizational structure for the management of CHF and COPD. We surveyed the chief of medicine and the chief of cardiology and pulmonary medicine at 120 Veterans Affairs facilities in the United States.Analogous questions about organizational structure that enhanced adherence to guideline-based care were compared between CHF and COPD surveys.We found large and notable differences in the organizational structure for disease management, with systematically less attention given to COPD than CHF. These differences were evident in multiple processes of care. Key differences included fewer facilities: having COPD clinics than CHF clinics (12.7% vs 50.8%; P < .01), relating performance measures with COPD providers than CHF providers (17.1% vs 70%; P < .01), and having home monitoring programs for COPD than for CHF (50.5% vs 87.4%; P < .01).Despite the growing burden of COPD, less organizational structure existed for COPD than CHF. Lack of organizational structure for COPD likely impedes an organization's abilities to encourage high-quality care and avoid recently implemented hospital readmission penalties. Our results suggest the need to develop a systematic approach for healthcare systems to provide essential organizational structure based on the burden of disease in the population.

  View details for Web of Science ID 000373573700001

  View details for PubMedID 26978239

• Heart Failure Patients Need More Than Heart Failure Care JACC-HEART FAILURE Heidenreich, P. 2016; 4 (3): 194–96

  View details for DOI 10.1016/j.jchf.2016.01.006

  View details for Web of Science ID 000371651600004

  View details for PubMedID 26940627

• Barriers to Adoption of Mineralocorticoid Receptor Antagonists in Patients With Heart Failure: A Mixed-Methods Study JOURNAL OF THE AMERICAN HEART ASSOCIATION Dev, S., Hoffman, T. K., Kavalieratos, D., Heidenreich, P., Wu, W., Schwenke, D. C., Tracy, S. J. 2016; 5 (3)

  Abstract

  Mineralocorticoid receptor antagonists (MRAs) are the most underutilized pharmacotherapy for heart failure. Minimal data are available on the barriers to MRA adoption from the perspective of prescribing clinicians.A mixed-methods study consisting of a survey (n=50), focus groups (n=39), interviews (n=6) with clinicians at a single US Department of Veterans Affairs medical center served to ascertain barriers to optimal use of MRAs. Participants were drawn from 6 groups: cardiology providers, cardiology fellows, hospitalists, clinical pharmacists, internal medicine residents, and primary care providers. Qualitative data were iteratively coded with qualitative data analysis software. The survey response rate was 17.3%. Overall, 51% of survey respondents were unfamiliar with eplerenone, and 6% were unfamiliar with spironolactone. In addition, 30% of respondents reported that they would order a laboratory test >2 weeks after a new MRA prescription, although that is beyond the guideline recommendation. Most providers correctly identified New York Heart Association class 3 and 4 patients as MRA eligible, but only 42% identified class 2 patients as MRA eligible. Through analysis of focus groups, we identified 8 barriers to MRA use in 3 categories: patient-based barriers (concerns about polypharmacy and comorbidities, adverse effects, perceived patient nonadherence), provider-based barriers (unclear roles and responsibilities, coordination and transitions of care, lack of experience or familiarity with MRAs), and system-based barriers (system overload and provider time constraints, lack of systematic follow-up procedures).Eight primary barriers to MRA adoption at the provider, patient, and health system levels were identified from the prescriber perspective. These barriers can inform the creation of multilevel interventions that will be required to close the gap in MRA adoption.

  View details for DOI 10.1161/JAHA.115.002493

  View details for Web of Science ID 000385312200007

  View details for PubMedID 27032719

  View details for PubMedCentralID PMC4943238

• Clinical Effectiveness of Hydralazine-Isosorbide Dinitrate Therapy in Patients With Heart Failure and Reduced Ejection Fraction: Findings From the Get With The Guidelines-Heart Failure Registry CIRCULATION-HEART FAILURE Khazanie, P., Liang, L., Curtis, L. H., Butler, J., Eapen, Z. J., Heidenreich, P. A., Bhatt, D. L., Peterson, E. D., Yancy, C. W., Fonarow, G. C., Hernandez, A. F. 2016; 9 (2): 1-9

  Abstract

  In clinical trials, hydralazine-isosorbide dinitrate (H-ISDN) for heart failure with reduced ejection fraction reduced morbidity and mortality among black patients and patients with intolerance to angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers. The effectiveness of H-ISDN in clinical practice is unknown.Using data from a clinical registry linked with Medicare claims, we examined the use and outcomes of H-ISDN between 2005 and 2011 among older patients hospitalized with heart failure and reduced ejection fraction. We adjusted for demographic and clinical characteristics using Cox proportional hazards models and inverse probability weighting. Among 4663 eligible patients, 22.7% of black patients and 18.2% of patients not on an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker were newly prescribed H-ISDN therapy at discharge. By 3 years, the cumulative incidence rates of mortality and readmission were similar between treated and untreated patients. After multivariable adjustment, 3-year outcomes remained similar for mortality [black patients: hazard ratio (HR), 0.92; 95% confidence interval (CI), 0.75-1.13; other patients: HR, 0.93; 95% CI, 0.79-1.09], all-cause readmission (black patients: HR, 0.98; 95% CI, 0.84-1.13; other patients: HR, 1.02; 95% CI, 0.90-1.17), and cardiovascular readmission (black patients: HR, 0.99; 95% CI, 0.82-1.19; other patients: HR, 0.94; 95% CI, 0.81-1.09). A post hoc analysis of Medicare Part D data revealed low postdischarge adherence to therapy.Guideline-recommended initiation of H-ISDN therapy at hospital discharge was uncommon, and adherence was low. For both black patients and patients of other races, there were no differences in outcomes between those treated and untreated at discharge.

  View details for DOI 10.1161/CIRCHEARTFAILURE.115.002444

  View details for Web of Science ID 000370369300001

  View details for PubMedID 26867758

  View details for PubMedCentralID PMC4755330

• Racial Differences in Quality of Anticoagulation Therapy for Atrial Fibrillation (from the TREAT-AF Study) AMERICAN JOURNAL OF CARDIOLOGY Yong, C., Azarbal, F., Abnousi, F., Heidenreich, P. A., Schmitt, S., Fan, J., Than, C. T., Ullal, A. J., Yang, F., Phibbs, C. S., Frayne, S. M., Ho, P. M., Shore, S., Mahaffey, K. W., Turakhia, M. P. 2016; 117 (1): 61-68

  Abstract

  The influence of race on quality of anticoagulation control is not well described. We examined the association between race, international normalized ratio (INR) monitoring intensity, and INR control in warfarin-treated patients with atrial fibrillation (AF). Using data from the Veterans Health Administration (VHA), we performed a retrospective cohort study of 184,161 patients with a new diagnosis of AF/flutter from 2004 to 2012 who received any VHA prescription within 90 days of diagnosis. The primary predictor was race, ascertained from multiple VHA and linked Medicare demographic files. The primary outcome was first-year and long-term time in therapeutic range (TTR) of INR 2.0 to 3.0. Secondary outcomes were INR monitoring intensity and warfarin persistence. Of the 116,021 patients who received warfarin in the cohort, INR monitoring intensity was similar across racial groups. However, TTR was lowest in blacks and highest in whites (first year 0.49 ± 0.23 vs 0.57 ± 0.21, p <0.001; long term 0.52 ± 0.20 vs 0.59 ± 0.18, p <0.001); 64% of whites and 49% of blacks had long-term TTR >55% (p <0.001). After adjusting for site and patient-level covariates, black race was associated with lower first-year and long-term TTRs (4.2% and 4.1% below the conditional mean, relative to whites; p <0.0001 for both). One-year warfarin persistence was slightly lower in blacks compared to whites (58% vs 60%, p <0.0001). In conclusion, in patients with AF anticoagulated with warfarin, differences in INR control are most evident among blacks, underscoring the need to determine if other types of intensive management or warfarin alternatives may be necessary to improve anticoagulation among vulnerable AF populations.

  View details for DOI 10.1016/j.amjcard.2015.09.047

  View details for Web of Science ID 000368048900010

• Racial Differences in Quality of Anticoagulation Therapy for Atrial Fibrillation (from the TREAT-AF Study). The American journal of cardiology Yong, C., Azarbal, F., Abnousi, F., Heidenreich, P. A., Schmitt, S., Fan, J., Than, C. T., Ullal, A. J., Yang, F., Phibbs, C. S., Frayne, S. M., Ho, P. M., Shore, S., Mahaffey, K. W., Turakhia, M. P. 2016; 117 (1): 61-8

  Abstract

  The influence of race on quality of anticoagulation control is not well described. We examined the association between race, international normalized ratio (INR) monitoring intensity, and INR control in warfarin-treated patients with atrial fibrillation (AF). Using data from the Veterans Health Administration (VHA), we performed a retrospective cohort study of 184,161 patients with a new diagnosis of AF/flutter from 2004 to 2012 who received any VHA prescription within 90 days of diagnosis. The primary predictor was race, ascertained from multiple VHA and linked Medicare demographic files. The primary outcome was first-year and long-term time in therapeutic range (TTR) of INR 2.0 to 3.0. Secondary outcomes were INR monitoring intensity and warfarin persistence. Of the 116,021 patients who received warfarin in the cohort, INR monitoring intensity was similar across racial groups. However, TTR was lowest in blacks and highest in whites (first year 0.49 ± 0.23 vs 0.57 ± 0.21, p <0.001; long term 0.52 ± 0.20 vs 0.59 ± 0.18, p <0.001); 64% of whites and 49% of blacks had long-term TTR >55% (p <0.001). After adjusting for site and patient-level covariates, black race was associated with lower first-year and long-term TTRs (4.2% and 4.1% below the conditional mean, relative to whites; p <0.0001 for both). One-year warfarin persistence was slightly lower in blacks compared to whites (58% vs 60%, p <0.0001). In conclusion, in patients with AF anticoagulated with warfarin, differences in INR control are most evident among blacks, underscoring the need to determine if other types of intensive management or warfarin alternatives may be necessary to improve anticoagulation among vulnerable AF populations.

  View details for DOI 10.1016/j.amjcard.2015.09.047

  View details for PubMedID 26552504

• Temporal Trends and Variation in Early Scheduled Follow-Up After a Hospitalization for Heart Failure: Findings from Get With The Guidelines-Heart Failure. Circulation. Heart failure DeVore, A. D., Cox, M., Eapen, Z. J., Yancy, C. W., Bhatt, D. L., Heidenreich, P. A., Peterson, E. D., Fonarow, G. C., Hernandez, A. F. 2016; 9 (1)

  Abstract

  Previous data demonstrate early follow-up (ie, within 7 days of discharge) after a hospitalization for heart failure is associated with a lower risk of readmission, yet is uncommon and varies widely across hospitals. Limited data exist on whether the use of early follow-up after discharge has improved over time.We used data from Get With The Guidelines-Heart Failure (GWTG-HF) linked to Medicare claims to examine temporal trends in early follow-up and to assess for patient and hospital characteristics associated with early scheduled follow-up. In the overall GWTG-HF cohort, we studied 52,438 patients discharged from 239 hospitals from 2009 to 2012. Scheduled early follow-up at the time of hospital discharge rose from 51% to 65% over time (P<0.001). After multivariable adjustment, patients with older age (odds ratio, 1.04; 95% confidence interval, 1.01-1.07), certain comorbidities (anemia, diabetes mellitus, and chronic kidney disease), and the use of anticoagulation at discharge (odds ratio, 1.16; 95% confidence interval, 1.11-1.22) were associated with greater likelihood for early scheduled follow-up. Patients treated in hospitals located in the Midwest (odds ratio, 0.67; 95% confidence interval, 0.50-0.91) were less likely to have early scheduled follow-up. In a subset of patients with linked Medicare claims, we observed smaller improvements in actual early follow-up visits over time from 26% to 30% (P=0.005).From 2009 to 2012, there was improvement in early scheduled outpatient follow-up and, in the subset analyzed, improvement in actual early follow-up visits for hospitalized patients with heart failure. However, substantial opportunities remain for improving heart failure transitional care.

  View details for DOI 10.1161/CIRCHEARTFAILURE.115.002344

  View details for PubMedID 26754624

• Should We Start Community Screening for Left Ventricular Dysfunction? JOURNAL OF CARDIAC FAILURE Heidenreich, P. A. 2016; 22 (1): 24–25

  View details for PubMedID 26592982

• Gender Differences in Clinical Outcomes After Catheter Ablation of Atrial Fibrillation JACC Clin Electrophysiol Kaiser, D. W., Fan, J., Schmitt, S., Than, C. T., Ullal, A. J., Piccini, J. P., Heidenreich, P. A., Turakhia, M. P. 2016

  View details for DOI 10.1016/j.jacep.2016.04.014

• Automating Guidelines for Clinical Decision Support: Knowledge Engineering and Implementation. AMIA ... Annual Symposium proceedings. AMIA Symposium Tso, G. J., Tu, S. W., Oshiro, C., Martins, S., Ashcraft, M., Yuen, K. W., Wang, D., Robinson, A., Heidenreich, P. A., Goldstein, M. K. 2016; 2016: 1189-1198

  Abstract

  As utilization of clinical decision support (CDS) increases, it is important to continue the development and refinement of methods to accurately translate the intention of clinical practice guidelines (CPG) into a computable form. In this study, we validate and extend the 13 steps that Shiffman et al.(5) identified for translating CPG knowledge for use in CDS. During an implementation project of ATHENA-CDS, we encoded complex CPG recommendations for five common chronic conditions for integration into an existing clinical dashboard. Major decisions made during the implementation process were recorded and categorized according to the 13 steps. During the implementation period, we categorized 119 decisions and identified 8 new categories required to complete the project. We provide details on an updated model that outlines all of the steps used to translate CPG knowledge into a CDS integrated with existing health information technology.

  View details for PubMedID 28269916

• Automating Performance Measures and Clinical Practice Guidelines: Differences and Complementarities. AMIA ... Annual Symposium proceedings. AMIA Symposium Tu, S. W., Martins, S., Oshiro, C., Yuen, K., Wang, D., Robinson, A., Ashcraft, M., Heidenreich, P. A., Goldstein, M. K. 2016; 2016: 1199-1208

  Abstract

  Through close analysis of two pairs of systems that implement the automated evaluation of performance measures (PMs) and guideline-based clinical decision support (CDS), we contrast differences in their knowledge encoding and necessary changes to a CDS system that provides management recommendations for patients failing performance measures. We trace the sources of differences to the implementation environments and goals of PMs and CDS.

  View details for PubMedID 28269917

• A Couples' Based Self-Management Program for Heart Failure: Results of a Feasibility Study. Frontiers in public health Trivedi, R., Slightam, C., Fan, V. S., Rosland, A., Nelson, K., Timko, C., Asch, S. M., Zeliadt, S. B., Heidenreich, P., Hebert, P. L., Piette, J. D. 2016; 4: 171-?

  Abstract

  Heart failure (HF) is associated with frequent exacerbations and shortened lifespan. Informal caregivers such as significant others often support self-management in patients with HF. However, existing programs that aim to enhance self-management seldom engage informal caregivers or provide tools that can help alleviate caregiver burden or improve collaboration between patients and their informal caregivers.To develop and pilot test a program targeting the needs of self-management support among HF patients as well as their significant others.We developed the Dyadic Health Behavior Change model and conducted semi-structured interviews to determine barriers to self-management from various perspectives. Participants' feedback was used to develop a family-centered self-management program called "SUCCEED: Self-management Using Couples' Coping EnhancEment in Diseases." The goals of this program are to improve HF self-management, quality of life, communication within couples, relationship quality, and stress and caregiver burden. We conducted a pilot study with 17 Veterans with HF and their significant others to determine acceptability of the program. We piloted psychosocial surveys at baseline and after participants' program completion to evaluate change in depressive symptoms, caregiver burden, self-management of HF, communication, quality of relationship, relationship mutuality, and quality of life.Of the 17 couples, 14 completed at least 1 SUCCEED session. Results showed high acceptability for each of SUCCEED's sessions. At baseline, patients reported poor quality of life, clinically significant depressive symptoms, and inadequate self-management of HF. After participating in SUCCEED, patients showed improvements in self-management of HF, communication, and relationship quality, while caregivers reported improvements in depressive symptoms and caregiver burden. Quality of life of both patients and significant others declined over time.In this small pilot study, we showed positive trends with involving significant others in self-management. SUCCEED has the potential of addressing the growing public health problem of HF among patients who receive care from their significant other.

  View details for DOI 10.3389/fpubh.2016.00171

  View details for PubMedID 27626029

  View details for PubMedCentralID PMC5004799

• Test Case Selection in Pre-Deployment Testing of Complex Clinical Decision Support Systems. AMIA Joint Summits on Translational Science proceedings. AMIA Joint Summits on Translational Science Tso, G. J., Yuen, K., Martins, S., Tu, S. W., Ashcraft, M., Heidenreich, P., Hoffman, B. B., Goldstein, M. K. 2016; 2016: 240-249

  Abstract

  Clinical decision support (CDS) systems with complex logic are being developed. Ensuring the quality of CDS is imperative, but there is no consensus on testing standards. We tested ATHENA-HTN CDS after encoding updated hypertension guidelines into the system. A logic flow and a complexity analysis of the encoding were performed to guide testing. 100 test cases were selected to test the major pathways in the CDS logic flow, and the effectiveness of the testing was analyzed. The encoding contained 26 decision points and 3120 possible output combinations. The 100 cases selected tested all of the major pathways in the logic, but only 1% of the possible output combinations. Test case selection is one of the most challenging aspects in CDS testing and has a major impact on testing coverage. A test selection strategy should take into account the complexity of the system, identification of major logic pathways, and available resources.

  View details for PubMedID 27570678

• A systematic comparison of sugar content in low-fat vs regular versions of food. Nutrition & diabetes Nguyen, P. K., Lin, S., Heidenreich, P. 2016; 6

  Abstract

  Obesity remains a significant public health concern. One of the primary messages from providers and health-care organizations is to eat healthier foods with lower fat. Many in the lay press, however, have suggested that lower fat versions of foods contain more sugar. To our knowledge, a systematic comparison of the sugar content in food with lower fat alternatives has not been performed. In this study, we compared fat free, low fat and regular versions of the same foods using data collected from the USDA National Nutrient Database. We found that the amount of sugar is higher in the low fat (that is, reduced calorie, light, low fat) and non-fat than 'regular' versions of tested items (Friedman P=0.00001, Wilcoxon P=0.0002 for low fat vs regular food and P=0.0003 for non-fat vs regular food). Our data support the general belief that food that is lower in fat may contain more sugar.

  View details for DOI 10.1038/nutd.2015.43

  View details for PubMedID 26807511

  View details for PubMedCentralID PMC4742721

• 2015 ACC/AHA Focused Update of Secondary Prevention Lipid Performance Measures A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES Drozda, J. P., Ferguson, T. B., Jneid, H., Krumholz, H. M., Nallamothu, B. K., Olin, J. W., Ting, H. H., Heidenreich, P. A., Albert, N. M., Chan, P. S., Curtis, L. H., Ferguson, T. B., Fonarow, G. C., Ho, P. M., O'Brien, S., Russo, A. M., Thomas, R. J., Ting, H. H., Varosy, P. D. 2016; 9 (1): 68-95

  View details for DOI 10.1161/HCQ.0000000000000014

  View details for Web of Science ID 000368611000011

• Association of Arterial Pulse Pressure With Long-Term Clinical Outcomes in Patients With Heart Failure JACC-HEART FAILURE Laskey, W. K., Wu, J., Schulte, P. J., Hernandez, A. F., Yancy, C. W., Heidenreich, P. A., Bhatt, D. L., Fonarow, G. C. 2016; 4 (1): 42-49

  Abstract

  This study assessed the association between pulse pressure (PP) and adverse outcomes at 1 year in patients hospitalized for heart failure (HF).PP has been shown to be predictive of the development of HF. The value and utility of PP assessment in patients with prevalent HF is less clear.We conducted a retrospective cohort study from clinical registry data linked to Medicare claims for 40,421 HF patients entered in the Get With the Guidelines-HF program. Cox proportional hazards models were used to estimate the association between discharge PP and all-cause mortality and the composite outcome of all-cause mortality/readmission by 1 year.A nonlinear association between PP and mortality (expressed as hazard ratio [HR] per 10-mm Hg increase in PP) was observed in patients with HF and reduced (<0.40) ejection fraction (EF). Risk decreased as PP increased up to 50 mm Hg (adjusted HR: 0.946; 95% confidence interval [CI]: 0.900 to 0.995; p = 0.03). When PP was ≥50 mm Hg, risk increased as PP increased (adjusted HR: 1.091; 95% CI: 1.050 to 1.135; p < 0.001). In patients with HF and preserved EF (≥0.40), there was a significant association between PP and mortality with risk increasing as PP increased, although the magnitude of the risk was significantly impacted by systolic blood pressure (SBP). Qualitatively similar observations were obtained for the composite outcome and use of EF ≥0.50 to define HF with preserved EF.The association between PP at hospital discharge and 1-year outcomes is a function of HF phenotype, SBP, and absolute PP.

  View details for DOI 10.1016/j.jchf.2015.09.012

  View details for Web of Science ID 000367766400008

• Temporal Trends and Variation in Early Scheduled Follow-Up After a Hospitalization for Heart Failure Findings from Get With The Guidelines-Heart Failure CIRCULATION-HEART FAILURE DeVore, A. D., Cox, M., Eapen, Z. J., Yancy, C. W., Bhatt, D. L., Heidenreich, P. A., Peterson, E. D., Fonarow, G. C., Hernandez, A. F. 2016; 9 (1)

  Abstract

  Previous data demonstrate early follow-up (ie, within 7 days of discharge) after a hospitalization for heart failure is associated with a lower risk of readmission, yet is uncommon and varies widely across hospitals. Limited data exist on whether the use of early follow-up after discharge has improved over time.We used data from Get With The Guidelines-Heart Failure (GWTG-HF) linked to Medicare claims to examine temporal trends in early follow-up and to assess for patient and hospital characteristics associated with early scheduled follow-up. In the overall GWTG-HF cohort, we studied 52,438 patients discharged from 239 hospitals from 2009 to 2012. Scheduled early follow-up at the time of hospital discharge rose from 51% to 65% over time (P<0.001). After multivariable adjustment, patients with older age (odds ratio, 1.04; 95% confidence interval, 1.01-1.07), certain comorbidities (anemia, diabetes mellitus, and chronic kidney disease), and the use of anticoagulation at discharge (odds ratio, 1.16; 95% confidence interval, 1.11-1.22) were associated with greater likelihood for early scheduled follow-up. Patients treated in hospitals located in the Midwest (odds ratio, 0.67; 95% confidence interval, 0.50-0.91) were less likely to have early scheduled follow-up. In a subset of patients with linked Medicare claims, we observed smaller improvements in actual early follow-up visits over time from 26% to 30% (P=0.005).From 2009 to 2012, there was improvement in early scheduled outpatient follow-up and, in the subset analyzed, improvement in actual early follow-up visits for hospitalized patients with heart failure. However, substantial opportunities remain for improving heart failure transitional care.

  View details for DOI 10.1161/CIRCHEARTFAILURE.115.002344

  View details for Web of Science ID 000368618600001

• ACC/AHA/STS Statement on the Future of Registries and the Performance Measurement Enterprise A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and The Society of Thoracic Surgeons CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES Bhatt, D. L., Drozda, J. P., Shahian, D. M., Chan, P. S., Fonarow, G. C., Heidenreich, P. A., Jacobs, J. P., Masoudi, F. A., Peterson, E. D., Welke, K. F., Heidenreich, P. A., Albert, N. M., Chan, P. S., Curtis, L. H., Ferguson, T. B., Fonarow, G. C., Ho, P. M., Jurgens, C., O'Brien, S., Russo, A. M., Thomas, R. J., Ting, H. H., Varosy, P. D. 2015; 8 (6): 634-648

  View details for DOI 10.1161/HCQ.0000000000000013

  View details for Web of Science ID 000364791200015

• ACC/AHA/STS Statement on the Future of Registries and the Performance Measurement Enterprise JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Bhatt, D. L., Drozda, J. P., Shahian, D. M., Chan, P. S., Fonarow, G. C., Heidenreich, P. A., Jacobs, J. P., Masoudi, F. A., Peterson, E. D., Welke, K. F. 2015; 66 (20): 2230-2245

  View details for DOI 10.1016/j.jacc.2015.07.010

  View details for Web of Science ID 000364434700011

• ACC/AHA/STS Statement on the Future of Registries and the Performance Measurement Enterprise: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and The Society of Thoracic Surgeons. Journal of the American College of Cardiology Bhatt, D. L., Drozda, J. P., Shahian, D. M., Chan, P. S., Fonarow, G. C., Heidenreich, P. A., Jacobs, J. P., Masoudi, F. A., Peterson, E. D., Welke, K. F. 2015; 66 (20): 2230-2245

  View details for DOI 10.1016/j.jacc.2015.07.010

  View details for PubMedID 26440214

• The Potential Impact of Expanding Cardiac Rehabilitation Coverage in Heart Failure: Insights From Get With the Guidelines Heart Failure Kelly, J. P., Hammill, B. G., Doll, J. A., Felker, G., Heidenreich, P. A., Yancy, C. W., Bhatt, D. L., Fonarow, G. C., Hernandez, A. F. LIPPINCOTT WILLIAMS & WILKINS. 2015

  View details for Web of Science ID 000209846302006

• Cost-effectiveness of the CardioMems Implantable Pulmonary Artery Pressure Monitoring System in Patients With Chronic Heart Failure Sandhu, A. T., Goldhaber-Fiebert, J. D., Turakhia, M. P., Kaiser, D. W., Heidenreich, P. A. LIPPINCOTT WILLIAMS & WILKINS. 2015

  View details for Web of Science ID 000381010601026

• Cost-effectiveness of Percutaneous Closure of the Left Atrial Appendage in Atrial Fibrillation Based on Results From PROTECT AF vs. PREVAIL Freeman, J. V., Hutton, D. W., Barnes, G. D., Zhu, R. P., Owens, D. K., Garber, A. M., Go, A. S., Hlatky, M. A., Heidenreich, P. A., Wang, P. J., Al-Ahmad, A., Turakhia, M. P. LIPPINCOTT WILLIAMS & WILKINS. 2015

  View details for Web of Science ID 000209846300014

• Characteristics, Treatments, and Outcomes of Hospitalized Heart Failure Patients Stratified by Etiologies of Cardiomyopathy JACC-HEART FAILURE Shore, S., Grau-Sepulveda, M. V., Bhatt, D. L., Heidenreich, P. A., Eapen, Z. J., Hernandez, A. F., Yancy, C. W., Fonarow, G. C. 2015; 3 (11): 906-916

  Abstract

  The authors sought to describe characteristics, treatments, and in-hospital outcomes of hospitalized heart failure (HF) patients stratified by etiology.Whether characteristics and outcomes of HF patients differ by cardiomyopathy etiology is unknown.The authors analyzed data on 156,013 hospitalized HF patients from 319 U.S. hospitals participating in Get With The Guidelines-HF between 2005 and 2013. Characteristics, treatments, and in-hospital outcomes were assessed by HF etiology. Standard regression techniques adjusted for site and patient-level characteristics were used to examine association between HF etiology and in-hospital outcomes.Median age was 75 years, 69.2% were white, and 49.5% were women. Overall, 92,361 patients (59.2%) had ischemic cardiomyopathy and 63,652 patients (40.8%) had nonischemic cardiomyopathy (NICM). Hypertensive (n = 28,141; 48.5%) and idiopathic (n = 17,808; 30.7%) cardiomyopathies accounted for the vast majority of NICM patients. Post-partum (n = 209; 0.4%), viral (n = 447; 0.8%), chemotherapy (n = 721; 1.2%), substance abuse (n = 2,653; 4.6%), familial (n = 556; 1.0%), and other (n = 7,523; 13.0%) etiologies were far less frequent. There were significant differences in baseline characteristics between those with ischemic cardiomyopathy compared with NICM with respect to age (76 years vs. 72 years), sex (44.4% vs. 56.9% women), and ejection fraction (38% vs. 45%). Risk-adjusted quality of care provided to eligible patients varied minimally by etiology. Similarly, in-hospital mortality did not differ among ischemic compared with NICM patients. However, among NICM patients, only hypertensive cardiomyopathy had a lower mortality rate compared with idiopathic NICM (adjusted odds ratio: 0.83; 95% confidence interval: 0.71 to 0.97).Characteristics of hospitalized HF patients vary by etiology. Both risk-adjusted quality of care and in-hospital outcomes did not differ by etiology.

  View details for DOI 10.1016/j.jchf.2015.06.012

  View details for Web of Science ID 000365657100010

  View details for PubMedID 26454848

• PROVIDERS' PERCEPTIONS OF INSTITUTIONAL, PATIENT, AND FAMILY BARRIERS TO HEART FAILURE SELF-MANAGEMENT Slightam, C., Piette, J. D., Nelson, K., Rosland, A., Heidenreich, P., Timko, C., Nevedal, A., Trivedi, R. OXFORD UNIV PRESS INC. 2015: 653

  View details for Web of Science ID 000374222703160

• SUCCEED: A PILOT STUDY OF A HEART FAILURE SELF-MANAGEMENT PROGRAM FOR COUPLES Trivedi, R., Slightam, C., Piette, J. D., Nelson, K., Rosland, A., Heidenreich, P., Asch, S., Timko, C. OXFORD UNIV PRESS INC. 2015: 822–23

  View details for Web of Science ID 000374222704263

• Amiodarone and risk of death in contemporary patients with atrial fibrillation: Findings from The Retrospective Evaluation and Assessment of Therapies in AF study AMERICAN HEART JOURNAL Ullal, A. J., Than, C. T., Fan, J., Schmitt, S., Perino, A. C., Kaiser, D. W., Heidenreich, P. A., Frayne, S. M., Phibbs, C. S., Turakhia, M. P. 2015; 170 (5): 1033-U231

  Abstract

  There are limited data on mortality outcomes associated with use of amiodarone in atrial fibrillation and flutter (AF).We evaluated the association of amiodarone use with mortality in patients with newly diagnosed AF using complete data from the Department of Veterans Affairs national health care system. We included patients seen in an outpatient setting within 90 days of a new diagnosis for nonvalvular AF between Veterans Affairs fiscal years 2004 and 2008. Multivariate analysis and propensity-matched Cox proportional hazards regression were used to evaluate the association of amiodarone use to death.Of 122,465 patients (353,168 person-years of follow-up, age 72.1 ± 10.3 years, 98.4% males), amiodarone was prescribed in 11,655 (9.5%). Cumulative, unadjusted mortality rates were higher for amiodarone recipients than for nonrecipients (87 vs 73 per 1,000 person-years, P < .001). However, in multivariate and propensity-matched survival analyses, there was no significant difference in mortality (multivariate hazard ratio 1.01, 95% CI 0.97-1.05, P = .51, and propensity-matched hazard ratio 1.02, 95% CI 0.97-1.07, P = .45). The hazard of death was not modified by age, sex, heart failure, kidney function, β-blocker use, or warfarin use, but there was evidence of effect modification among patients diagnosed with AF as an inpatient versus outpatient.In a national health care system population of newly diagnosed AF, overall use of amiodarone as an early treatment strategy was not associated with mortality.

  View details for DOI 10.1016/j.ahj.2015.07.023

  View details for Web of Science ID 000364434600026

  View details for PubMedID 26542514

  View details for PubMedCentralID PMC4800972

• Anticoagulation in Atrial Fibrillation: Impact of Mental Illness AMERICAN JOURNAL OF MANAGED CARE Schmitt, S. K., Turakhia, M. P., Phibbs, C. S., Moos, R. H., Berlowitz, D., Heidenreich, P., Chiu, V. Y., Go, A. S., Friedman, S. A., Than, C. T., Frayne, S. M. 2015; 21 (11): E609-E617

  Abstract

  To characterize warfarin eligibility and receipt among Veterans Health Administration (VHA) patients with and without mental health conditions (MHCs).Retrospective cohort study.This observational study identified VHA atrial fibrillation (AF) patients with and without MHCs in 2004. We examined unadjusted MHC-related differences in warfarin eligibility and warfarin receipt among warfarin-eligible patients, using logistic regression for any MHC and for specific MHCs (adjusting for sociodemographic and clinical characteristics).Of 125,670 patients with AF, most (96.8%) were warfarin-eligible based on a CHADS2 stroke risk score. High stroke risk and contraindications to anticoagulation were both more common in patients with MHC. Warfarin-eligible patients with MHC were less likely to receive warfarin than those without MHC (adjusted odds ratio [AOR], 0.90; 95% CI, 0.87-0.94). The association between MHC and warfarin receipt among warfarin-eligible patients varied by specific MHC. Patients with anxiety disorders (AOR, 0.86; 95% CI, 0.80-0.93), psychotic disorders (AOR, 0.77; 95% CI, 0.65-0.90), and alcohol use disorders (AOR 0.62, 95% CI 0.54-0.72) were less likely to receive warfarin than patients without these conditions, whereas patients with depressive disorders and posttraumatic stress disorder were no less likely to receive warfarin than patients without these conditions.Compared with patients with AF without MHCs, those with MHCs are less likely to be eligible for warfarin receipt and, among those eligible, are less likely to receive such treatment. Although patients with AF with MHC need careful assessment of bleeding risk, this finding suggests potential missed opportunities for more intensive therapy among some individuals with MHCs.

  View details for Web of Science ID 000379911700003

  View details for PubMedID 26735294

• Amiodarone and risk of death in contemporary patients with atrial fibrillation: Findings from The Retrospective Evaluation and Assessment of Therapies in AF study. American heart journal Ullal, A. J., Than, C. T., Fan, J., Schmitt, S., Perino, A. C., Kaiser, D. W., Heidenreich, P. A., Frayne, S. M., Phibbs, C. S., Turakhia, M. P. 2015; 170 (5): 1033-1041 e1

  Abstract

  There are limited data on mortality outcomes associated with use of amiodarone in atrial fibrillation and flutter (AF).We evaluated the association of amiodarone use with mortality in patients with newly diagnosed AF using complete data from the Department of Veterans Affairs national health care system. We included patients seen in an outpatient setting within 90 days of a new diagnosis for nonvalvular AF between Veterans Affairs fiscal years 2004 and 2008. Multivariate analysis and propensity-matched Cox proportional hazards regression were used to evaluate the association of amiodarone use to death.Of 122,465 patients (353,168 person-years of follow-up, age 72.1 ± 10.3 years, 98.4% males), amiodarone was prescribed in 11,655 (9.5%). Cumulative, unadjusted mortality rates were higher for amiodarone recipients than for nonrecipients (87 vs 73 per 1,000 person-years, P < .001). However, in multivariate and propensity-matched survival analyses, there was no significant difference in mortality (multivariate hazard ratio 1.01, 95% CI 0.97-1.05, P = .51, and propensity-matched hazard ratio 1.02, 95% CI 0.97-1.07, P = .45). The hazard of death was not modified by age, sex, heart failure, kidney function, β-blocker use, or warfarin use, but there was evidence of effect modification among patients diagnosed with AF as an inpatient versus outpatient.In a national health care system population of newly diagnosed AF, overall use of amiodarone as an early treatment strategy was not associated with mortality.

  View details for DOI 10.1016/j.ahj.2015.07.023

  View details for PubMedID 26542514

  View details for PubMedCentralID PMC4800972

• ACC/AHA/STS Statement on the Future of Registries and the Performance Measurement Enterprise: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and The Society of Thoracic Surgeons ANNALS OF THORACIC SURGERY Bhatt, D. L., Drozda, J. P., Shahian, D. M., Chan, P. S., Fonarow, G. C., Heidenreich, P. A., Jacobs, J. P., Masoudi, F. A., Peterson, E. D., Welke, K. F. 2015; 100 (5): 1926-1941

  View details for DOI 10.1016/j.athoracsur.2015.07.078

  View details for Web of Science ID 000365820400085

  View details for PubMedID 26438978

• Team-Based Care and Quality A Move Toward Evidence-Based Policy JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Harrington, R. A., Heidenreich, P. A. 2015; 66 (16): 1813–15

  View details for PubMedID 26483106

• Medication Initiation Burden Required to Comply With Heart Failure Guideline Recommendations and Hospital Quality Measures CIRCULATION Allen, L. A., Fonarow, G. C., Liang, L., Schulte, P. J., Masoudi, F. A., Rumsfeld, J. S., Ho, P. M., Eapen, Z. J., Hernandez, A. F., Heidenreich, P. A., Bhatt, D. L., Peterson, E. D., Krumholz, H. M. 2015; 132 (14): 1347-1353

  Abstract

  Guidelines for heart failure (HF) recommend prescription of guideline-directed medical therapy before hospital discharge; some of these therapies are included in publicly reported performance measures. The burden of new medications for individual patients has not been described.We used Get With The Guidelines-HF registry data from 2008 to 2013 to characterize prescribing, indications, and contraindications for angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, β-blockers, aldosterone antagonists, hydralazine/isosorbide dinitrate, and anticoagulants. The difference between a patient's medication regimen at hospital admission and that recommended by HF quality measures at discharge was calculated. Among 158 922 patients from 271 hospitals with a primary discharge diagnosis of HF, initiation of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was indicated in 18.1% of all patients (55.5% of those eligible at discharge were not receiving angiotensin-converting enzyme inhibitors or angiotensin receptor blockers at admission), β-blockers in 20.3% (50.5% of eligible), aldosterone antagonists in 24.1% (87.4% of eligible), hydralazine/isosorbide dinitrate in 8.6% (93.1% of eligible), and anticoagulants in 18.0% (58.0% of eligible). Cumulatively, 0.4% of patients were eligible for 5 new medication groups, 4.1% for 4 new medication groups, 9.4% for 3 new medication groups, 10.1% for 2 new medication groups, and 22.7% for 1 new medication group; 15.0% were not eligible for new medications because of adequate prescribing at admission; and 38.4% were not eligible for any medications recommended by HF quality measures. Compared with newly indicated medications (mean, 1.45 ± 1.23), actual new prescriptions were lower (mean, 1.16 ± 1.00).A quarter of patients hospitalized with HF need to start >1 medication to meet HF quality measures. Systems for addressing medication initiation and managing polypharmacy are central to HF transitional care.

  View details for DOI 10.1161/CIRCULATIONAHA.115.014281

  View details for Web of Science ID 000362217000008

  View details for PubMedID 26316616

  View details for PubMedCentralID PMC4941099

• Variation in use of echocardiography among veterans who use the Veterans Health Administration vs Medicare. American heart journal Kini, V., McCarthy, F. H., Rajaei, S., Epstein, A. J., Heidenreich, P. A., Groeneveld, P. W. 2015; 170 (4): 805-811

  Abstract

  Rapid growth in the provision of cardiac imaging tests has led to concerns about overuse. Little is known about the degree to which health care delivery system characteristics influence use and variation in echocardiography.We analyzed administrative claims of veterans with heart failure older than 65 years from 2007 to 2010 across 34 metropolitan service areas (MSAs). We compared overall rates and geographic variation in use of transthoracic echocardiography (TTE) between veterans who used the Veterans Health Administration (VA) and propensity-matched veterans who used Medicare. "Dual users" were excluded.There were no significant differences in clinical characteristics or mortality between the propensity-matched cohorts (overall n = 30,404 veterans, mean age 76 years, mortality rate 52%). The Medicare cohort had a significantly higher overall rate of TTE use compared with the VA cohort (1.25 vs 0.38 TTEs per person-year, incidence rate ratio 2.89 [95% CI 2.80-3.00], both P < .001), but a similar coefficient of variation across MSAs (0.36 [95% CI 0.27-0.45] vs 0.48 [95% CI 0.37-0.59]). There was a moderate to strong correlation in variation at the MSA level between cohorts (Spearman r = 0.58, P < .001).Overall rates of TTE use were significantly higher in a Medicare cohort compared with a propensity score-matched VA cohort of veterans with heart failure living in urban areas, with similar relative degrees of geographic variation and moderate to strong regional correlation. Rates of TTE use may be strongly influenced by health care system characteristics, but local practice styles influence echocardiography rates irrespective of health system.

  View details for DOI 10.1016/j.ahj.2015.07.016

  View details for PubMedID 26386805

  View details for PubMedCentralID PMC4777352

• Defibrillator implantations for primary prevention in the United States: Inappropriate care or inadequate documentation: Insights from the National Cardiovascular Data ICD Registry. Heart rhythm Kaiser, D. W., Tsai, V., Heidenreich, P. A., Goldstein, M. K., Wang, Y., Curtis, J., Turakhia, M. P. 2015; 12 (10): 2086-2093

  Abstract

  Prior studies have reported that more than 20% of implantable cardioverter-defibrillator (ICD) implantations in the United States do not adhere to trial-based criteria.We sought to investigate the patient characteristics associated with not meeting the inclusion criteria of the clinical trials that have demonstrated the efficacy of primary prevention ICDs.Using data from the National Cardiovascular Data Registry's ICD Registry, we identified patients who received ICDs for primary prevention from January 2006 to December 2008. We determined whether patients met the inclusion criteria of at least 1 of the 4 ICD primary prevention trials: Multicenter Automatic Defibrillator Implantation Trial (MADIT), MADIT-II, Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT), and the Multicenter Unsustained Tachycardia Trial (MUSTT).Among 150,264 patients, 86% met criteria for an ICD implantation based on trial data. The proportion of patients who did not meet trial-based criteria increased as age decreased. In multivariate analysis, the significant predictors for not meeting trial criteria included prior cardiac transplantation (odds ratio [OR] 2.1), pediatric electrophysiology operator (OR 2.0), and high-grade atrioventricular conduction disease (OR 1.4).Among National Cardiovascular Data Registry registrants receiving first-time ICDs for primary prevention, the majority met trial-based criteria. Multivariate analyses suggested that many patients who did not meet the trial-based criteria may have had clinical circumstances that warranted ICD implantation. These findings caution against the use of trial-based indications to determine site quality metrics that could penalize sites that care for younger patients. The planned incorporation of appropriate use criteria into the ICD registry may better characterize patient- and site-level quality and performance.

  View details for DOI 10.1016/j.hrthm.2015.05.010

  View details for PubMedID 25982720

• Facility variation and predictors of serum potassium monitoring after initiation of a mineralocorticoid receptor antagonist in patients with heart failure. American heart journal Chauhan, V., Dev, S., Pham, M., Lin, S., Heidenreich, P. 2015; 170 (3): 543-549

  Abstract

  Mineralocorticoid receptor antagonists (MRAs) have been shown to reduce morbidity and mortality in patients with heart failure (HF) with reduced ejection fraction but are associated with hyperkalemia. We sought to evaluate the frequency, variation, and predictors associated with serum potassium monitoring in patients with HF initiated on an MRA among facilities in the Veterans Affairs (VA) Health Care System.We performed a retrospective cohort analysis of patients with HF across 133 Veterans Affairs facilities from 2003 to 2013 who were given a new prescription of an MRA. The primary outcome was the mean percentage of patients per facility with serum potassium monitoring within 14 days of MRA dispensing. Univariate and covariate analyses were performed to determine factors associated with monitoring.There were 142,880 patients identified with HF initiated on an MRA who met the study inclusion and exclusion criteria. The mean (SD) percentage of patients per facility with serum potassium monitoring within 14 days was 41.6% (standard deviation 8.0%; minimum 18.9%, maximum 56.7%). Facilities with a higher frequency of monitoring were associated with membership in the Council on Teaching Hospitals (n = 70, P < .0001), had academic affiliations (n = 100, P < .0001), and a higher annual volume of patients with HF (≥200 patients, P < .0001).In a large multicenter national sample of patients with HF receiving a new MRA prescription, the frequency of serum potassium monitoring was below recommended guidelines. Academic facilities and those with a higher volume of patients with HF were associated with an increased frequency of monitoring.

  View details for DOI 10.1016/j.ahj.2015.06.006

  View details for PubMedID 26385038

• Association Between Comorbidities and Outcomes in Heart Failure Patients With and Without an Implantable Cardioverter-Defibrillator for Primary Prevention JOURNAL OF THE AMERICAN HEART ASSOCIATION Khazanie, P., Hellkamp, A. S., Fonarow, G. C., Bhatt, D. L., Masoudi, F. A., Anstrom, K. J., Heidenreich, P. A., Yancy, C. W., Curtis, L. H., Hernandez, A. F., Peterson, E. D., Al-Khatib, S. M. 2015; 4 (8)

  Abstract

  Implantable cardioverter-defibrillator (ICD) therapy is associated with improved outcomes in patients with heart failure (HF), but whether this association holds among older patients with multiple comorbid illnesses and worse HF burden remains unclear.Using the National Cardiovascular Data Registry's ICD Registry and the Get With The Guidelines-Heart Failure (GWTG-HF) registry linked with Medicare claims, we examined outcomes associated with primary-prevention ICD versus no ICD among HF patients aged ≥65 years in clinical practice. We included patients with an ejection fraction ≤35% who received (ICD Registry) and who did not receive (GWTG-HF) an ICD. Compared with patients with an ICD, patients in the non-ICD group were older and more likely to be female and white. In matched cohorts, the 3-year adjusted mortality rate was lower in the ICD group versus the non-ICD group (46.7% versus 55.8%; adjusted hazard ratio [HR] 0.76; 95% CI 0.69 to 0.83). There was no associated difference in all-cause readmission (HR 0.99; 95% CI 0.92 to 1.08) but a lower risk of HF readmission (HR 0.88; 95% CI 0.80 to 0.97). When compared with no ICD, ICDs were also associated with better survival in patients with ≤3 comorbidities (HR 0.77; 95% CI 0.69 to 0.87) and >3 comorbidities (HR 0.77; 95% CI 0.64 to 0.93) and in patients with no hospitalization for HF (HR 0.75; 95% CI 0.65 to 0.86) and at least 1 prior HF hospitalization (HR 0.69; 95% CI 0.58 to 0.82). In subgroup analyses, there were no interactions between ICD and mortality risk for comorbidity burden (P=0.95) and for prior HF hospitalization (P=0.46).Among older HF patients, ICDs for primary prevention were associated with lower risk of mortality even among those with high comorbid illness burden and prior HF hospitalization.

  View details for DOI 10.1161/JAHA.115.002061

  View details for Web of Science ID 000364150900016

  View details for PubMedID 26251283

• Lack of Improvement in 30-day Readmission Rates for Patients Hospitalized with Heart Failure: Data from Get With The Guidelines-Heart Failure Registry Bergethon, K. E., Ju, C., DeVore, A. D., Hardy, N., Fonarow, G. C., Yancy, C. W., Heidenreich, P. A., Bhatt, D. L., Peterson, E. D., Hemandez, A. F. CHURCHILL LIVINGSTONE INC MEDICAL PUBLISHERS. 2015: S10

  View details for DOI 10.1016/j.cardfail.2015.06.068

  View details for Web of Science ID 000359392200023

• Trends in the Use of Guideline-based Therapies Among Dialysis Patients Hospitalized with Heart Failure: Findings from Get With The Guidelines-Heart Failure Pandey, A., Golwala, H., DeVore, A., Lu, D., Madden, G., Bhatt, D. L., Schulte, P., Heidenreich, P., Yancy, C., Hernandez, A., Fonarow, G. C. CHURCHILL LIVINGSTONE INC MEDICAL PUBLISHERS. 2015: S114–S115

  View details for DOI 10.1016/j.cardfail.2015.06.330

  View details for Web of Science ID 000359392200284

• Heart failure patients hospitalised with bacterial infections: a US nationwide analysis of concomitant clostridium difficile infection rates and in-hospital mortality Mamic, P., Heidenreich, P., Tennakoon, L., Staudenmayer, K. OXFORD UNIV PRESS. 2015: 29

  View details for Web of Science ID 000361205101098

• Cluster-Randomized Trial of Personalized Site Performance Feedback in Get With The Guidelines-Heart Failure CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES DeVore, A. D., Cox, M., Heidenreich, P. A., Fonarow, G. C., Yancy, C. W., Eapen, Z. J., Peterson, E. D., Hernandez, A. F. 2015; 8 (4): 421-427

  Abstract

  There is significant variation in the delivery of evidence-based care for patients with heart failure (HF), but there is limited evidence defining the best methods to improve the quality of care.We performed a cluster-randomized trial of personalized site performance feedback at 147 hospitals participating in the Get With The Guidelines-Heart Failure quality improvement program from October 2009 to March 2011. The intervention provided sites with specific data on their heart failure achievement and quality measures in addition to the usual Get With The Guidelines-Heart Failure tools. The primary outcome for our trial was improvement in site composite quality of care score. Overall, 73 hospitals (n=33 886 patients) received the intervention, whereas 74 hospitals (n=37 943 patients) did not. One year after the intervention, both the intervention and control arms had a similar mean change in percentage points in their composite quality score (absolute change, +0.31 [SE, 1.51] versus +3.18 [SE, 1.68] in control; P=0.21). Similarly, none of the individual achievement measures or quality measures improved more at intervention versus control hospitals.Our site-based intervention, which included personalized site feedback on adherence to quality metrics, was not able to elicit more quality improvement beyond that already associated with participation in the Get With The Guidelines-Heart Failure program.URL: http://www.clinicaltrials.gov. Unique identifier: NCT00979264.

  View details for DOI 10.1161/CIRCOUTCOMES.114.001333

  View details for Web of Science ID 000358214000014

• Heart Failure Prevention and Team-based Interventions HEART FAILURE CLINICS Heidenreich, P. 2015; 11 (3): 349-?

  Abstract

  There is substantial opportunity to reduce health care costs through prevention of heart failure. Team-based management of medical homes and large populations will be important for the success of any prevention interventions. Clinical trials of treatment are needed to show that heart failure is reduced by treatment. A team-based approach to treatment of asymptomatic left ventricular systolic dysfunction (LVSD) can work well with the availability of electronic medical records and a population approach to health. Attention should be given to optimizing risk factor reduction and preventive treatment with angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and β-blockers if LVSD is present.

  View details for DOI 10.1016/j.hfc.2015.03.001

  View details for Web of Science ID 000357570900003

  View details for PubMedID 26142634

• Cluster-Randomized Trial of Personalized Site Performance Feedback in Get With The Guidelines-Heart Failure. Circulation. Cardiovascular quality and outcomes DeVore, A. D., Cox, M., Heidenreich, P. A., Fonarow, G. C., Yancy, C. W., Eapen, Z. J., Peterson, E. D., Hernandez, A. F. 2015; 8 (4): 421-427

  Abstract

  There is significant variation in the delivery of evidence-based care for patients with heart failure (HF), but there is limited evidence defining the best methods to improve the quality of care.We performed a cluster-randomized trial of personalized site performance feedback at 147 hospitals participating in the Get With The Guidelines-Heart Failure quality improvement program from October 2009 to March 2011. The intervention provided sites with specific data on their heart failure achievement and quality measures in addition to the usual Get With The Guidelines-Heart Failure tools. The primary outcome for our trial was improvement in site composite quality of care score. Overall, 73 hospitals (n=33 886 patients) received the intervention, whereas 74 hospitals (n=37 943 patients) did not. One year after the intervention, both the intervention and control arms had a similar mean change in percentage points in their composite quality score (absolute change, +0.31 [SE, 1.51] versus +3.18 [SE, 1.68] in control; P=0.21). Similarly, none of the individual achievement measures or quality measures improved more at intervention versus control hospitals.Our site-based intervention, which included personalized site feedback on adherence to quality metrics, was not able to elicit more quality improvement beyond that already associated with participation in the Get With The Guidelines-Heart Failure program.URL: http://www.clinicaltrials.gov. Unique identifier: NCT00979264.

  View details for DOI 10.1161/CIRCOUTCOMES.114.001333

  View details for PubMedID 26175533

• Variation in performance measure criteria significantly affects cardiology practice rankings: Insights from the National Cardiovascular Data Registry's Practice Innovation and Clinical Excellence Registry AMERICAN HEART JOURNAL Eapen, Z. J., Tang, F., Jones, P. G., Maddox, T. M., Oetgen, W. J., Spertus, J. A., Rumsfeld, J. S., Heidenreich, P. A., Peterson, E. D., Drozda, J. P. 2015; 169 (6): 847-853

  Abstract

  Million Hearts is a national initiative to prevent 1 million heart attacks and strokes over 5 years by improving cardiovascular prevention. An important tool in the success of programs like Million Hearts is public ranking on the quality of practices, yet different measures may provide different rankings, so the true quality of practices is difficult to discern. We evaluated the quality of ambulatory cardiology care using performance measure metrics.We compared rankings of practices participating in the National Cardiovascular Data Registry's Practice Innovation and Clinical Excellence Registry using measures from (1) the physician quality reporting system and (2) the American College of Cardiology/American Heart Association/Physician Consortium for Performance Improvement. We compared achievement rates for measures between the 2 frameworks and determined correlations in rankings using Spearman correlation coefficients.From January 1, 2008 to December 31, 2012, there were 1,711,326 patients enrolled from 111 US practices. Among eligible patients, the physician quality reporting system and American College of Cardiology/American Heart Association/Physician Consortium for Performance Improvement measures were achieved in 76.1% versus 77.4% for antiplatelet prescription (P < .001), 68.3% versus 90.8% for blood pressure control (P < .001), 26.9% versus 43.4% for cholesterol control (P < .001), and 37.4% versus 40.6% for smoking cessation (P = .383). Practice rankings were strongly correlated for antiplatelet prescription (correlation coefficient 0.98) and cholesterol control (0.92) but poorly correlated for blood pressure control (0.39) and smoking cessation (0.22).Evaluation of preventive care and individual practice rankings vary significantly depending on how measures are defined. Publicly reported measures need to be validly associated with outcomes to avoid incorrectly evaluating practice performance and failing to achieve public health goals.

  View details for DOI 10.1016/j.ahj.2015.02.021

  View details for Web of Science ID 000355213300014

  View details for PubMedID 26027623

• Lack of Impact of Electronic Health Records on Quality of Care and Outcomes for Ischemic Stroke JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Joynt, K. E., Bhatt, D. L., Schwamm, L. H., Xian, Y., Heidenreich, P. A., Fonarow, G. C., Smith, E. E., Neely, M. L., Grau-Sepulveda, M. V., Hernandez, A. F. 2015; 65 (18): 1964-1972

  Abstract

  Electronic health records (EHRs) may be key tools for improving the quality of health care, particularly for conditions for which guidelines are rapidly evolving and timely care is critical, such as ischemic stroke.The goal of this study was to determine whether hospitals with EHRs differed on quality or outcome measures for ischemic stroke from those without EHRs.We studied 626,473 patients from 1,236 U.S. hospitals in Get With the Guidelines-Stroke (GWTG-Stroke) from 2007 through 2010, linked with the American Hospital Association annual survey to determine the presence of EHRs. We conducted patient-level logistic regression analyses for each of the outcomes of interest.A total of 511 hospitals had EHRs by the end of the study period. Hospitals with EHRs were larger and were more often teaching hospitals and stroke centers. After controlling for patient and hospital characteristics, patients admitted to hospitals with EHRs had similar odds of receiving "all-or-none" care (odds ratio [OR]: 1.03; 95% CI: 0.99 to 1.06; p=0.12), of discharge home (OR: 1.02; 95% CI: 0.99 to 1.04; p=0.15), and of in-hospital mortality (OR: 1.01; 95% CI: 0.96 to 1.05; p=0.82). The odds of having a length of stay>4 days was slightly lower at hospitals with EHRs (OR: 0.97; 95% CI: 0.95 to 0.99; p=0.01).In our sample of GWTG-Stroke hospitals, EHRs were not associated with higher-quality care or better clinical outcomes for stroke care. Although EHRs may be necessary for an increasingly high-tech, transparent healthcare system, as currently implemented, they do not appear to be sufficient to improve outcomes for this important disease.

  View details for DOI 10.1016/j.jacc.2015.02.059

  View details for Web of Science ID 000353991000009

  View details for PubMedID 25953748

• Feasibility of Extended Ambulatory Electrocardiogram Monitoring to Identify Silent Atrial Fibrillation in High-risk Patients: The Screening Study for Undiagnosed Atrial Fibrillation (STUDY-AF) CLINICAL CARDIOLOGY Turakhia, M. P., Ullal, A. J., Hoang, D. D., Than, C. T., Miller, J. D., Friday, K. J., Perez, M. V., Freeman, J. V., Wang, P. J., Heidenreich, P. A. 2015; 38 (5): 285-292

  Abstract

  Identification of silent atrial fibrillation (AF) could prevent stroke and other sequelae.Screening for AF using continuous ambulatory electrocardiographic (ECG) monitoring can detect silent AF in asymptomatic in patients with known risk factors.We performed a single-center prospective screening study using a wearable patch-based device that provides up to 2 weeks of continuous ambulatory ECG monitoring (iRhythm Technologies, Inc.). Inclusion criteria were age ≥55 years and ≥2 of the following risk factors: coronary disease, heart failure, hypertension, diabetes, sleep apnea. We excluded patients with prior AF, stroke, transient ischemic attack, implantable pacemaker or defibrillator, or with palpitations or syncope in the prior year.Out of 75 subjects (all male, age 69 ± 8.0 years; ejection fraction 57% ± 8.7%), AF was detected in 4 subjects (5.3%; AF burden 28% ± 48%). Atrial tachycardia (AT) was present in 67% (≥4 beats), 44% (≥8 beats), and 6.7% (≥60 seconds) of subjects. The combined diagnostic yield of sustained AT/AF was 11%. In subjects without sustained AT/AF, 11 (16%) had ≥30 supraventricular ectopic complexes per hour.Outpatient extended ECG screening for asymptomatic AF is feasible, with AF identified in 1 in 20 subjects and sustained AT/AF identified in 1 in 9 subjects, respectively. We also found a high prevalence of asymptomatic AT and frequent supraventricular ectopic complexes, which may be relevant to development of AF or stroke. If confirmed in a larger study, primary screening for AF could have a significant impact on public health.

  View details for DOI 10.1002/clc.22387

  View details for PubMedID 25873476

• Primary Results of the Patient-Centered Disease Management (PCDM) for Heart Failure Study A Randomized Clinical Trial JAMA INTERNAL MEDICINE Bekelman, D. B., Plomondon, M. E., Carey, E. P., Sullivan, M. D., Nelson, K. M., Hattler, B., McBryde, C. F., Lehmann, K. G., Gianola, K., Heidenreich, P. A., Rumsfeld, J. S. 2015; 175 (5): 725-732

  Abstract

  Heart failure (HF) has a major effect on patients' health status, including their symptom burden, functional status, and health-related quality of life.To determine the effectiveness of a collaborative care patient-centered disease management (PCDM) intervention to improve the health status of patients with HF.The Patient-Centered Disease Management (PCDM) trial was a multisite randomized clinical trial comparing a collaborative care PCDM intervention with usual care in patients with HF. A population-based sample of 392 patients with an HF diagnosis from 4 Veterans Affairs centers who had a Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary score of less than 60 (heavy symptom burden and impaired functional status and quality of life) were enrolled between May 2009 and June 2011.The PCDM intervention included collaborative care by a multidisciplinary care team consisting of a nurse coordinator, cardiologist, psychiatrist, and primary care physician; home telemonitoring and patient self-management support; and screening and treatment for comorbid depression.The primary outcome was change in the KCCQ overall summary score at 1 year (a 5-point change is clinically significant). Mortality, hospitalization, and depressive symptoms (Patient Health Questionnaire 9) were secondary outcomes.There were no significant differences in baseline characteristics between patients randomized to the PCDM intervention (n=187) vs usual care (n=197); baseline mean KCCQ overall summary scores were 37.9 vs 36.9 (P=.48). There was significant improvement in the KCCQ overall summary scores in both groups after 1 year (mean change, 13.5 points in each group), with no significant difference between groups (P=.97). The intervention was not associated with greater improvement in the KCCQ overall summary scores when the effect over time was estimated using 3-month, 6-month, and 12-month data (P=.74). Among secondary outcomes, there were significantly fewer deaths at 1 year in the intervention arm (8 of 187 [4.3%]) than in the usual care arm (19 of 197 [9.6%]) (P = .04). Among those who screened positive for depression, there was a greater improvement in the Patient Health Questionnaire 9 scores after 1 year in the intervention arm than in the usual care arm (2.1 points lower, P=.01). There was no significant difference in 1-year hospitalization rates between the intervention arm and the usual care arm (29.4% vs 29.9%, P=.87).This multisite randomized trial of a multifaceted HF PCDM intervention did not demonstrate improved patient health status compared with usual care.clinicaltrials.gov Identifier: NCT00461513.

  View details for DOI 10.1001/jamainternmed.2015.0315

  View details for Web of Science ID 000356178400010

  View details for PubMedID 25822284

• Effect of Minor Liver Function Test Abnormalities and Values Within the Normal Range on Survival in Heart Failure AMERICAN JOURNAL OF CARDIOLOGY Ambrosy, A. P., Dunn, T. P., Heidenreich, P. A. 2015; 115 (7): 938-941

  Abstract

  Liver function test (LFT) abnormalities are often observed in patients with heart failure (HF). However, the relation of LFTs with outcomes has not been well described. Patients of the VA Palo Alto Health Care System (3 inpatient facilities and 7 community clinics) with a complete set of LFTs in the 60 days before a first HF diagnosis were included in the analysis from January 2005 to April 2013. A total of 2,096 patients met inclusion criteria. Patients were a mean of 71 ± 12 years old, 97% were men, 57% had a previous diagnosis of ischemic heart disease, and the mean left ventricular ejection fraction was 51 ± 12%. The median (twenty fifth and seventy fifth) values were albumin 3.6 g/dl (3.3, 3.9), alanine transaminase 21 IU/L (16, 30), aspartate transaminase 24 IU/L (20,31), AP 70 IU/L (57, 87), and total bilirubin 0.8 mg/dl (0.6, 1.0). There were 851 deaths (41%) over a mean duration of 41 ± 27 months. Mortality significantly increased with lower values of albumin and alanine transaminase and higher levels of aspartate transaminase and AP. The association with total bilirubin was not significant. In conclusion, many LFT values in the "normal" range are independently associated with decreased survival beyond traditional risk factors for mortality in HF.

  View details for DOI 10.1016/j.amjcard.2015.01.023

  View details for Web of Science ID 000352253000015

  View details for PubMedID 25708860

• Support for Management of Multiple Comorbidities through a Performance Measure Clinical Dashboard for Primary Care Goldstein, M. K., Tu, S. W., Martins, S. B., Oshiro, C., Yuen, K., Hwang, T., Wang, D., Furman, A., Ashcraft, M., Heidenreich, P. WILEY-BLACKWELL. 2015: S208

  View details for Web of Science ID 000352578900584

• Heart Rate at Hospital Discharge in Patients With Heart Failure Is Associated With Mortality and Rehospitalization JOURNAL OF THE AMERICAN HEART ASSOCIATION Laskey, W. K., Alomari, I., Cox, M., Schulte, P. J., Zhao, X., Hernandez, A. F., Heidenreich, P. A., Eapen, Z. J., Yancy, C., Bhatt, D. L., Fonarow, G. C. 2015; 4 (4)

  Abstract

  Whether heart rate upon discharge following hospitalization for heart failure is associated with long-term adverse outcomes and whether this association differs between patients with sinus rhythm (SR) and atrial fibrillation (AF) have not been well studied.We conducted a retrospective cohort study from clinical registry data linked to Medicare claims for 46 217 patients participating in Get With The Guidelines(®)-Heart Failure. Cox proportional-hazards models were used to estimate the association between discharge heart rate and all-cause mortality, all-cause readmission, and the composite outcome of mortality/readmission through 1 year. For SR and AF patients with heart rate ≥75, the association between heart rate and mortality (expressed as hazard ratio [HR] per 10 beats-per-minute increment) was significant at 0 to 30 days (SR: HR 1.30, 95% CI 1.22 to 1.39; AF: HR 1.23, 95% CI 1.16 to 1.29) and 31 to 365 days (SR: HR 1.15, 95% CI 1.12 to 1.20; AF: HR 1.05, 95% CI 1.01 to 1.08). Similar associations between heart rate and all-cause readmission and the composite outcome were obtained for SR and AF patients from 0 to 30 days but only in the composite outcome for SR patients over the longer term. The HR from 0 to 30 days exceeded that from 31 to 365 days for both SR and AF patients. At heart rates <75, an association was significant for mortality only for both SR and AF patients.Among older patients hospitalized with heart failure, higher discharge heart rate was associated with increased risks of death and rehospitalization, with higher risk in the first 30 days and for SR compared with AF.

  View details for DOI 10.1161/JAHA.114.001626

  View details for Web of Science ID 000354137300017

  View details for PubMedID 25904590

• USE OF HIGH POTENCY STATINS FOR PATIENTS WITH ESTABLISHED ATHEROSCLEROTIC CARDIOVASCULAR DISEASE: PRACTICE IMPACT OF THE NEW CHOLESTEROL GUIDELINES Rodriguez, F., Heidenreich, P. ELSEVIER SCIENCE INC. 2015: A1436

  View details for DOI 10.1016/S0735-1097(15)61436-X

  View details for Web of Science ID 000375328801756

• TEMPORAL TRENDS IN CARE AND OUTCOMES OF PATIENTS RECEIVING FIBRINOLYTIC THERAPY COMPARED TO PRIMARY PERCUTANEOUS CORONARY INTERVENTION IN THE GET WITH THE GUIDELINES CORONARY ARTERY DISEASE (GWTG-CAD) REGISTRY Hira, R. S., Bhatt, D., Fonarow, G., Heidenreich, P., Ju, C., Virani, S., Hernandez, A., Schwamm, L., Eapen, Z., Albert, M., Peterson, E., Jneid, H. ELSEVIER SCIENCE INC. 2015: A68

  View details for DOI 10.1016/S0735-1097(15)60068-7

  View details for Web of Science ID 000375328800069

• BARRIERS TO ADOPTION AND MONITORING OF MINERALOCORTICOID RECEPTOR ANTAGONISTS IN A VA MEDICAL CENTER Dev, S., Hoffman, T., Kavalieratos, D., Schwenke, D., Heidenreich, P., Wu, W., Tracy, S. ELSEVIER SCIENCE INC. 2015: A847

  View details for DOI 10.1016/S0735-1097(15)60847-6

  View details for Web of Science ID 000375328801167

• ANTI-HYPERGLYCEMIC MEDICATION USE AMONG MEDICARE BENEFICIARIES WITH HEART FAILURE, DIABETES, AND CHRONIC KIDNEY DISEASE Patel, P., Liang, L., Khazanie, P., Hammill, B., Fonarow, G., Heidenreich, P., Yancy, C., Bhatt, D., Curtis, L., Hernandez, A. ELSEVIER SCIENCE INC. 2015: A1024

  View details for DOI 10.1016/S0735-1097(15)61024-5

  View details for Web of Science ID 000375328801344

• COST VARIATION AND ASSOCIATED OUTCOMES OF CATHETER ABLATION FOR ATRIAL FIBRILLATION Perino, A., Fan, J., Schmitt, S., Chang, A. Y., Kaiser, D., Heidenreich, P., Swan, C., Narayan, S., Wang, P., Turakhia, M. ELSEVIER SCIENCE INC. 2015: A277

  View details for DOI 10.1016/S0735-1097(15)60277-7

  View details for Web of Science ID 000375328800278

• READMISSIONS IN HEART FAILURE AND MYOCARDIAL INFARCTIONS: A PARADOXICAL IMPROVEMENT IN QUALITY OF CARE Rajaei, S., Teerlink, J., Whooley, M., Sahay, A., Heidenreich, P. ELSEVIER SCIENCE INC. 2015: A1055

  View details for DOI 10.1016/S0735-1097(15)61055-5

  View details for Web of Science ID 000375328801375

• Incentives for Clinical Decisions Where Evidence Is Lacking JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Heidenreich, P. 2015; 65 (9): 928–30

  View details for DOI 10.1016/j.jacc.2015.01.015

  View details for Web of Science ID 000350216700010

  View details for PubMedID 25744010

• Primary prevention implantable cardioverter-defibrillators and survival in older women. JACC. Heart failure Zeitler, E. P., Hellkamp, A. S., Fonarow, G. C., Hammill, S. C., Curtis, L. H., Hernandez, A. F., Al-Khalidi, H. R., Curtis, J. P., Heidenreich, P. A., Anstrom, K. J., Peterson, E. D., Mark, D. B., Hammill, B. G., Sanders, G. D., Al-Khatib, S. M. 2015; 3 (2): 159-167

  Abstract

  The purpose of this study was to assess the benefit of primary prevention implantable cardioverter defibrillators (ICDs) in women.Clinical trials of primary prevention ICDs enrolled a limited number of women.Using a propensity score method, we matched 490 women ≥65 years of age who received an ICD during a hospitalization for heart failure in the National Cardiovascular Data Registry ICD Registry from January 1, 2006, through December 31, 2007, to 490 ICD-eligible women without an ICD hospitalized for heart failure in the Get With The Guidelines for Heart Failure database from January 1, 2006, through December 31, 2009. The primary endpoint was all-cause mortality obtained from the Medicare Claims Database. An identical analysis was conducted in men.Median follow-up for patients with an ICD was 4.6 years versus 3.2 years for patients with no ICD. Compared with women with no ICD, those with an ICD were younger and less frequently white. In the matched cohorts, the survival of women with an ICD was significantly longer than that of women without an ICD (adjusted hazard ratio: 0.79, 95% confidence interval: 0.66 to 0.95; p = 0.013). Similarly, men with an ICD had longer survival than men without an ICD (adjusted hazard ratio: 0.73, 95% confidence interval: 0.65 to 0.83; p < 0.0001). There was no interaction between sex and the presence of an ICD with respect to survival (p = 0.44).Among older women with left ventricular dysfunction, a primary prevention ICD was associated with a significant survival benefit that was nearly identical to that seen in men. These findings support the use of primary prevention ICDs in eligible patients regardless of sex.

  View details for DOI 10.1016/j.jchf.2014.09.006

  View details for PubMedID 25543969

• Primary Prevention Implantable Cardioverter-Defibrillators in Older Racial and Ethnic Minority Patients CIRCULATION-ARRHYTHMIA AND ELECTROPHYSIOLOGY Pokorney, S. D., Hellkamp, A. S., Yancy, C. W., Curtis, L. H., Hammill, S. C., Peterson, E. D., Masoudi, F. A., Bhatt, D. L., Al-Khalidi, H. R., Heidenreich, P. A., Anstrom, K. J., Fonarow, G. C., Al-Khatib, S. M. 2015; 8 (1): 145-U215

  Abstract

  Racial and ethnic minorities are under-represented in clinical trials of primary prevention implantable cardioverter-defibrillators (ICDs). This analysis investigates the association between primary prevention ICDs and mortality among Medicare, racial/ethnic minority patients.Data from Get With The Guidelines-Heart Failure Registry and National Cardiovascular Data Registry's ICD Registry were used to perform an adjusted comparative effectiveness analysis of primary prevention ICDs in Medicare, racial/ethnic minority patients (nonwhite race or Hispanic ethnicity). Mortality data were obtained from the Medicare denominator file. The relationship of ICD with survival was compared between minority and white non-Hispanic patients. Our analysis included 852 minority patients, 426 ICD and 426 matched non-ICD patients, and 2070 white non-Hispanic patients (1035 ICD and 1035 matched non-ICD patients). Median follow-up was 3.1 years. Median age was 73 years, and median ejection fraction was 23%. Adjusted 3-year mortality rates for minority ICD and non-ICD patients were 44.9% (95% confidence interval [CI], 44.2%-45.7%) and 54.3% (95% CI, 53.4%-55.1%), respectively (adjusted hazard ratio, 0.79; 95% CI, 0.63-0.98; P=0.034). White non-Hispanic patients receiving an ICD had lower adjusted 3-year mortality rates of 47.8% (95% CI, 47.3%-48.3%) compared with 57.3% (95% CI, 56.8%-57.9%) for those with no ICD (adjusted hazard ratio, 0.75; 95% CI, 0.67%-0.83%; P<0.0001). There was no significant interaction between race/ethnicity and lower mortality risk with ICD (P=0.70).Primary prevention ICDs are associated with lower mortality in nonwhite and Hispanic patients, similar to that seen in white, non-Hispanic patients. These data support a similar approach to ICD patient selection, regardless of race or ethnicity.

  View details for DOI 10.1161/CIRCEP.114.001878

  View details for Web of Science ID 000349873000021

  View details for PubMedID 25504649

  View details for PubMedCentralID PMC4426962

• Reply: increased mortality by digoxin in patients with atrial fibrillation? Journal of the American College of Cardiology Turakhia, M. P., Heidenreich, P. A. 2015; 65 (2): 221-?

  View details for DOI 10.1016/j.jacc.2014.10.032

  View details for PubMedID 25593068

• Facilitation of a Multihospital Community of Practice to Increase Enrollment in the Hospital to Home National Quality Improvement Initiative. Joint Commission journal on quality and patient safety / Joint Commission Resources Heidenreich, P. A., Sahay, A., Mittman, B. S., Oliva, N., Gholami, P., Rumsfeld, J. S., Massie, B. M. 2015; 41 (8): 361-369

  Abstract

  Hospital to Home (H2H) is a national quality improvement (QI) initiative composed of three recommended hospital interventions to improve the transition of care for hospitalized patients with heart disease. A study was conducted to determine if enrollment of Department of Veterans Affairs (VA) hospitals in H2H and adoption of the recommended interventions would both increase following facilitation of an existing Heart Failure (HF) provider-based community of practice (COP) within the VA health care system. The VA HF COP includes more than 800 VA providers and other VA staff from VA inpatient medical centers.In 2010, 122 VA hospitals were randomized to facilitation using the VA HF COP (intervention) or no facilitation (control). COP members from intervention hospitals were invited to periodic teleconferences promoting H2H and received multiple e-mails asking members to report interest and then progress in H2H implementation.Among the 61 hospitals randomized to HF COP facilitation, 33 (54%) enrolled in H2H, compared with 6 (10%) of 61 control hospitals (p < .001) at five months after randomization. Of 38 intervention hospitals responding to the follow-up survey, 13 stated they had initiated 22 QI projects as a result of the H2H campaign. Another 7 hospitals had planned H2H projects. Of 20 control hospitals that responded, 5 had initiated 9 projects as a result of H2H, and no additional hospitals had plans to do so.Facilitation using the VA HF COP was successful in increasing enrollment in the H2H initiative and providing implementation support for recommended QI projects. Multihospital provider groups are a potentially valuable tool for implementation of national QI campaigns.

  View details for PubMedID 26215525

• INTERVENTIONS USING THE ELECTRONIC MEDICAL RECORD TO IMPROVE CARE OF PATIENTS WITH HEART DISEASE Heidenreich, P. A. KARGER. 2015: 343

  View details for Web of Science ID 000358518200332

• 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society CIRCULATION January, C. T., Wann, L., Alpert, J. S., Calkins, H., Cigarroa, J. E., Cleveland, J. C., Conti, J. B., Ellinor, P. T., Ezekowitz, M. D., Field, M. E., Murray, K. T., Sacco, R. L., Stevenson, W. G., Tchou, P. J., Tracy, C. M., Yancy, C. W., Writing Comm Members 2014; 130 (23): 2071-2104

  View details for DOI 10.1161/CIR.0000000000000040

  View details for Web of Science ID 000346033700019

  View details for PubMedID 24682348

• Socioeconomic inequalities in quality of care and outcomes among patients with acute coronary syndrome in the modern era of drug eluting stents. Journal of the American Heart Association Yong, C. M., Abnousi, F., Asch, S. M., Heidenreich, P. A. 2014; 3 (6)

  Abstract

  The rapidly changing landscape of percutaneous coronary intervention provides a unique model for examining disparities over time. Previous studies have not examined socioeconomic inequalities in the current era of drug eluting stents (DES).We analyzed 835 070 hospitalizations for acute coronary syndrome (ACS) from the Healthcare Cost and Utilization Project across all insurance types from 2008 to 2011, examining whether quality of care and outcomes for patients with ACS differed by income (based on zip code of residence) with adjustment for patient characteristics and clustering by hospital. We found that lower-income patients were less likely to receive an angiogram within 24 hours of a ST elevation myocardial infarction (STEMI) (69.5% for IQ1 versus 73.7% for IQ4, P<0.0001, OR 0.79 [0.68 to 0.91]) or within 48 hours of a Non-STEMI (47.6% for IQ1 versus 51.8% for IQ4, P<0.0001, OR 0.86 [0.75 to 0.99]). Lower income was associated with less use of a DES (64.7% for IQ1 versus 71.2% for IQ4, P<0.0001, OR 0.83 [0.74 to 0.93]). However, no differences were found for coronary artery bypass surgery. Among STEMI patients, lower-income patients also had slightly increased adjusted mortality rates (10.8% for IQ1 versus 9.4% for IQ4, P<0.0001, OR 1.17 [1.11 to 1.25]). After further adjusting for time to reperfusion among STEMI patients, mortality differences across income groups decreased.For the most well accepted procedural treatments for ACS, income inequalities have faded. However, such inequalities have persisted for DES use, a relatively expensive and until recently, controversial revascularization procedure. Differences in mortality are significantly associated with differences in time to primary PCI, suggesting an important target for understanding why these inequalities persist.

  View details for DOI 10.1161/JAHA.114.001029

  View details for PubMedID 25398888

  View details for PubMedCentralID PMC4338689

• A Call to Arms: New Approaches to an Old Heart Failure Problem JOURNAL OF CARDIAC FAILURE Abnousi, F., Yock, P., Heidenreich, P. 2014; 20 (12): 878–80

  View details for PubMedID 25267078

• Socioeconomic Inequalities in Quality of Care and Outcomes Among Patients With Acute Coronary Syndrome in the Modern Era of Drug Eluting Stents JOURNAL OF THE AMERICAN HEART ASSOCIATION Yong, C. M., Abnousi, F., Asch, S. M., Heidenreich, P. A. 2014; 3 (6)

  Abstract

  The rapidly changing landscape of percutaneous coronary intervention provides a unique model for examining disparities over time. Previous studies have not examined socioeconomic inequalities in the current era of drug eluting stents (DES).We analyzed 835 070 hospitalizations for acute coronary syndrome (ACS) from the Healthcare Cost and Utilization Project across all insurance types from 2008 to 2011, examining whether quality of care and outcomes for patients with ACS differed by income (based on zip code of residence) with adjustment for patient characteristics and clustering by hospital. We found that lower-income patients were less likely to receive an angiogram within 24 hours of a ST elevation myocardial infarction (STEMI) (69.5% for IQ1 versus 73.7% for IQ4, P<0.0001, OR 0.79 [0.68 to 0.91]) or within 48 hours of a Non-STEMI (47.6% for IQ1 versus 51.8% for IQ4, P<0.0001, OR 0.86 [0.75 to 0.99]). Lower income was associated with less use of a DES (64.7% for IQ1 versus 71.2% for IQ4, P<0.0001, OR 0.83 [0.74 to 0.93]). However, no differences were found for coronary artery bypass surgery. Among STEMI patients, lower-income patients also had slightly increased adjusted mortality rates (10.8% for IQ1 versus 9.4% for IQ4, P<0.0001, OR 1.17 [1.11 to 1.25]). After further adjusting for time to reperfusion among STEMI patients, mortality differences across income groups decreased.For the most well accepted procedural treatments for ACS, income inequalities have faded. However, such inequalities have persisted for DES use, a relatively expensive and until recently, controversial revascularization procedure. Differences in mortality are significantly associated with differences in time to primary PCI, suggesting an important target for understanding why these inequalities persist.

  View details for DOI 10.1161/JAHA.114.001029

  View details for Web of Science ID 000345067600027

  View details for PubMedID 25398888

  View details for PubMedCentralID PMC4338689

• Variation in Laboratory Monitoring After Initiation of a Mineralocorticoid Receptor Antagonist in Patients With Heart Failure Chauhan, V. R., Dev, S., Pham, M., Lin, S., Heidenreich, P. LIPPINCOTT WILLIAMS & WILKINS. 2014

  View details for Web of Science ID 000209800301112

• Incidence Rate of Hyperkalemia-related Hospitalization After Initiation of a Mineralocorticoid Receptor Antagonist in Patients with Heart Failure Chauhan, V. R., Dev, S., Pham, M., Lin, S., Heidenreich, P. LIPPINCOTT WILLIAMS & WILKINS. 2014

  View details for Web of Science ID 000209800301043

• Medication Initiation Burden Required to Comply with Hospital Quality Measures for Heart Failure Allen, L. A., Fonarow, G. C., Liang, L., Schulte, P., Masoudi, F. A., John, S., Rumsfeld, Ho, M., Eapen, Z. J., Hernandez, A. F., Heidenreich, P. A., Bhatt, D. L., Peterson, E. D., Krumholz, H. M. LIPPINCOTT WILLIAMS & WILKINS. 2014

  View details for Web of Science ID 000209800301139

• ACC/AHA/AACVPR/AAFP/ANA Concepts for Clinician-Patient Shared Accountability in Performance Measures JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Peterson, E. D., Ho, P. M., Barton, M., Beam, C., Burgess, L. H., Casey, D. E., Drozda, J. P., Fonarow, G. C., Goff, D., Grady, K. L., King, D. E., King, M. L., Masoudi, F. A., Nielsen, D. R., Stanko, S., Heidenreich, P. A., Albert, N. M., Chan, P. S., Curtis, L. H., Ferguson, T. B., Jurgens, C., O'Brien, S., Russo, A. M., Thomas, R. J., Ting, H. H., Varosy, P. D. 2014; 64 (20): 2133-2145

  View details for DOI 10.1016/j.jacc.2014.09.003

  View details for Web of Science ID 000344617400011

  View details for PubMedCentralID PMC4476791

• Clinical Effectiveness of Cardiac Resynchronization Therapy Versus Medical Therapy Alone Among Patients With Heart Failure Analysis of the ICD Registry and ADHERE CIRCULATION-HEART FAILURE Khazanie, P., Hammill, B. G., Qualls, L. G., Fonarow, G. C., Hammill, S. C., Heidenreich, P. A., Al-Khatib, S. M., Piccini, J. P., Masoudi, F. A., Peterson, P. N., Curtis, J. P., Hernandez, A. F., Curtis, L. H. 2014; 7 (6): 926-U98

  Abstract

  Cardiac resynchronization therapy with defibrillator (CRT-D) reduces morbidity and mortality among selected patients with heart failure in clinical trials. The effectiveness of this therapy in clinical practice has not been well studied.We compared a cohort of 4471 patients from the National Cardiovascular Data Registry's Implantable Cardioverter-Defibrillator (ICD) Registry hospitalized primarily for heart failure and who received CRT-D between April 1, 2006, and December 31, 2009, to a historical control cohort of 4888 patients with heart failure without CRT-D from the Acute Decompensated Heart Failure National Registry (ADHERE) hospitalized between January 1, 2002, and March 31, 2006. Both registries were linked with Medicare claims to evaluate longitudinal outcomes. We included patients from the ICD Registry with left ventricular ejection fraction ≤35% and QRS duration ≥120 ms who were admitted for heart failure. We used Cox proportional hazards models to compare outcomes with and without CRT-D after adjustment for important covariates. After multivariable adjustment, CRT-D was associated with lower 3-year risks of death (hazard ratio, 0.52; 95% confidence interval, 0.48-0.56; P<0.001), all-cause readmission (hazard ratio, 0.69; 95% confidence interval, 0.65-0.73; P<0.001), and cardiovascular readmission (hazard ratio, 0.60; 95% confidence interval, 0.56-0.64; P<0.001). The association of CRT-D with mortality did not vary significantly among subgroups defined by age, sex, race, QRS duration, and optimal medical therapy.CRT-D was associated with lower risks of mortality, all-cause readmission, and cardiovascular readmission than medical therapy alone among patients with heart failure in community practice.

  View details for DOI 10.1161/CIRCHEARTFAILURE.113.000838

  View details for Web of Science ID 000345288800010

  View details for PubMedID 25227768

  View details for PubMedCentralID PMC4244212

• Evaluating the Cost-effectiveness of Catheter Ablation of Atrial Fibrillation. Arrhythmia & electrophysiology review Chang, A. Y., Kaiser, D., Ullal, A., Perino, A. C., Heidenreich, P. A., Turakhia, M. P. 2014; 3 (3): 177-183

  Abstract

  Atrial fibrillation (AF) is one of the most common cardiac conditions treated in primary care and specialty cardiology settings, and is associated with considerable morbidity, mortality and cost. Catheter ablation, typically by electrically isolating the pulmonary veins and surrounding tissue, is more effective at maintaining sinus rhythm than conventional antiarrhythmic drug therapy and is now recommended as first-line therapy. From a value standpoint, the cost-effectiveness of ablation must incorporate the upfront procedural costs and risks with the benefits of longer term improvements in quality of life (QOL) and healthcare utilisation. Here, we present a primer on cost-effectiveness analysis (CEA), review the data on cost-effectiveness of AF ablation and outline key areas for further investigation.

  View details for DOI 10.15420/aer.2014.3.3.177

  View details for PubMedID 26835088

• Outcomes in patients with heart failure with preserved, borderline, and reduced ejection fraction in the Medicare population AMERICAN HEART JOURNAL Cheng, R. K., Cox, M., Neely, M. L., Heidenreich, P. A., Bhatt, D. L., Eapen, Z. J., Hernandez, A. F., Butler, J., Yancy, C. W., Fonarow, G. C. 2014; 168 (5): 721-730

  Abstract

  Studies on outcomes among patients with heart failure (HF) with preserved left ventricular ejection fraction (HFpEF), borderline left ventricular ejection fraction (HFbEF), and reduced left ventricular ejection fraction (HFrEF) remain limited. We sought to characterize mortality and readmission in patients with HF in the contemporary era.Get With The Guidelines-HF was linked to Medicare data for longitudinal follow-up. Patients were grouped into HFpEF (left ventricular ejection fraction [EF] ≥ 50%), HFbEF (40% ≤ EF < 50%), and HFrEF (EF < 40%). Multivariable models were constructed to examine the relationship between EF and outcomes at 30 days and 1 year and to study trends over time.A total of 40,239 patients from 220 hospitals between 2005 and 2011 were included in the study: 18,897 (47%) had HFpEF, 5,626 (14%) had HFbEF, and 15,716 (39%) had HFrEF. In crude survival analysis, patients with HFrEF had slightly increased mortality compared with HFbEF and HFpEF. After risk adjustment, mortality at 1 year was not significantly different for HFrEF, HFbEF, and HFpEF (HFrEF vs HFpEF, hazard ratio [HR] 1.040 [95% CI 0.998-1.084], and HFbEF vs HFpEF, HR 0.967 [95% CI 0.917-1.020]). Patients with HFpEF had increased risk of all-cause readmission compared with HFrEF. Conversely, risk of cardiovascular and HF readmissions were higher in HFrEF and HFbEF compared with HFpEF.Among patients hospitalized with HF, patients with HFpEF and HFbEF had slightly lower mortality and higher all-cause readmission risk than patients with HFrEF, although the mortality differences did not persist after risk adjustment. Irrespective of EF, these patients experience substantial mortality and readmission highlighting the need for new therapeutic strategies.

  View details for DOI 10.1016/j.ahj.2014.07.008

  View details for Web of Science ID 000344434300015

  View details for PubMedID 25440801

• Healthy Lifestyles and Personal Responsibility JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Heidenreich, P. A. 2014; 64 (17): 1786–88

  View details for PubMedID 25443699

• Impact of an Expanded Hospital Recognition Program for Heart Failure Quality of Care JOURNAL OF THE AMERICAN HEART ASSOCIATION Heidenreich, P. A., Zhao, X., Hernandez, A. F., Yancy, C. W., Schwamm, L. H., Albert, N. M., Fonarow, G. C. 2014; 3 (5)

  Abstract

  In 2009, the Get With The Guidelines-Heart Failure program enhanced the standard recognition of hospitals by offering additional recognition if hospitals performed well on certain quality measures. We sought to determine whether initiation of this enhanced recognition opportunity led to acceleration in quality of care for all hospitals participating in the program.We examined hospital-level performance on 9 quality-of-care (process) measures that were added to an existing recognition program (based on existing published performance measures). The rate of increase in use over time 6 months to 2 years after the start of the program was compared with the rate of increase in use for the measures during the 18-month period prior to the start of the program. Use increased for all 9 new quality measures from 2008 to 2011. Among 4 measures with baseline use near or lower than 50%, a statistically significant greater increase in use during the program was seen for implantable cardioverter defibrillator use (program versus preprogram use: odds ratio 1.14, 95% CI 1.06 to 1.23). Among the 5 measures for which baseline use was 50% or higher, the increase in influenza vaccination rates actually slowed. There was no evidence of adverse impact on the 4 established quality measures, a composite of which actually increased faster during the expanded program (adjusted odds ratio 1.08, 95% CI 1.01 to 1.15).A program providing expanded hospital recognition for heart failure had mixed results in accelerating the use of 9 quality measures.

  View details for DOI 10.1161/JAHA.114.000950

  View details for Web of Science ID 000341861200005

  View details for PubMedID 25208954

  View details for PubMedCentralID PMC4323821

• Short- and Long-term Rehospitalization and Mortality for Heart Failure in 4 Racial/Ethnic Populations JOURNAL OF THE AMERICAN HEART ASSOCIATION Vivo, R. P., Krim, S. R., Liang, L., Neely, M., Hernandez, A. F., Eapen, Z. J., Peterson, E. D., Bhatt, D. L., Heidenreich, P. A., Yancy, C. W., Fonarow, G. C. 2014; 3 (5)

  Abstract

  The degree to which outcomes following hospitalization for acute heart failure (HF) vary by racial and ethnic groups is poorly characterized. We sought to compare 30-day and 1-year rehospitalization and mortality rates for HF among 4 race/ethnic groups.Using the Get With The Guidelines-HF registry linked with Medicare data, we compared 30-day and 1-year outcomes between racial/ethnic groups by using a multivariable Cox proportional hazards model adjusting for clinical, hospital, and socioeconomic status characteristics. We analyzed 47 149 Medicare patients aged ≥65 years who had been discharged for HF between 2005 and 2011: there were 39 213 whites (83.2%), 4946 blacks (10.5%), 2347 Hispanics (5.0%), and 643 Asians/Pacific Islanders (1.4%). Relative to whites, blacks and Hispanics had higher 30-day and 1-year unadjusted readmission rates but lower 30-day and 1-year mortality; Asians had similar 30-day readmission rates but lower 1-year mortality. After risk adjustment, blacks had higher 30-day and 1-year CV readmission than whites but modestly lower short- and long-term mortality; Hispanics had higher 30-day and 1-year readmission rates and similar 1-year mortality than whites, while Asians had similar outcomes. When socioeconomic status data were added to the model, the majority of associations persisted, but the difference in 30-day and 1-year readmission rates between white and Hispanic patients became nonsignificant.Among Medicare patients hospitalized with HF, short- and long-term readmission rates and mortality differed among the 4 major racial/ethnic populations and persisted even after controlling for clinical, hospital, and socioeconomic status variables.

  View details for DOI 10.1161/JAHA.114.001134

  View details for Web of Science ID 000357396800021

  View details for PubMedID 25324354

  View details for PubMedCentralID PMC4323790

• Temporal Trends in Patient Characteristics and Outcomes Among Medicare Beneficiaries Undergoing Primary Prevention Implantable Cardioverter-Defibrillator Placement in the United States, 2006-2010 Results from the National Cardiovascular Data Registry's Implantable Cardioverter-Defibrillator Registry CIRCULATION Borne, R. T., Peterson, P. N., Greenlee, R., Heidenreich, P. A., Wang, Y., Curtis, J. P., Tzou, W. S., Varosy, P. D., Kremers, M. S., Masoudi, F. A. 2014; 130 (10): 845-853

  Abstract

  Contemporary patterns of use and outcomes of implantable cardioverter-defibrillators (ICDs) in community practice settings are not well characterized. We assessed temporal trends in patient characteristics and outcomes among older patients undergoing primary prevention ICD therapy in US hospitals between 2006 and 2010.Using the National Cardiovascular Data Registry's ICD Registry, we identified Medicare fee-for-service beneficiaries aged ≥65 years and older with left ventricular ejection fraction ≤35% who underwent primary prevention ICD implantation, including those receiving concomitant cardiac resynchronization therapy between 2006 and 2010 and could be matched to Medicare claims. Outcomes were mortality and hospitalization (all-cause and heart failure) at 180 days, and device-related complications. We used multivariable hierarchical logistic regression to assess temporal trends in outcomes accounting for changes in patient, physician, and hospital characteristics. The cohort included 117 100 patients. Between 2006 and 2010, only modest changes in patient characteristics were noted. Fewer single lead devices and more cardiac resynchronization therapy devices were used over time. Between 2006 and 2010, there were significant improvements in all outcomes, including 6-month all cause mortality (7.1% in 2006, 6.5% 2010; adjusted odds ratio, 0.88; 95% confidence interval, 0.82-0.95), 6-month rehospitalization (36.3% in 2006, 33.7% in 2010; adjusted odds ratio, 0.87; 95% confidence interval, 0.83-0.91), and device-related complications (5.8% in 2006, 4.8% in 2010; adjusted odds ratio, 0.80; 95% confidence interval, 0.74-0.88).The clinical characteristics of this national population of Medicare patients undergoing primary prevention ICD implantation were stable between 2006 and 2010. Simultaneous improvements in outcomes suggest meaningful advances in the care for this patient population.

  View details for DOI 10.1161/CIRCULATIONAHA.114.008653

  View details for Web of Science ID 000341689100012

  View details for PubMedID 25095884

• Association Between Success Rate and Citation Count of Studies of Radiofrequency Catheter Ablation for Atrial Fibrillation Possible Evidence of Citation Bias CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES Perino, A. C., Hoang, D. D., Holmes, T. H., Santangeli, P., Heidenreich, P. A., Perez, M. V., Wang, P. J., Turakhia, M. P. 2014; 7 (5): 687-692

  Abstract

  The preferential citation of studies with the highest success rates could exaggerate perceived effectiveness, particularly for treatments with widely varying published success rates such as radiofrequency catheter ablation for atrial fibrillation.We systematically identified observational studies and clinical trials of radiofrequency catheter ablation of atrial fibrillation between 1990 and 2012. Generalized Poisson regression was used to estimate association between study success rate and total citation count, adjusting for sample size, journal impact factor, time since publication, study design, and whether first or last author was a consensus-defined pre-eminent expert. We identified 174 articles meeting our inclusion criteria (36 289 subjects). After adjustment only for time since publication, a 10-point increase above the mean in pooled reported success rates was associated with a 17.8% increase in citation count at 5 years postpublication (95% confidence interval, 7.1-28.4%; P<0.001). After additional adjustment for impact factor, sample size, randomized trial design, and pre-eminent expert authorship, the association remained significant (18.6% increase in citation count; 95% confidence interval, 7.6-29.6%; P<0.0001). In this full model, time since publication, impact factor, and pre-eminent expert authorship were significant covariates, whereas randomized control trial design and study sample size were not.Among studies of radiofrequency catheter ablation of atrial fibrillation, high success rate was independently associated with citation count, which may indicate citation bias. To readers of the literature, radiofrequency catheter ablation of atrial fibrillation could be perceived to be more effective than the data supports. These findings may have implications for a wide variety of novel cardiovascular therapies.

  View details for DOI 10.1161/CIRCOUTCOMES.114.000912

  View details for Web of Science ID 000342365200011

• Association between success rate and citation count of studies of radiofrequency catheter ablation for atrial fibrillation: possible evidence of citation bias. Circulation. Cardiovascular quality and outcomes Perino, A. C., Hoang, D. D., Holmes, T. H., Santangeli, P., Heidenreich, P. A., Perez, M. V., Wang, P. J., Turakhia, M. P. 2014; 7 (5): 687-692

  Abstract

  The preferential citation of studies with the highest success rates could exaggerate perceived effectiveness, particularly for treatments with widely varying published success rates such as radiofrequency catheter ablation for atrial fibrillation.We systematically identified observational studies and clinical trials of radiofrequency catheter ablation of atrial fibrillation between 1990 and 2012. Generalized Poisson regression was used to estimate association between study success rate and total citation count, adjusting for sample size, journal impact factor, time since publication, study design, and whether first or last author was a consensus-defined pre-eminent expert. We identified 174 articles meeting our inclusion criteria (36 289 subjects). After adjustment only for time since publication, a 10-point increase above the mean in pooled reported success rates was associated with a 17.8% increase in citation count at 5 years postpublication (95% confidence interval, 7.1-28.4%; P<0.001). After additional adjustment for impact factor, sample size, randomized trial design, and pre-eminent expert authorship, the association remained significant (18.6% increase in citation count; 95% confidence interval, 7.6-29.6%; P<0.0001). In this full model, time since publication, impact factor, and pre-eminent expert authorship were significant covariates, whereas randomized control trial design and study sample size were not.Among studies of radiofrequency catheter ablation of atrial fibrillation, high success rate was independently associated with citation count, which may indicate citation bias. To readers of the literature, radiofrequency catheter ablation of atrial fibrillation could be perceived to be more effective than the data supports. These findings may have implications for a wide variety of novel cardiovascular therapies.

  View details for DOI 10.1161/CIRCOUTCOMES.114.000912

  View details for PubMedID 25205786

• Associations Between Anticoagulation Therapy and Risks of Mortality and Readmission Among Patients With Heart Failure and Atrial Fibrillation CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES Hernandez, A. F., Liang, L., Fonarow, G. C., Hammill, B. G., Hammill, S. C., Heidenreich, P. A., Masoudi, F. A., Qualls, L. G., Al-Khatib, S. M., Piccini, J. P., Curtis, L. H. 2014; 7 (5): 670-679

  Abstract

  Patients with heart failure and atrial fibrillation are at higher risk of thromboembolic events than patients with heart failure alone. Yet, the use of anticoagulation therapy varies in clinical practice, especially among older patients, for whom its effectiveness is poorly understood.Using clinical registry data linked to Medicare claims from 2005 to 2011, we examined outcomes of older patients hospitalized with heart failure and atrial fibrillation who newly initiated anticoagulation therapy at discharge. We used Cox proportional hazards models and inverse probability-weighted treatment estimates to adjust for selection bias. Main outcomes were mortality and readmission at 1 and 3 years. Among 5105 patients in 195 hospitals, 1623 (31.8%) started anticoagulation therapy at discharge. Treated patients had lower unadjusted rates of all-cause mortality (26.4% versus 42.8%; P<0.001) and all-cause readmission (58.4% versus 63.7%; P<0.001) at 1 year. After inverse weighting for the probability of treatment and adjustment for other discharge medications, anticoagulation therapy was associated with significantly lower 1-year mortality (hazard ratio, 0.70; 99% confidence interval, 0.59-0.82), but there was no statistically significant difference in the risk of all-cause readmission (hazard ratio, 0.89; 99% confidence interval, 0.78-1.01) or other readmission outcomes. Results were similar at 3 years.Initiation of anticoagulation therapy at hospital discharge was associated with improved mortality at 1 and 3 years but was not associated with improved cardiovascular readmission among older patients with heart failure and atrial fibrillation.

  View details for DOI 10.1161/CIRCOUTCOMES.113.000632

  View details for Web of Science ID 000342365200009

  View details for PubMedID 25205789

• Increased Mortality Associated With Digoxin in Contemporary Patients With Atrial Fibrillation: Findings From the TREAT-AF Study. Journal of the American College of Cardiology Turakhia, M. P., Santangeli, P., Winkelmayer, W. C., Xu, X., Ullal, A. J., Than, C. T., Schmitt, S., Holmes, T. H., Frayne, S. M., Phibbs, C. S., Yang, F., Hoang, D. D., Ho, P. M., Heidenreich, P. A. 2014; 64 (7): 660-668

  Abstract

  Despite endorsement of digoxin in clinical practice guidelines, there exist limited data on its safety in atrial fibrillation/flutter (AF).The goal of this study was to evaluate the association of digoxin with mortality in AF.Using complete data of the TREAT-AF (The Retrospective Evaluation and Assessment of Therapies in AF) study from the U.S. Department of Veterans Affairs (VA) healthcare system, we identified patients with newly diagnosed, nonvalvular AF seen within 90 days in an outpatient setting between VA fiscal years 2004 and 2008. We used multivariate and propensity-matched Cox proportional hazards to evaluate the association of digoxin use with death. Residual confounding was assessed by sensitivity analysis.Of 122,465 patients with 353,168 person-years of follow-up (age 72.1 ± 10.3 years, 98.4% male), 28,679 (23.4%) patients received digoxin. Cumulative mortality rates were higher for digoxin-treated patients than for untreated patients (95 vs. 67 per 1,000 person-years; p < 0.001). Digoxin use was independently associated with mortality after multivariate adjustment (hazard ratio [HR]: 1.26, 95% confidence interval [CI]: 1.23 to 1.29, p < 0.001) and propensity matching (HR: 1.21, 95% CI: 1.17 to 1.25, p < 0.001), even after adjustment for drug adherence. The risk of death was not modified by age, sex, heart failure, kidney function, or concomitant use of beta-blockers, amiodarone, or warfarin.Digoxin was associated with increased risk of death in patients with newly diagnosed AF, independent of drug adherence, kidney function, cardiovascular comorbidities, and concomitant therapies. These findings challenge current cardiovascular society recommendations on use of digoxin in AF.

  View details for DOI 10.1016/j.jacc.2014.03.060

  View details for PubMedID 25125296

• Depression and Outcome among Veterans with Implantable Cardioverter Defibrillators with or without Cardiac Resynchronization Therapy Capability PACE-PACING AND CLINICAL ELECTROPHYSIOLOGY Shalaby, A. A., Brumberg, G. E., Pointer, L., Bekelman, D. B., Rumsfeld, J. S., Yang, Y., Pellegrini, C. N., Heidenreich, P. A., Keung, E., Massie, B. M., Varosy, P. D. 2014; 37 (8): 994-1001

  Abstract

  The impact of depression on outcome in implantable cardioverter defibrillator (ICD) recipients has not been fully appreciated. We assessed the prevalence of depression and its association with heart failure (HF) outcome among veterans with ICDs.Patients enrolled between January 2005 and January 2010 in the Outcomes among Veterans with Implantable Defibrillators Registry were studied. We examined the cross-sectional association of depression with severity of HF functional class as well as the association of depression with the composite outcome of mortality or HF hospitalization over a mean follow-up time of 2.7 years. There were 3,862 patients enrolled. Patients with depression (1,162, 43%) were younger (63.1 ± 9.4 years vs 66.6 ± 9.9 years, P < 0.001), more likely to have a history of tobacco or alcohol abuse (P < 0.0001) or atrial fibrillation (P = 0.05) while having a higher ejection fraction (28.3% vs 27.4%, P = 0.03). Depression was associated with advanced HF class at time of implant; odds ratio (OR; vs class I) for class III: 1.65 (confidence interval [CI] 1.17-2.33), class IV: 1.73 (95% CI 1.08-2.76). Death or HF hospitalization was more likely to occur in patients with depression (35.2% vs 32.0%, HR: 1.15 [95% CI 0.99-1.33]). The predictive value of depression was stronger after multivariable adjustment; HR: 1.25 (95% CI 1.05-1.49).Depression was prevalent among veterans with ICDs. Depression was associated with severity of HF. The predictive value of associated depression was significant after multivariable adjustment.

  View details for DOI 10.1111/pace.12361

  View details for Web of Science ID 000342831900011

  View details for PubMedID 24520992

• Differential effects of professional leaders on health care teams in chronic disease management groups. Health care management review Wholey, D. R., Disch, J., White, K. M., Powell, A., Rector, T. S., Sahay, A., Heidenreich, P. A. 2014; 39 (3): 186-197

  Abstract

  Leadership by health care professionals is likely to vary because of differences in the social contexts within which they are situated, socialization processes and societal expectations, education and training, and the way their professions define and operationalize key concepts such as teamwork, collaboration, and partnership. This research examines the effect of the nurse and physician leaders on interdependence and encounter preparedness in chronic disease management practice groups.The aim of this study was to examine the effect of complementary leadership by nurses and physicians involved in jointly producing a health care service on care team functioning.The design is a retrospective observational study based on survey data. The unit of analysis is heart failure care groups in U.S. Veterans Health Administration medical centers. Survey and administrative data were collected in 2009 from 68 Veterans Health Administration medical centers. Key variables include nurse and physician leadership, interdependence, psychological safety, coordination, and encounter preparedness. Reliability and validity of survey measures were assessed with exploratory factor analysis and Cronbach alphas. Multivariate analyses tested hypotheses.Professional leadership by nurses and physicians is related to encounter preparedness by different paths. Nurse leadership is associated with greater team interdependence, and interdependence is positively associated with respect. Physician leadership is positively associated with greater psychological safety, respect, and shared goals but is not associated with interdependence. Respect is associated with involvement in learning activities, and shared goals are associated with coordination. Coordination and involvement in learning activities are positively associated with encounter preparedness.By focusing on increasing interdependence and a constructive climate, nurse and physician leaders have the opportunity to increase care coordination and involvement in learning activities.

  View details for DOI 10.1097/HMR.0b013e3182993b7f

  View details for PubMedID 23860515

• pSCANNER: patient-centered Scalable National Network for Effectiveness Research JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION Ohno-Machado, L., Agha, Z., Bell, D. S., Dahm, L., Day, M. E., Doctor, J. N., Gabriel, D., Kahlon, M. K., Kim, K. K., Hogarth, M., Matheny, M. E., Meeker, D., Nebeker, J. R., pSCANNER Team 2014; 21 (4): 621-626

  Abstract

  This article describes the patient-centered Scalable National Network for Effectiveness Research (pSCANNER), which is part of the recently formed PCORnet, a national network composed of learning healthcare systems and patient-powered research networks funded by the Patient Centered Outcomes Research Institute (PCORI). It is designed to be a stakeholder-governed federated network that uses a distributed architecture to integrate data from three existing networks covering over 21 million patients in all 50 states: (1) VA Informatics and Computing Infrastructure (VINCI), with data from Veteran Health Administration's 151 inpatient and 909 ambulatory care and community-based outpatient clinics; (2) the University of California Research exchange (UC-ReX) network, with data from UC Davis, Irvine, Los Angeles, San Francisco, and San Diego; and (3) SCANNER, a consortium of UCSD, Tennessee VA, and three federally qualified health systems in the Los Angeles area supplemented with claims and health information exchange data, led by the University of Southern California. Initial use cases will focus on three conditions: (1) congestive heart failure; (2) Kawasaki disease; (3) obesity. Stakeholders, such as patients, clinicians, and health service researchers, will be engaged to prioritize research questions to be answered through the network. We will use a privacy-preserving distributed computation model with synchronous and asynchronous modes. The distributed system will be based on a common data model that allows the construction and evaluation of distributed multivariate models for a variety of statistical analyses.

  View details for DOI 10.1136/amiajnl-2014-002751

  View details for Web of Science ID 000337660600012

  View details for PubMedID 24780722

  View details for PubMedCentralID PMC4078293

• Can Natural Language Processing Fulfill the Promise of Electronic Medical Records? JOURNAL OF CARDIAC FAILURE Heidenreich, P. A. 2014; 20 (7): 465-466

  View details for DOI 10.1016/j.cardfail.2014.04.020

  View details for Web of Science ID 000338904400002

  View details for PubMedID 24814872

• Differential effects of professional leaders on health care teams in chronic disease management groups HEALTH CARE MANAGEMENT REVIEW Wholey, D. R., Disch, J., White, K. M., Powell, A., Rector, T. S., Sahay, A., Heidenreich, P. A. 2014; 39 (3): 186-197

  Abstract

  Leadership by health care professionals is likely to vary because of differences in the social contexts within which they are situated, socialization processes and societal expectations, education and training, and the way their professions define and operationalize key concepts such as teamwork, collaboration, and partnership. This research examines the effect of the nurse and physician leaders on interdependence and encounter preparedness in chronic disease management practice groups.The aim of this study was to examine the effect of complementary leadership by nurses and physicians involved in jointly producing a health care service on care team functioning.The design is a retrospective observational study based on survey data. The unit of analysis is heart failure care groups in U.S. Veterans Health Administration medical centers. Survey and administrative data were collected in 2009 from 68 Veterans Health Administration medical centers. Key variables include nurse and physician leadership, interdependence, psychological safety, coordination, and encounter preparedness. Reliability and validity of survey measures were assessed with exploratory factor analysis and Cronbach alphas. Multivariate analyses tested hypotheses.Professional leadership by nurses and physicians is related to encounter preparedness by different paths. Nurse leadership is associated with greater team interdependence, and interdependence is positively associated with respect. Physician leadership is positively associated with greater psychological safety, respect, and shared goals but is not associated with interdependence. Respect is associated with involvement in learning activities, and shared goals are associated with coordination. Coordination and involvement in learning activities are positively associated with encounter preparedness.By focusing on increasing interdependence and a constructive climate, nurse and physician leaders have the opportunity to increase care coordination and involvement in learning activities.

  View details for DOI 10.1097/HMR.0b013e3182993b7f

  View details for Web of Science ID 000337347200002

• Association Between Prophylactic Implantable Cardioverter-Defibrillators and Survival in Patients With Left Ventricular Ejection Fraction Between 30% and 35% JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Al-Khatib, S. M., Hellkamp, A. S., Fonarow, G. C., Mark, D. B., Curtis, L. H., Hernandez, A. F., Anstrom, K. J., Peterson, E. D., Sanders, G. D., Al-Khalidi, H. R., Hammill, B. G., Heidenreich, P. A., Hammill, S. C. 2014; 311 (21): 2209-2215

  Abstract

  Clinical trials of prophylactic implantable cardioverter-defibrillators (ICDs) have included a minority of patients with a left ventricular ejection fraction (LVEF) between 30% and 35%. Because a large number of ICDs in the United States are implanted in such patients, it is important to study survival associated with this therapy.To characterize patients with LVEF between 30% and 35% and compare the survival of those with and without ICDs.Retrospective cohort study of Medicare beneficiaries in the National Cardiovascular Data Registry ICD registry (January 1, 2006, through December 31, 2007) with an LVEF between 30% and 35% who received an ICD during a heart failure hospitalization and similar patients in the Get With The Guidelines-Heart Failure (GWTG-HF) database (January 1, 2005, through December 31, 2009) with no ICD. The analysis was repeated in patients with an LVEF less than 30%. There were 3120 patients with an LVEF between 30% and 35% (816 in matched cohorts) and 4578 with an LVEF less than 30% (2176 in matched cohorts). Propensity score matching and Cox models were applied.The primary outcome was all-cause mortality; data were obtained from Medicare claims through December 31, 2011.There were no significant differences in the baseline characteristics of the matched groups (n = 408 for both groups). Among patients with an LVEF between 30% and 35%, there were 248 deaths in the ICD Registry group, within a median follow-up of 4.4 years (interquartile range, 2.7-4.9) and 249 deaths in the GWTG HF group, within a median follow-up of 2.9 years (interquartile range, 2.1-4.4). The risk of all-cause mortality in patients with an LVEF between 30% and 35% and an ICD was significantly lower than that in matched patients without an ICD (3-year mortality rates: 51.4% vs 55.0%; hazard ratio, 0.83 [95% CI, 0.69-0.99]; P = .04). Presence of an ICD also was associated with better survival in patients with an LVEF less than 30% (3-year mortality rates: 45.0% vs 57.6%; 634 and 660 total deaths; hazard ratio, 0.72 [95% CI, 0.65-0.81]; P < .001) (P = .20 for interaction).Among Medicare beneficiaries hospitalized for heart failure and with an LVEF between 30% and 35% and less than 30%, survival at 3 years was better in patients who received a prophylactic ICD than in comparable patients with no ICD. These findings support guideline recommendations to implant prophylactic ICDs in eligible patients with an LVEF of 35% or less.

  View details for DOI 10.1001/jama.2014.5310

  View details for PubMedID 24893088

• ACC/AHA statement on cost/value methodology in clinical practice guidelines and performance measures: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and Task Force on Practice Guidelines. Circulation Anderson, J. L., Heidenreich, P. A., Barnett, P. G., Creager, M. A., Fonarow, G. C., Gibbons, R. J., Halperin, J. L., Hlatky, M. A., Jacobs, A. K., Mark, D. B., Masoudi, F. A., Peterson, E. D., Shaw, L. J. 2014; 129 (22): 2329-2345

  View details for DOI 10.1161/CIR.0000000000000042

  View details for PubMedID 24677315

• B-Type Natriuretic Peptide Predicts 30-Day Readmission for Heart Failure but not Readmission for Other Causes JOURNAL OF THE AMERICAN HEART ASSOCIATION Flint, K. M., Allen, L. A., Pham, M., Heidenreich, P. A. 2014; 3 (3)

  Abstract

  B-type natriuretic peptide (BNP) is a marker for heart failure (HF) severity, but its association with hospital readmission is not well defined.We identified all hospital discharges (n=109 875) with a primary diagnosis of HF in the Veterans Affairs Health Care System from 2006 to 2009. We examined the association between admission (n=53 585), discharge (n=24 326), and change in BNP (n=7187) and 30-day readmission for HF or other causes. Thirty-day HF readmission was associated with elevated admission BNP, elevated discharge BNP, and smaller percent change in BNP from admission to discharge. Patients with a discharge BNP ≥ 1000 ng/L had an unadjusted 30-day HF readmission rate over 3 times as high as patients whose discharge BNP was ≤ 200 ng/L (15% vs. 4.1%). BNP improved discrimination and risk classification for 30-day HF readmission when added to a base clinical model, with discharge BNP having the greatest effect (C-statistic, 0.639 to 0.664 [P<0.0001]; net reclassification improvement, 9% [P<0.0001]). In contrast, 30-day readmission for non-HF causes was not associated with BNP levels during index HF hospitalization.In this study of over 50 000 veterans hospitalized with a primary diagnosis of HF, BNP levels measured during hospitalization were associated with 30-day HF readmission, but not readmissions for other causes. These data may help guide future study aimed at identifying the optimal timing for hospital discharge and help allocate high-intensity, HF-specific transitional care interventions to the patients most likely to benefit.

  View details for DOI 10.1161/JAHA.114.000806

  View details for Web of Science ID 000209562400010

• Comparative effectiveness of cardiac resynchronization therapy with an implantable cardioverter-defibrillator versus defibrillator therapy alone: a cohort study. Annals of internal medicine Masoudi, F. A., Mi, X., Curtis, L. H., Peterson, P. N., Curtis, J. P., Fonarow, G. C., Hammill, S. C., Heidenreich, P. A., Al-Khatib, S. M., Piccini, J. P., Qualls, L. G., Hernandez, A. F. 2014; 160 (9): 603-611

  Abstract

  Trials comparing implantable cardioverter-defibrillator (ICD) therapy with cardiac resynchronization therapy with a defibrillator (CRT-D) are limited to selected patients treated at centers with extensive experience.To compare outcomes after CRT-D versus ICD therapy in contemporary practice.Retrospective cohort study using the National Cardiovascular Data Registry's ICD Registry linked with Medicare claims.780 U.S. hospitals implanting both CRT-D and ICD devices.7090 propensity-matched patients older than 65 years with reduced left ventricular ejection fraction (<0.35) and prolonged QRS duration on electrocardiography (≥120 ms) having CRT-D or ICD implantation between 1 April 2006 and 31 December 2009.Risks for death, readmission, and device-related complications over 3 years.Compared with ICD therapy, CRT-D was associated with lower risks for mortality (cumulative incidence, 25.7% vs. 29.8%; adjusted hazard ratio [HR], 0.82 [99% CI, 0.73 to 0.93]), all-cause readmission (cumulative incidence, 68.6% vs. 72.8%; adjusted HR, 0.86 [CI, 0.81 to 0.93]), cardiovascular readmission (cumulative incidence, 45.0% vs. 52.4%; adjusted HR, 0.80 [CI, 0.73 to 0.88]), and heart failure readmission (cumulative incidence, 24.3% vs. 29.4%; adjusted HR, 0.78 [CI, 0.69 to 0.88]). It was also associated with greater risks for device-related infection (cumulative incidence, 1.9% vs. 1.0%; adjusted HR, 1.90 [CI, 1.07 to 3.37]). The lower risks for heart failure readmission associated with CRT-D compared with ICD therapy were most pronounced among patients with left bundle branch block or a QRS duration at least 150 ms and in women.Patients were not randomly assigned to treatment groups, and few patients could be propensity-matched. The findings may not extend to younger patients or those outside of fee-for-service Medicare.In older patients with reduced left ventricular ejection fraction and prolonged QRS duration, CRT-D was associated with lower risks for death and readmission than ICD therapy alone.Agency for Healthcare Research and Quality.

  View details for DOI 10.7326/M13-1879

  View details for PubMedID 24798523

• Comparative Effectiveness of Cardiac Resynchronization Therapy With an Implantable Cardioverter-Defibrillator Versus Defibrillator Therapy Alone ANNALS OF INTERNAL MEDICINE Masoudi, F. A., Mi, X., Curtis, L. H., Peterson, P. N., Curtis, J. P., Fonarow, G. C., Hammill, S. C., Heidenreich, P. A., Al-Khatib, S. M., Piccini, J. P., Qualls, L. G., Hernandez, A. F. 2014; 160 (9): 603-U148

  Abstract

  Trials comparing implantable cardioverter-defibrillator (ICD) therapy with cardiac resynchronization therapy with a defibrillator (CRT-D) are limited to selected patients treated at centers with extensive experience.To compare outcomes after CRT-D versus ICD therapy in contemporary practice.Retrospective cohort study using the National Cardiovascular Data Registry's ICD Registry linked with Medicare claims.780 U.S. hospitals implanting both CRT-D and ICD devices.7090 propensity-matched patients older than 65 years with reduced left ventricular ejection fraction (<0.35) and prolonged QRS duration on electrocardiography (≥120 ms) having CRT-D or ICD implantation between 1 April 2006 and 31 December 2009.Risks for death, readmission, and device-related complications over 3 years.Compared with ICD therapy, CRT-D was associated with lower risks for mortality (cumulative incidence, 25.7% vs. 29.8%; adjusted hazard ratio [HR], 0.82 [99% CI, 0.73 to 0.93]), all-cause readmission (cumulative incidence, 68.6% vs. 72.8%; adjusted HR, 0.86 [CI, 0.81 to 0.93]), cardiovascular readmission (cumulative incidence, 45.0% vs. 52.4%; adjusted HR, 0.80 [CI, 0.73 to 0.88]), and heart failure readmission (cumulative incidence, 24.3% vs. 29.4%; adjusted HR, 0.78 [CI, 0.69 to 0.88]). It was also associated with greater risks for device-related infection (cumulative incidence, 1.9% vs. 1.0%; adjusted HR, 1.90 [CI, 1.07 to 3.37]). The lower risks for heart failure readmission associated with CRT-D compared with ICD therapy were most pronounced among patients with left bundle branch block or a QRS duration at least 150 ms and in women.Patients were not randomly assigned to treatment groups, and few patients could be propensity-matched. The findings may not extend to younger patients or those outside of fee-for-service Medicare.In older patients with reduced left ventricular ejection fraction and prolonged QRS duration, CRT-D was associated with lower risks for death and readmission than ICD therapy alone.Agency for Healthcare Research and Quality.

  View details for Web of Science ID 000336524400003

• HEART FAILURE ADMISSION IN HIV-INFECTED PATIENTS Bahrami, H., Fonarow, G., Heidenreich, P. ELSEVIER SCIENCE INC. 2014: A1351

  View details for DOI 10.1016/S0735-1097(14)61351-6

  View details for Web of Science ID 000359579102109

• CHARACTERISTICS, TREATMENTS, AND OUTCOMES OF HOSPITALIZED HEART FAILURE PATIENTS STRATIFIED BY ETIOLOGIES OF NON-ISCHEMIC CARDIOMYOPATHY Shore, S., Grau-Sepulveda, M., Bhatt, D., Heidenreich, P., Eapen, Z., Hernandez, A., Yancy, C., Fonarow, G. ELSEVIER SCIENCE INC. 2014: A537

  View details for DOI 10.1016/S0735-1097(14)60537-4

  View details for Web of Science ID 000359579101195

• SHORT- AND LONG-TERM REHOSPITALIZATION AND MORTALITY FOR HEART FAILURE IN FOUR RACIAL/ETHNIC POPULATIONS Vivo, R., Krim, S., Liang, L., Bhatt, D., Heidenreich, P., Eapen, Z., Hernandez, A., Yancy, C. W., Fonarow, G. ELSEVIER SCIENCE INC. 2014: A740

  View details for DOI 10.1016/S0735-1097(14)60740-3

  View details for Web of Science ID 000359579101398

• POST-DISCHARGE MORTALITY AND READMISSION IN HEART FAILURE PATIENTS WITH PRESERVED, BORDERLINE, AND REDUCED LEFT VENTRICULAR EJECTION FRACTION Cheng, R., Cox, M., Neely, M., Heidenreich, P., Bhatt, D., Eapen, Z., Hernandez, A., Butler, J., Yancy, C., Fonarow, G. ELSEVIER SCIENCE INC. 2014: A741

  View details for DOI 10.1016/S0735-1097(14)60741-5

  View details for Web of Science ID 000359579101399

• TEMPORAL TRENDS IN EARLY FOLLOW-UP AFTER HOSPITALIZATION FOR HEART FAILURE: DATA FROM GET WITH THE GUIDELINES-HEART FAILURE DeVore, A., Cox, M., Eapen, Z., Yancy, C., Bhatt, D., Heidenreich, P., Peterson, E., Fonarow, G., Hernandez, A. ELSEVIER SCIENCE INC. 2014: A745

  View details for DOI 10.1016/S0735-1097(14)60745-2

  View details for Web of Science ID 000359579101403

• VARIATION IN PERFORMANCE MEASURE CRITERIA FOR MILLION HEARTS(TM) SIGNIFICANTLY AFFECTS PRACTICE RANKINGS: RESULTS FROM 3,630,462 OUTPATIENTS IN 127 US PRACTICES FROM THE NCDR (R) PINACLE REGISTRY Eapen, Z., Tang, F., Jones, P., Maddox, T., Oetgen, W., Spertus, J., Rumsfeld, J., Heidenreich, P., Peterson, E., Drozda, J. ELSEVIER SCIENCE INC. 2014: A1297

  View details for DOI 10.1016/S0735-1097(14)61297-3

  View details for Web of Science ID 000359579102055

• Capsule commentary on Zhang et al., Race/ethnicity, Disability, and Medication Adherence Among Medicare Beneficiaries with Heart Failure JOURNAL OF GENERAL INTERNAL MEDICINE Heidenreich, P. A. 2014; 29 (4): 648

  View details for DOI 10.1007/s11606-013-2736-2

  View details for Web of Science ID 000333532600021

  View details for PubMedID 24481685

  View details for PubMedCentralID PMC3965754

• HIGH LEFT VENTRICULAR EJECTION FRACTION IS ASOCIATED WITH WORSE OUTCOMES IN PATIENTS WITH AND WITHOUT HEART FAILURE Bahrami, H., McConnell, M., Heidenreich, P. ELSEVIER SCIENCE INC. 2014: A732

  View details for DOI 10.1016/S0735-1097(14)60732-4

  View details for Web of Science ID 000359579101390

• PROGNOSTIC VALUE OF LIVER FUNCTION TEST ABNORMALITIES IN PATIENTS WITH HEART FAILURE Ambrosy, A., Dunn, T. P., Heidenreich, P. ELSEVIER SCIENCE INC. 2014: A739

  View details for DOI 10.1016/S0735-1097(14)60739-7

  View details for Web of Science ID 000359579101397

• Prescribing warfarin at discharge for heart failure patients: Findings from the Get With The Guidelines-Heart Failure Registry. International journal of cardiology Eapen, Z. J., Grau-Sepulveda, M. V., Fonarow, G. C., Heidenreich, P. A., Peterson, E. D., Hernandez, A. F. 2014; 172 (2): e322-3

  View details for DOI 10.1016/j.ijcard.2013.12.161

  View details for PubMedID 24444488

• Hospital variation in intravenous inotrope use for patients hospitalized with heart failure: insights from Get With The Guidelines. Circulation. Heart failure Allen, L. A., Fonarow, G. C., Grau-Sepulveda, M. V., Hernandez, A. F., Peterson, P. N., Partovian, C., Li, S., Heidenreich, P. A., Bhatt, D. L., Peterson, E. D., Krumholz, H. M. 2014; 7 (2): 251-260

  Abstract

  Prior claims analyses suggest that the use of intravenous inotropic therapy for patients hospitalized with heart failure varies substantially by hospital. Whether differences in the clinical characteristics of the patients explain observed differences in the use of inotropic therapy is not known.We sought to characterize institutional variation in inotrope use among patients hospitalized with heart failure before and after accounting for clinical factors of patients. Hierarchical generalized linear regression models estimated risk-standardized hospital-level rates of inotrope use within 209 hospitals participating in Get With The Guidelines-Heart Failure (GWTG-HF) registry between 2005 and 2011. The association between risk-standardized rates of inotrope use and clinical outcomes was determined. Overall, an inotropic agent was administered in 7691 of 126 564 (6.1%) heart failure hospitalizations: dobutamine 43%, dopamine 24%, milrinone 17%, or a combination 16%. Patterns of inotrope use were stable during the 7-year study period. Use of inotropes varied significantly between hospitals even after accounting for patient and hospital characteristics (median risk-standardized hospital rate, 5.9%; interquartile range, 3.7%-8.6%; range, 1.3%-32.9%). After adjusting for case-mix and hospital structural differences, model intraclass correlation indicated that 21% of the observed variation in inotrope use was potentially attributable to random hospital effects (ie, institutional preferences). Hospitals with higher risk-standardized inotrope use had modestly longer risk-standardized length of stay (P=0.005) but had no difference in risk-standardized inpatient mortality (P=0.12).Use of intravenous inotropic agents during hospitalization for heart failure varies significantly among US hospitals even after accounting for patient and hospital factors.

  View details for DOI 10.1161/CIRCHEARTFAILURE.113.000761

  View details for PubMedID 24488983

• Feasibility and Acceptability of a Collaborative Care Intervention To Improve Symptoms and Quality of Life in Chronic Heart Failure: Mixed Methods Pilot Trial JOURNAL OF PALLIATIVE MEDICINE Bekelman, D. B., Hooker, S., Nowels, C. T., Main, D. S., Meek, P., McBryde, C., Hattler, B., Lorenz, K. A., Heidenreich, P. A. 2014; 17 (2): 145-151

  Abstract

  People with chronic heart failure (HF) suffer from numerous symptoms that worsen quality of life. The CASA (Collaborative Care to Alleviate Symptoms and Adjust to Illness) intervention was designed to improve symptoms and quality of life by integrating palliative and psychosocial care into chronic care.Our aim was to determine the feasibility and acceptability of CASA and identify necessary improvements.We conducted a prospective mixed-methods pilot trial. The CASA intervention included (1) nurse phone visits involving structured symptom assessments and guidelines to alleviate breathlessness, fatigue, pain, or depression; (2) structured phone counseling targeting adjustment to illness and depression if present; and (3) weekly team meetings with a palliative care specialist, cardiologist, and primary care physician focused on medical recommendations to primary care providers (PCPs, physician or nurse practioners) to improve symptoms. Study subjects were outpatients with chronic HF from a Veteran's Affairs hospital (n=15) and a university hospital (n=2). Measurements included feasibility (cohort retention rate, medical recommendation implementation rate, missing data, quality of care) and acceptability (an end-of-study semi-structured participant interview).Participants were male with a median age of 63 years. One withdrew early and there were <5% missing data. Overall, 85% of 87 collaborative care team medical recommendations were implemented. All participants who screened positive for depression were either treated for depression or thought to not have a depressive disorder. In the qualitative interviews, patients reported a positive experience and provided several constructive critiques.The CASA intervention was feasible based on participant enrollment, cohort retention, implementation of medical recommendations, minimal missing data, and acceptability. Several intervention changes were made based on participant feedback.

  View details for DOI 10.1089/jpm.2013.0143

  View details for Web of Science ID 000331230400008

  View details for PubMedID 24329424

  View details for PubMedCentralID PMC3924799

• Outcomes of medicare beneficiaries with heart failure and atrial fibrillation. JACC. Heart failure Khazanie, P., Liang, L., Qualls, L. G., Curtis, L. H., Fonarow, G. C., Hammill, B. G., Hammill, S. C., Heidenreich, P. A., Masoudi, F. A., Hernandez, A. F., Piccini, J. P. 2014; 2 (1): 41-48

  Abstract

  This study sought to examine the long-term outcomes of patients hospitalized with heart failure and atrial fibrillation.Atrial fibrillation is common among patients hospitalized with heart failure. Associations of pre-existing and new-onset atrial fibrillation with long-term outcomes are unclear.We analyzed 27,829 heart failure admissions between 2006 and 2008 at 281 hospitals in the American Heart Association's Get With The Guidelines-Heart Failure program linked with Medicare claims. Patients were classified as having pre-existing, new-onset, or no atrial fibrillation. Cox proportional hazards models were used to identify factors that were independently associated with all-cause mortality, all-cause readmission, and readmission for heart failure, stroke, and other cardiovascular disease at 1 and 3 years.After multivariable adjustment, pre-existing atrial fibrillation was associated with greater 3-year risks of all-cause mortality (hazard ratio [HR]: 1.14 [99% confidence interval (CI): 1.08 to 1.20]), all-cause readmission (HR: 1.09 [99% CI: 1.05 to 1.14]), heart failure readmission (HR: 1.15 [99% CI: 1.08 to 1.21]), and stroke readmission (HR: 1.20 [99% CI: 1.01 to 1.41]), compared with no atrial fibrillation. There was also a greater hazard of mortality at 1 year among patients with new-onset atrial fibrillation (HR: 1.12 [99% CI: 1.01 to 1.24]). Compared with no atrial fibrillation, new-onset atrial fibrillation was not associated with a greater risk of the readmission outcomes. Stroke readmission rates at 1 year were just as high for patients with preserved ejection fraction as for patients with reduced ejection fraction.Both pre-existing and new-onset atrial fibrillation were associated with greater long-term mortality among older patients with heart failure. Pre-existing atrial fibrillation was associated with greater risk of readmission.

  View details for DOI 10.1016/j.jchf.2013.11.002

  View details for PubMedID 24622118

  View details for PubMedCentralID PMC4174273

• Outcomes of medicare beneficiaries with heart failure and atrial fibrillation. JACC. Heart failure Khazanie, P., Liang, L., Qualls, L. G., Curtis, L. H., Fonarow, G. C., Hammill, B. G., Hammill, S. C., Heidenreich, P. A., Masoudi, F. A., Hernandez, A. F., Piccini, J. P. 2014; 2 (1): 41-48

  Abstract

  This study sought to examine the long-term outcomes of patients hospitalized with heart failure and atrial fibrillation.Atrial fibrillation is common among patients hospitalized with heart failure. Associations of pre-existing and new-onset atrial fibrillation with long-term outcomes are unclear.We analyzed 27,829 heart failure admissions between 2006 and 2008 at 281 hospitals in the American Heart Association's Get With The Guidelines-Heart Failure program linked with Medicare claims. Patients were classified as having pre-existing, new-onset, or no atrial fibrillation. Cox proportional hazards models were used to identify factors that were independently associated with all-cause mortality, all-cause readmission, and readmission for heart failure, stroke, and other cardiovascular disease at 1 and 3 years.After multivariable adjustment, pre-existing atrial fibrillation was associated with greater 3-year risks of all-cause mortality (hazard ratio [HR]: 1.14 [99% confidence interval (CI): 1.08 to 1.20]), all-cause readmission (HR: 1.09 [99% CI: 1.05 to 1.14]), heart failure readmission (HR: 1.15 [99% CI: 1.08 to 1.21]), and stroke readmission (HR: 1.20 [99% CI: 1.01 to 1.41]), compared with no atrial fibrillation. There was also a greater hazard of mortality at 1 year among patients with new-onset atrial fibrillation (HR: 1.12 [99% CI: 1.01 to 1.24]). Compared with no atrial fibrillation, new-onset atrial fibrillation was not associated with a greater risk of the readmission outcomes. Stroke readmission rates at 1 year were just as high for patients with preserved ejection fraction as for patients with reduced ejection fraction.Both pre-existing and new-onset atrial fibrillation were associated with greater long-term mortality among older patients with heart failure. Pre-existing atrial fibrillation was associated with greater risk of readmission.

  View details for DOI 10.1016/j.jchf.2013.11.002

  View details for PubMedID 24622118

• End-of-Life Care in Patients With Heart Failure JOURNAL OF CARDIAC FAILURE Whellan, D. J., Goodlin, S. J., Dickinson, M. G., Heidenreich, P. A., Jaenicke, C., Stough, W. G., Rich, M. W. 2014; 20 (2): 121-134

  Abstract

  Stage D heart failure (HF) is associated with poor prognosis, yet little consensus exists on the care of patients with HF approaching the end of life. Treatment options for end-stage HF range from continuation of guideline-directed medical therapy to device interventions and cardiac transplantation. However, patients approaching the end of life may elect to forego therapies or procedures perceived as burdensome, or to deactivate devices that were implanted earlier in the disease course. Although discussing end-of-life issues such as advance directives, palliative care, or hospice can be difficult, such conversations are critical to understanding patient and family expectations and to developing mutually agreed-on goals of care. Because patients with HF are at risk for rapid clinical deterioration or sudden cardiac death, end-of-life issues should be discussed early in the course of management. As patients progress to advanced HF, the need for such discussions increases, especially among patients who have declined, failed, or been deemed to be ineligible for advanced HF therapies. Communication to define goals of care for the individual patient and then to design therapy concordant with these goals is fundamental to patient-centered care. The objectives of this white paper are to highlight key end-of-life considerations in patients with HF, to provide direction for clinicians on strategies for addressing end-of-life issues and providing optimal patient care, and to draw attention to the need for more research focusing on end-of-life care for the HF population.

  View details for DOI 10.1016/j.cardfail.2013.12.003

  View details for PubMedID 24556532

• Effectiveness of preoperative beta-blockade on intra-operative heart rate in vascular surgery cases conducted under regional or local anesthesia. SpringerPlus Mudumbai, S. C., Wagner, T., Mahajan, S., King, R., Heidenreich, P. A., Hlatky, M., Wallace, A. W., Mariano, E. R. 2014; 3: 227-?

  Abstract

  Preoperative β-blockade has been posited to result in better outcomes for vascular surgery patients by attenuating acute hemodynamic changes associated with stress. However, the incremental effectiveness, if any, of β-blocker usage in blunting heart rate responsiveness for vascular surgery patients who avoid general anesthesia remains unknown.We reviewed an existing database and identified 213 consecutive vascular surgery cases from 2005-2011 conducted without general anesthesia (i.e., under monitored anesthesia care or regional anesthesia) at a tertiary care Veterans Administration medical center and categorized patients based on presence or absence of preoperative β-blocker prescription. For this series of patients, with the primary outcome of maximum heart rate during the interval between operating room entry to surgical incision, we examined the association of maximal heart rate and preoperative β-blocker usage by performing crude and multivariate linear regression, adjusting for relevant patient factors.Of 213 eligible cases, 137 were prescribed preoperative β-blockers, and 76 were not. The two groups were comparable across baseline patient factors and intraoperative medication doses. The β-blocker group experienced lower maximal heart rates during the period of evaluation compared to the non-β-blocker group (85 ± 22 bpm vs. 98 ± 36 bpm, respectively; p = 0.002). Adjusted linear regression confirmed a statistically-significant association between lower maximal heart rate and the use of β-blockers (Beta = -11.5; 95% CI [-3.7, -19.3] p = 0.004).The addition of preoperative β-blockers, even when general anesthesia is avoided, may be beneficial in further attenuating stress-induced hemodynamic changes for vascular surgery patients.

  View details for DOI 10.1186/2193-1801-3-227

  View details for PubMedID 24855591

  View details for PubMedCentralID PMC4024108

• CAN WE PREVENT HEART FAILURE READMISSIONS? Heidenreich, P. KARGER. 2014: 431

  View details for Web of Science ID 000341933400417

• B-Type Natriuretic Peptide Predicts 30-Day Readmission for Heart Failure but not Readmission for Other Causes. Journal of the American Heart Association Flint, K. M., Allen, L. A., Pham, M., Heidenreich, P. A. 2014; 3 (3)

  Abstract

  B-type natriuretic peptide (BNP) is a marker for heart failure (HF) severity, but its association with hospital readmission is not well defined.We identified all hospital discharges (n=109 875) with a primary diagnosis of HF in the Veterans Affairs Health Care System from 2006 to 2009. We examined the association between admission (n=53 585), discharge (n=24 326), and change in BNP (n=7187) and 30-day readmission for HF or other causes. Thirty-day HF readmission was associated with elevated admission BNP, elevated discharge BNP, and smaller percent change in BNP from admission to discharge. Patients with a discharge BNP ≥ 1000 ng/L had an unadjusted 30-day HF readmission rate over 3 times as high as patients whose discharge BNP was ≤ 200 ng/L (15% vs. 4.1%). BNP improved discrimination and risk classification for 30-day HF readmission when added to a base clinical model, with discharge BNP having the greatest effect (C-statistic, 0.639 to 0.664 [P<0.0001]; net reclassification improvement, 9% [P<0.0001]). In contrast, 30-day readmission for non-HF causes was not associated with BNP levels during index HF hospitalization.In this study of over 50 000 veterans hospitalized with a primary diagnosis of HF, BNP levels measured during hospitalization were associated with 30-day HF readmission, but not readmissions for other causes. These data may help guide future study aimed at identifying the optimal timing for hospital discharge and help allocate high-intensity, HF-specific transitional care interventions to the patients most likely to benefit.

  View details for DOI 10.1161/JAHA.114.000806

  View details for PubMedID 24922626

• Effectiveness of preoperative beta-blockade on intra-operative heart rate in vascular surgery cases conducted under regional or local anesthesia. SpringerPlus Mudumbai, S. C., Wagner, T., Mahajan, S., King, R., Heidenreich, P. A., Hlatky, M., Wallace, A. W., Mariano, E. R. 2014; 3: 227-?

  View details for DOI 10.1186/2193-1801-3-227

  View details for PubMedID 24855591

• Cost-Effectiveness of Optimal Use of Acute Myocardial Infarction Treatments and Impact on Coronary Heart Disease Mortality in China CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES Wang, M., Moran, A. E., Liu, J., Coxson, P. G., Heidenreich, P. A., Gu, D., He, J., Goldman, L., Zhao, D. 2014; 7 (1): 78-85

  Abstract

  The cost-effectiveness of the optimal use of hospital-based acute myocardial infarction (AMI) treatments and their potential impact on coronary heart disease (CHD) mortality in China is not well known.The effectiveness and costs of optimal use of hospital-based AMI treatments were estimated by the CHD Policy Model-China, a Markov-style computer simulation model. Changes in simulated AMI, CHD mortality, quality-adjusted life years, and total healthcare costs were the outcomes. The incremental cost-effectiveness ratio was used to assess projected cost-effectiveness. Optimal use of 4 oral drugs (aspirin, β-blockers, statins, and angiotensin-converting enzyme inhibitors) in all eligible patients with AMI or unfractionated heparin in non-ST-segment-elevation myocardial infarction was a highly cost-effective strategy (incremental cost-effectiveness ratios approximately US $3100 or less). Optimal use of reperfusion therapies in eligible patients with ST-segment-elevation myocardial infarction was moderately cost effective (incremental cost-effectiveness ratio ≤$10,700). Optimal use of clopidogrel for all eligible patients with AMI or primary percutaneous coronary intervention among high-risk patients with non-ST-segment-elevation myocardial infarction in tertiary hospitals alone was less cost effective. Use of all the selected hospital-based AMI treatment strategies together would be cost-effective and reduce the total CHD mortality rate in China by ≈9.6%.Optimal use of most standard hospital-based AMI treatment strategies, especially combined strategies, would be cost effective in China. However, because so many AMI deaths occur outside of the hospital in China, the overall impact on preventing CHD deaths was projected to be modest.

  View details for DOI 10.1161/CIRCOUTCOMES.113.000674

  View details for Web of Science ID 000331071200012

  View details for PubMedID 24425706

  View details for PubMedCentralID PMC4191653

• Adherence and persistence in the use of warfarin after hospital discharge among patients with heart failure and atrial fibrillation. Journal of cardiac failure Eapen, Z. J., Mi, X., Qualls, L. G., Hammill, B. G., Fonarow, G. C., Turakhia, M. P., Heidenreich, P. A., Peterson, E. D., Curtis, L. H., Hernandez, A. F., Al-Khatib, S. M. 2014; 20 (1): 23-30

  Abstract

  Postdischarge adherence and long-term persistence in the use of warfarin among patients with heart failure and atrial fibrillation without contraindications have not been fully described.We identified patients with heart failure and atrial fibrillation who were ≥65 years old, eligible for warfarin, and discharged home from hospitals in the Get With the Guidelines-Heart Failure registry from January 1, 2006, to December 31, 2009. We used linked Medicare prescription drug event data to measure adherence and persistence. The main outcome measures were rates of prescription at discharge, outpatient dispensing, discontinuation, and adherence as measured by the medication possession ratio. We hypothesized that adherence to warfarin would differ according to whether patients received the prescription at discharge. Among 2,691 eligible patients, 1,856 (69.0%) were prescribed warfarin at discharge. Patients prescribed warfarin at discharge had significantly higher prescription fill rates within 90 days (84.5% vs 12.3%; P < .001) and 1 year (91.6% vs 16.8%; P < .001) and significantly higher medication possession ratios (0.78 vs 0.63; P < .001). Among both previous nonusers and existing users, fill rates at 90 days and 1 year and possession ratios were significantly higher among those prescribed warfarin at discharge.One-third of eligible patients with heart failure and atrial fibrillation were not prescribed warfarin at discharge from a heart failure hospitalization, and few started therapy as outpatients. In contrast, most patients who were prescribed warfarin at discharge filled the prescription within 90 days and remained on therapy at 1 year.

  View details for DOI 10.1016/j.cardfail.2013.11.006

  View details for PubMedID 24275703

• Expert consensus for multi-modality imaging evaluation of cardiovascular complications of radiotherapy in adults: a report from the European Association of Cardiovascular Imaging and the American Society of Echocardiography (vol 26, pg 1013, 2013) EUROPEAN HEART JOURNAL-CARDIOVASCULAR IMAGING Lancellotti, P., Nkomo, V. T., Badano, L. P., Bergler-Klein, J., Bogaert, J., Davin, L., Cosyns, B., Coucke, P., Dulgheru, R., Edvardsen, T., Gaemperli, O., Galderisi, M., Griffin, B., Heidenreich, P. A., Nieman, K., Plana, J. C., Port, S. C., Scherrer-Crosbie, M., Schwartz, R. G., Sebag, I. A., Voigt, J., Wann, S., Yang, P. C., European Soc, Amer Soc Nucl Cardiology, Soc Cardiovasc Magnetic Resonance, Soc Cardiovasc Comp Tomography 2013; 14 (12): 1217

  View details for DOI 10.1093/ehjci/jet238

  View details for Web of Science ID 000326966100020

• Factors Associated With DNR Status Among Patients Hospitalized for Heart Failure in California Phadke, A., Heidenreich, P. LIPPINCOTT WILLIAMS & WILKINS. 2013

  View details for Web of Science ID 000332162906187

• Clinical Effectiveness of Cardiac Resynchronization Therapy Compared to Medical Therapy Alone Among Patients With Heart Failure: An Analysis of the ICD and ADHERE National Registries Khazanie, P., Hammill, B. G., Quails, L. G., Fonarow, G. C., Hammill, S. C., Heidenreich, P. A., Al-Khatib, S. M., Piccini, J. P., Masoudi, F. A., Peterson, P. N., Curtis, J. P., Hernandez, A. F., Curtis, L. H. LIPPINCOTT WILLIAMS & WILKINS. 2013

  View details for Web of Science ID 000332162906476

• Racial Disparities in Warfarin Time in INR Therapeutic Range in Patients With Atrial Fibrillation: Findings From the TREAT-AF Study Yong, C., Xu, X., Than, C., Ullal, A., Schmitt, S., Azarbal, F., Heidenreich, P., Turakhia, M. LIPPINCOTT WILLIAMS & WILKINS. 2013

  View details for Web of Science ID 000332162903466

• Genetic Variation Near HCRTR2 Associates With Dramatic Improvement of Heart Function in Patients With Heart Failure Perez, M. V., Pavlovic, A., Wheeler, M. T., Miller, C. L., Thanaporn, P., Dewey, F. E., Pan, S., Absher, D., Cretti, E., Southwick, A., Heidenreich, P., Sedehi, D., Brandimarto, J., Kao, D., Salisbury, H., Chan, K., Rosenthal, D., Bernstein, D., Fowler, M. B., Robbins, R. C., Meyers, R., Meyers, R., Quertermous, T., Cappola, T., Ashley, E. LIPPINCOTT WILLIAMS & WILKINS. 2013

  View details for Web of Science ID 000332162905323

• Cardiovascular Care Facts JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Masoudi, F. A., Ponirakis, A., Yeh, R. W., Maddox, T. M., Beachy, J., Casale, P. N., Curtis, J. P., de Lemos, J., Fonarow, G., Heidenreich, P., Koutras, C., Kremers, M., Messenger, J., Moussa, I., Oetgen, W. J., Roe, M. T., Rosenfield, K., Shields, T. P., Spertus, J. A., Wei, J., White, C., Young, C. H., Rumsfeld, J. S. 2013; 62 (21): 1931-1947

  Abstract

  The aim of this report was to characterize the patients, participating centers, and measures of quality of care and outcomes for 5 NCDR (National Cardiovascular Data Registry) programs: 1) ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry-GWTG (Get With The Guidelines) for acute coronary syndromes; 2) CathPCI Registry for coronary angiography and percutaneous coronary intervention; 3) CARE (Carotid Artery Revascularization and Endarterectomy) Registry for carotid revascularization; 4) ICD Registry for implantable cardioverter defibrillators; and the 5) PINNACLE (Practice INNovation And CLinical Excellence) Registry for outpatients with cardiovascular disease (CVD).CVD is a leading cause of death and disability in the United States. The quality of care for patients with CVD is suboptimal. National registry programs, such as NCDR, permit assessments of the quality of care and outcomes for broad populations of patients with CVD.For the year 2011, we assessed for each of the 5 NCDR programs: 1) demographic and clinical characteristics of enrolled patients; 2) key characteristics of participating centers; 3) measures of processes of care; and 4) patient outcomes. For selected variables, we assessed trends over time.In 2011 ACTION Registry-GWTG enrolled 119,967 patients in 567 hospitals; CathPCI enrolled 632,557 patients in 1,337 hospitals; CARE enrolled 4,934 patients in 130 hospitals; ICD enrolled 139,991 patients in 1,435 hospitals; and PINNACLE enrolled 249,198 patients (1,436,328 individual encounters) in 74 practices (1,222 individual providers). Data on performance metrics and outcomes, in some cases risk-adjusted with validated NCDR models, are presented.The NCDR provides a unique opportunity to understand the characteristics of large populations of patients with CVD, the centers that provide their care, quality of care provided, and important patient outcomes.

  View details for DOI 10.1016/j.jacc.2013.05.099

  View details for Web of Science ID 000326939500006

• Statins and cognitive function: a systematic review. Annals of internal medicine Richardson, K., Schoen, M., French, B., Umscheid, C. A., Mitchell, M. D., Arnold, S. E., Heidenreich, P. A., Rader, D. J., DeGoma, E. M. 2013; 159 (10): 688-697

  Abstract

  Despite the U.S. Food and Drug Administration (FDA) warning regarding cognitive impairment, the relationship between statins and cognition remains unknown.To examine the effect of statins on cognition.PubMed, Embase, and Cochrane Library from inception through October 2012; FDA databases from January 1986 through March 2012.Randomized, controlled trials (RCTs) and cohort, case-control, and cross-sectional studies evaluating cognition in patients receiving statins.Two reviewers extracted data, 1 reviewer assessed study risk of bias, and 1 reviewer checked all assessments.Among statin users, low-quality evidence suggested no increased incidence of Alzheimer disease and no difference in cognitive performance related to procedural memory, attention, or motor speed. Moderate-quality evidence suggested no increased incidence of dementia or mild cognitive impairment or any change in cognitive performance related to global cognitive performance scores, executive function, declarative memory, processing speed, or visuoperception. Examination of the FDA postmarketing surveillance databases revealed a low reporting rate for cognitive-related adverse events with statins that was similar to the rates seen with other commonly prescribed cardiovascular medications.The absence of many well-powered RCTs for most outcomes resulted in final strengths of evidence that were low or moderate. Imprecision, inconsistency, and risk of bias also limited the strength of findings.Larger and better-designed studies are needed to draw unequivocal conclusions about the effect of statins on cognition. Published data do not suggest an adverse effect of statins on cognition; however, the strength of available evidence is limited, particularly with regard to high-dose statins.

  View details for DOI 10.7326/0003-4819-159-10-201311190-00007

  View details for PubMedID 24247674

• Cardiovascular care facts: a report from the national cardiovascular data registry: 2011. Journal of the American College of Cardiology Masoudi, F. A., Ponirakis, A., Yeh, R. W., Maddox, T. M., Beachy, J., Casale, P. N., Curtis, J. P., de Lemos, J., Fonarow, G., Heidenreich, P., Koutras, C., Kremers, M., Messenger, J., Moussa, I., Oetgen, W. J., Roe, M. T., Rosenfield, K., Shields, T. P., Spertus, J. A., Wei, J., White, C., Young, C. H., Rumsfeld, J. S. 2013; 62 (21): 1931-1947

  Abstract

  The aim of this report was to characterize the patients, participating centers, and measures of quality of care and outcomes for 5 NCDR (National Cardiovascular Data Registry) programs: 1) ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry-GWTG (Get With The Guidelines) for acute coronary syndromes; 2) CathPCI Registry for coronary angiography and percutaneous coronary intervention; 3) CARE (Carotid Artery Revascularization and Endarterectomy) Registry for carotid revascularization; 4) ICD Registry for implantable cardioverter defibrillators; and the 5) PINNACLE (Practice INNovation And CLinical Excellence) Registry for outpatients with cardiovascular disease (CVD).CVD is a leading cause of death and disability in the United States. The quality of care for patients with CVD is suboptimal. National registry programs, such as NCDR, permit assessments of the quality of care and outcomes for broad populations of patients with CVD.For the year 2011, we assessed for each of the 5 NCDR programs: 1) demographic and clinical characteristics of enrolled patients; 2) key characteristics of participating centers; 3) measures of processes of care; and 4) patient outcomes. For selected variables, we assessed trends over time.In 2011 ACTION Registry-GWTG enrolled 119,967 patients in 567 hospitals; CathPCI enrolled 632,557 patients in 1,337 hospitals; CARE enrolled 4,934 patients in 130 hospitals; ICD enrolled 139,991 patients in 1,435 hospitals; and PINNACLE enrolled 249,198 patients (1,436,328 individual encounters) in 74 practices (1,222 individual providers). Data on performance metrics and outcomes, in some cases risk-adjusted with validated NCDR models, are presented.The NCDR provides a unique opportunity to understand the characteristics of large populations of patients with CVD, the centers that provide their care, quality of care provided, and important patient outcomes.

  View details for DOI 10.1016/j.jacc.2013.05.099

  View details for PubMedID 24036027

• Statins and Cognitive Function ANNALS OF INTERNAL MEDICINE Richardson, K., Schoen, M., French, B., Umscheid, C. A., Mitchell, M. D., Arnold, S. E., Heidenreich, P. A., Rader, D. J., deGoma, E. M. 2013; 159 (10): 688-?

  Abstract

  Despite the U.S. Food and Drug Administration (FDA) warning regarding cognitive impairment, the relationship between statins and cognition remains unknown.To examine the effect of statins on cognition.PubMed, Embase, and Cochrane Library from inception through October 2012; FDA databases from January 1986 through March 2012.Randomized, controlled trials (RCTs) and cohort, case-control, and cross-sectional studies evaluating cognition in patients receiving statins.Two reviewers extracted data, 1 reviewer assessed study risk of bias, and 1 reviewer checked all assessments.Among statin users, low-quality evidence suggested no increased incidence of Alzheimer disease and no difference in cognitive performance related to procedural memory, attention, or motor speed. Moderate-quality evidence suggested no increased incidence of dementia or mild cognitive impairment or any change in cognitive performance related to global cognitive performance scores, executive function, declarative memory, processing speed, or visuoperception. Examination of the FDA postmarketing surveillance databases revealed a low reporting rate for cognitive-related adverse events with statins that was similar to the rates seen with other commonly prescribed cardiovascular medications.The absence of many well-powered RCTs for most outcomes resulted in final strengths of evidence that were low or moderate. Imprecision, inconsistency, and risk of bias also limited the strength of findings.Larger and better-designed studies are needed to draw unequivocal conclusions about the effect of statins on cognition. Published data do not suggest an adverse effect of statins on cognition; however, the strength of available evidence is limited, particularly with regard to high-dose statins.

  View details for Web of Science ID 000328732700017

• Survival after shock therapy in implantable cardioverter-defibrillator and cardiac resynchronization therapy-defibrillator recipients according to rhythm shocked. The ALTITUDE survival by rhythm study. Journal of the American College of Cardiology Powell, B. D., Saxon, L. A., Boehmer, J. P., Day, J. D., Gilliam, F. R., Heidenreich, P. A., Jones, P. W., Rousseau, M. J., Hayes, D. L. 2013; 62 (18): 1674-1679

  Abstract

  We sought to determine if the mortality risk associated with inappropriate ICD shocks is due to the underlying arrhythmia or the shock itself.Shocks delivered from ICDs are associated with increased mortality risk. It is unknown if all patients that experience inappropriate ICD shocks have an increased risk of death.We evaluated survival outcomes in ICD and CRT-D patients enrolled in the LATITUDE remote monitoring system through January 1, 2010. First shock episode rhythms from 3,809 patients who acutely survived the initial shock were adjudicated by seven electrophysiologists. Patients with a shock were matched to patients without a shock (n=3,630) by age at implant, implant year, gender, and device type.The mean age of the study group was 64±13 years, with 78% male. Compared to no shock, there was increased mortality in those who received their first shock for monomorphic ventricular tachycardia (HR 1.65, p<0.0001), ventricular fibrillation/polymorphic ventricular tachycardia (HR 2.10, p<0.0001), and atrial fibrillation/flutter (HR 1.61, p=0.003). In contrast, mortality following first shocks due to sinus tachycardia and supraventricular tachycardia (HR 0.97, p=0.86), and noise/artifact/oversensing (HR 0.91, p=0.76) was comparable to that in patients without a shock.Compared to no shock, those who received their first shock for ventricular rhythms and atrial fibrillation had an increased risk of death. There was no significant difference in survival after inappropriate shocks for sinus tachycardia or noise/artifact/oversensing. In this study, the adverse prognosis following first shock appears to be more related to the underlying arrhythmia than to an adverse effect from the shock itself.

  View details for DOI 10.1016/j.jacc.2013.04.083

  View details for PubMedID 23810882

• Survival After Shock Therapy in Implantable Cardioverter-Defibrillator and Cardiac Resynchronization Therapy-Defibrillator Recipients According to Rhythm Shocked JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Powell, B. D., Saxon, L. A., Boehmer, J. P., Day, J. D., Gilliam, F. R., Heidenreich, P. A., Jones, P. W., Rousseau, M. J., Hayes, D. L. 2013; 62 (18): 1674-1679

  Abstract

  We sought to determine if the mortality risk associated with inappropriate ICD shocks is due to the underlying arrhythmia or the shock itself.Shocks delivered from ICDs are associated with increased mortality risk. It is unknown if all patients that experience inappropriate ICD shocks have an increased risk of death.We evaluated survival outcomes in ICD and CRT-D patients enrolled in the LATITUDE remote monitoring system through January 1, 2010. First shock episode rhythms from 3,809 patients who acutely survived the initial shock were adjudicated by seven electrophysiologists. Patients with a shock were matched to patients without a shock (n=3,630) by age at implant, implant year, gender, and device type.The mean age of the study group was 64±13 years, with 78% male. Compared to no shock, there was increased mortality in those who received their first shock for monomorphic ventricular tachycardia (HR 1.65, p<0.0001), ventricular fibrillation/polymorphic ventricular tachycardia (HR 2.10, p<0.0001), and atrial fibrillation/flutter (HR 1.61, p=0.003). In contrast, mortality following first shocks due to sinus tachycardia and supraventricular tachycardia (HR 0.97, p=0.86), and noise/artifact/oversensing (HR 0.91, p=0.76) was comparable to that in patients without a shock.Compared to no shock, those who received their first shock for ventricular rhythms and atrial fibrillation had an increased risk of death. There was no significant difference in survival after inappropriate shocks for sinus tachycardia or noise/artifact/oversensing. In this study, the adverse prognosis following first shock appears to be more related to the underlying arrhythmia than to an adverse effect from the shock itself.

  View details for DOI 10.1016/j.jacc.2013.04.083

  View details for Web of Science ID 000326237300006

• Reasons for Not Prescribing Guideline-recommended Medications to Adults With Heart Failure MEDICAL CARE Steinman, M. A., Dimaano, L., Peterson, C. A., Heidenreich, P. A., Knight, S. J., Fung, K. Z., Kaboli, P. J. 2013; 51 (10): 901-907

  Abstract

  Little is known about how often contextual factors such as patient preferences and competing priorities impact prescribing of guideline-recommended medications, or about the extent to which these factors are documented in medical records and available to performance measurement systems.Mixed-methods study of 295 veterans aged 50 years and older in 4 VA health care systems who had systolic heart failure and were not prescribed a β-blocker and/or an angiotensin converting enzyme inhibitor or angiotensin-receptor blocker. Reasons for nontreatment were identified from clinic notes and from interviews with 62 primary care clinicians caring for these patients. These reasons were classified using a published taxonomy.Among 295 patients not receiving guideline-recommended drugs for heart failure, chart review identified biomedical reasons for nonprescribing in 42%-58% of patients and contextual reasons in 11%-17%. Clinician interviews identified twice as many reasons for nonprescribing as chart review (mean 1.6 vs. 0.8 reasons per patient, P<0.001). In these interviews, biomedical reasons for nonprescribing were cited in 50%-70% of patients, and contextual reasons in 64%-70%. The most common contextual reasons were comanagement with other clinicians (32%-35% of patients), patient preferences and nonadherence (15%-24%), and clinician belief that the medication is not indicated in the patient (12%-20%).Contextual reasons for not prescribing angiotensin converting enzyme inhibitor / angiotensin-receptor blockers and β-blockers are present in two thirds of patients with heart failure who did not receive these medications, yet are poorly documented in medical records. The structure of medical records should be improved to facilitate documentation of contextual reasons for not providing guideline-recommended care.

  View details for PubMedID 23969589

• Associations Between Use of the Hospitalist Model and Quality of Care and Outcomes of Older Patients Hospitalized for Heart Failure JACC-HEART FAILURE Kociol, R. D., Hammill, B. G., Fonarow, G. C., Heidenreich, P. A., Go, A. S., Peterson, E. D., Curtis, L. H., Hernandez, A. F. 2013; 1 (5): 445-453

  Abstract

  This study sought to examine the associations of hospitalist and cardiologist care of patients with heart failure with outcomes and adherence to quality measures.The hospitalist model of inpatient care has grown nationally, but its associations with quality of care and outcomes of patients hospitalized with heart failure are not known.We analyzed data from the Get With the Guidelines-Heart Failure registry linked to Medicare claims for 2005 through 2008. For each hospital, we calculated the percentage of heart failure hospitalizations for which a hospitalist was the attending physician. We examined outcomes and care quality for patients stratified by rates of hospitalist use. Using multivariable models, we estimated associations between hospital-level use of hospitalists and cardiologists and 30-day risk-adjusted outcomes and adherence to measures of quality care.The analysis included 31,505 Medicare beneficiaries in 166 hospitals. Across hospitals, the use of hospitalists varied from 0% to 83%. After multivariable adjustment, a 10% increase in the use of hospitalists was associated with a slight increase in mortality (risk ratio: 1.03; 95% confidence interval [CI]: 1.00 to 1.06) and decrease in length of stay (0.09 days; 95% CI: 0.02 to 0.16). There was no association with 30-day readmission. Increased use of hospitalists in hospitals with high use of cardiologists was associated with improved defect-free adherence to a composite of heart failure performance measures (risk ratio: 1.03; 95% CI: 1.01 to 1.06).Hospitalist care varied significantly across hospitals for heart failure admissions and was not associated with improved 30-day outcomes. Comanagement by hospitalists and cardiologists may help to improve adherence to some quality measures, but it remains unclear what care model improves 30-day clinical outcomes.

  View details for DOI 10.1016/j.jchf.2013.07.001

  View details for Web of Science ID 000209535900012

• Associations between use of the hospitalist model and quality of care and outcomes of older patients hospitalized for heart failure. JACC. Heart failure Kociol, R. D., Hammill, B. G., Fonarow, G. C., Heidenreich, P. A., Go, A. S., Peterson, E. D., Curtis, L. H., Hernandez, A. F. 2013; 1 (5): 445-453

  Abstract

  This study sought to examine the associations of hospitalist and cardiologist care of patients with heart failure with outcomes and adherence to quality measures.The hospitalist model of inpatient care has grown nationally, but its associations with quality of care and outcomes of patients hospitalized with heart failure are not known.We analyzed data from the Get With the Guidelines-Heart Failure registry linked to Medicare claims for 2005 through 2008. For each hospital, we calculated the percentage of heart failure hospitalizations for which a hospitalist was the attending physician. We examined outcomes and care quality for patients stratified by rates of hospitalist use. Using multivariable models, we estimated associations between hospital-level use of hospitalists and cardiologists and 30-day risk-adjusted outcomes and adherence to measures of quality care.The analysis included 31,505 Medicare beneficiaries in 166 hospitals. Across hospitals, the use of hospitalists varied from 0% to 83%. After multivariable adjustment, a 10% increase in the use of hospitalists was associated with a slight increase in mortality (risk ratio: 1.03; 95% confidence interval [CI]: 1.00 to 1.06) and decrease in length of stay (0.09 days; 95% CI: 0.02 to 0.16). There was no association with 30-day readmission. Increased use of hospitalists in hospitals with high use of cardiologists was associated with improved defect-free adherence to a composite of heart failure performance measures (risk ratio: 1.03; 95% CI: 1.01 to 1.06).Hospitalist care varied significantly across hospitals for heart failure admissions and was not associated with improved 30-day outcomes. Comanagement by hospitalists and cardiologists may help to improve adherence to some quality measures, but it remains unclear what care model improves 30-day clinical outcomes.

  View details for DOI 10.1016/j.jchf.2013.07.001

  View details for PubMedID 24621978

• Expert Consensus for Multi-Modality Imaging Evaluation of Cardiovascular Complications of Radiotherapy in Adults: A Report from the European Association of Cardiovascular Imaging and the American Society of Echocardiography JOURNAL OF THE AMERICAN SOCIETY OF ECHOCARDIOGRAPHY Lancellotti, P., Nkomo, V. T., Badano, L. P., Bergler, J., Bogaert, J., Davin, L., Cosyns, B., Coucke, P., Dulgheru, R., Edvardsen, T., Gaemperli, O., Galderisi, M., Griffin, B., Heidenreich, P. A., Nieman, K., Plana, J. C., Port, S. C., Scherrer-Crosbie, M., Schwartz, R. G., Sebag, I. A., Voigt, J., Wann, S., Yang, P. C. 2013; 26 (9): 1013-1032

  Abstract

  Cardiac toxicity is one of the most concerning side effects of anti-cancer therapy. The gain in life expectancy obtained with anti-cancer therapy can be compromised by increased morbidity and mortality associated with its cardiac complications. While radiosensitivity of the heart was initially recognized only in the early 1970s, the heart is regarded in the current era as one of the most critical dose-limiting organs in radiotherapy. Several clinical studies have identified adverse clinical consequences of radiation-induced heart disease (RIHD) on the outcome of long-term cancer survivors. A comprehensive review of potential cardiac complications related to radiotherapy is warranted. An evidence-based review of several imaging approaches used to detect, evaluate, and monitor RIHD is discussed. Recommendations for the early identification and monitoring of cardiovascular complications of radiotherapy by cardiac imaging are also proposed.

  View details for DOI 10.1016/j.echo.2013.07.005

  View details for Web of Science ID 000324028300003

  View details for PubMedID 23998694

• Diagnostic utility of a novel leadless arrhythmia monitoring device. American journal of cardiology Turakhia, M. P., Hoang, D. D., Zimetbaum, P., Miller, J. D., Froelicher, V. F., Kumar, U. N., Xu, X., Yang, F., Heidenreich, P. A. 2013; 112 (4): 520-524

  Abstract

  Although extending the duration of ambulatory electrocardiographic monitoring beyond 24 to 48 hours can improve the detection of arrhythmias, lead-based (Holter) monitors might be limited by patient compliance and other factors. We, therefore, evaluated compliance, analyzable signal time, interval to arrhythmia detection, and diagnostic yield of the Zio Patch, a novel leadless, electrocardiographic monitoring device in 26,751 consecutive patients. The mean wear time was 7.6 ± 3.6 days, and the median analyzable time was 99% of the total wear time. Among the patients with detected arrhythmias (60.3% of all patients), 29.9% had their first arrhythmia and 51.1% had their first symptom-triggered arrhythmia occur after the initial 48-hour period. Compared with the first 48 hours of monitoring, the overall diagnostic yield was greater when data from the entire Zio Patch wear duration were included for any arrhythmia (62.2% vs 43.9%, p <0.0001) and for any symptomatic arrhythmia (9.7% vs 4.4%, p <0.0001). For paroxysmal atrial fibrillation (AF), the mean interval to the first detection of AF was inversely proportional to the total AF burden, with an increasing proportion occurring after 48 hours (11.2%, 10.5%, 20.8%, and 38.0% for an AF burden of 51% to 75%, 26% to 50%, 1% to 25%, and <1%, respectively). In conclusion, extended monitoring with the Zio Patch for ≤14 days is feasible, with high patient compliance, a high analyzable signal time, and an incremental diagnostic yield beyond 48 hours for all arrhythmia types. These findings could have significant implications for device selection, monitoring duration, and care pathways for arrhythmia evaluation and AF surveillance.

  View details for DOI 10.1016/j.amjcard.2013.04.017

  View details for PubMedID 23672988

• QRS Duration, Bundle-Branch Block Morphology, and Outcomes Among Older Patients With Heart Failure Receiving Cardiac Resynchronization Therapy JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Peterson, P. N., Greiner, M. A., Qualls, L. G., Al-Khatib, S. M., Curtis, J. P., Fonarow, G. C., Hammill, S. C., Heidenreich, P. A., Hammill, B. G., Piccini, J. P., Hernandez, A. F., Curtis, L. H., Masoudi, F. A. 2013; 310 (6): 617-626

  Abstract

  The benefits of cardiac resynchronization therapy (CRT) in clinical trials were greater among patients with left bundle-branch block (LBBB) or longer QRS duration.To measure associations between QRS duration and morphology and outcomes among patients receiving a CRT defibrillator (CRT-D) in clinical practice.Retrospective cohort study of Medicare beneficiaries in the National Cardiovascular Data Registry's ICD Registry between 2006 and 2009 who underwent CRT-D implantation. Patients were stratified according to whether they were admitted for CRT-D implantation or for another reason, then categorized as having either LBBB or no LBBB and QRS duration of either 150 ms or greater or 120 to 149 ms.All-cause mortality; all-cause, cardiovascular, and heart failure readmission; and complications. Patients underwent follow-up for up to 3 years, with follow-up through December 2011.Among 24 169 patients admitted for CRT-D implantation, 1-year and 3-year mortality rates were 9.2% and 25.9%, respectively. All-cause readmission rates were 10.2% at 30 days and 43.3% at 1 year. Both the unadjusted rate and adjusted risk of 3-year mortality were lowest among patients with LBBB and QRS duration of 150 ms or greater (20.9%), compared with LBBB and QRS duration of 120 to 149 ms (26.5%; adjusted hazard ratio [HR], 1.30 [99% CI, 1.18-1.42]), no LBBB and QRS duration of 150 ms or greater (30.7%; HR, 1.34 [99% CI, 1.20-1.49]), and no LBBB and QRS duration of 120 to 149 ms (32.3%; HR, 1.52 [99% CI, 1.38-1.67]). The unadjusted rate and adjusted risk of 1-year all-cause readmission were also lowest among patients with LBBB and QRS duration of 150 ms or greater (38.6%), compared with LBBB and QRS duration of 120 to 149 ms (44.8%; adjusted HR, 1.18 [99% CI, 1.10-1.26]), no LBBB and QRS duration of 150 ms or greater (45.7%; HR, 1.16 [99% CI, 1.08-1.26]), and no LBBB and QRS duration of 120 to 149 ms (49.6%; HR, 1.31 [99% CI, 1.23-1.40]). There were no observed associations with complications.Among fee-for-service Medicare beneficiaries undergoing CRT-D implantation in clinical practice, LBBB and QRS duration of 150 ms or greater, compared with LBBB and QRS duration less than 150 ms or no LBBB regardless of QRS duration, was associated with lower risk of all-cause mortality and of all-cause, cardiovascular, and heart failure readmissions.

  View details for DOI 10.1001/jama.2013.8641

  View details for Web of Science ID 000323058400017

  View details for PubMedID 23942680

• QRS Duration, Bundle-Branch Block Morphology, and Outcomes Among Older Patients With Heart Failure Receiving Cardiac Resynchronization Therapy (vol 310, pg 617, 2013) JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Peterson, P. N., Greiner, M. A., Qualls, L. G., Al-Khatib, S. M., Curtis, J. P., Fonarow, G. C., Hammill, S. C., Heidenreich, P. A., Hammill, B. G., Piccini, J. P., Hernandez, A. F., Curtis, L. H., Masoudi, F. A. 2013; 310 (6)

  View details for Web of Science ID 000323197600001

• Risk-Standardizing Survival for In-Hospital Cardiac Arrest to Facilitate Hospital Comparisons JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Chan, P. S., Berg, R. A., Spertus, J. A., Schwamm, L. H., Bhatt, D. L., Fonarow, G. C., Heidenreich, P. A., Nallamothu, B. K., Tang, F., Merchant, R. M. 2013; 62 (7): 601-609

  Abstract

  OBJECTIVES: To develop a method for risk-standardizing hospital survival after cardiac arrest. BACKGROUND: A foundation with which hospitals can improve quality is to be able to benchmark their risk-adjusted performance against other hospitals, something that cannot currently be done for survival after in-hospital cardiac arrest. METHODS: Within the Get With The Guidelines-Resuscitation registry, we identified 48,841 patients admitted between 2007 and 2010 with an in-hospital cardiac arrest. Using hierarchical logistic regression, we derived and validated a model for survival to hospital discharge and calculated risk-standardized survival rates (RSSRs) for 272 hospitals with at least 10 cardiac arrest cases. RESULTS: The survival rate was 21.0% and 21.2% for the derivation and validation cohorts, respectively. The model had good discrimination (C-statistic 0.74) and excellent calibration. Eighteen variables were associated with survival to discharge, and a parsimonious model contained 9 variables with minimal change in model discrimination. Prior to risk-adjustment, the median hospital survival rate was 20% (IQR: 14%-26%), with a wide range (0%-85%). After adjustment, the distribution of RSSRs was substantially narrower: median of 21% (IQR: 19%-23%; range: 11%-35%). More than half (143 [52.6%]) of hospitals had at least a 10% positive or negative absolute change in percentile rank after risk standardization, and 50 (23.2%) had a ≥20% absolute change in percentile rank. CONCLUSION: We have derived and validated a model to risk-standardize hospital rates of survival for in-hospital cardiac arrest. Use of this model can support efforts to compare hospitals in resuscitation outcomes as a foundation for quality assessment and improvement.

  View details for DOI 10.1016/j.jacc.2013.05.051

  View details for Web of Science ID 000323605200007

  View details for PubMedID 23770167

• Expert consensus for multi-modality imaging evaluation of cardiovascular complications of radiotherapy in adults: a report from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. European heart journal cardiovascular Imaging Lancellotti, P., Nkomo, V. T., Badano, L. P., Bergler-Klein, J., Bogaert, J., Davin, L., Cosyns, B., Coucke, P., Dulgheru, R., Edvardsen, T., Gaemperli, O., Galderisi, M., Griffin, B., Heidenreich, P. A., Nieman, K., Plana, J. C., Port, S. C., Scherrer-Crosbie, M., Schwartz, R. G., Sebag, I. A., Voigt, J., Wann, S., Yang, P. C. 2013; 14 (8): 721-740

  Abstract

  Cardiac toxicity is one of the most concerning side effects of anti-cancer therapy. The gain in life expectancy obtained with anti-cancer therapy can be compromised by increased morbidity and mortality associated with its cardiac complications. While radiosensitivity of the heart was initially recognized only in the early 1970s, the heart is regarded in the current era as one of the most critical dose-limiting organs in radiotherapy. Several clinical studies have identified adverse clinical consequences of radiation-induced heart disease (RIHD) on the outcome of long-term cancer survivors. A comprehensive review of potential cardiac complications related to radiotherapy is warranted. An evidence-based review of several imaging approaches used to detect, evaluate, and monitor RIHD is discussed. Recommendations for the early identification and monitoring of cardiovascular complications of radiotherapy by cardiac imaging are also proposed.

  View details for DOI 10.1093/ehjci/jet123

  View details for PubMedID 23847385

• COST-EFFECTIVENESS OF IMPROVING ACUTE MYOCARDIAL INFARCTION TREATMENTS AND THE IMPACT ON MORTALITY RATE OF CORONARY HEART DISEASE IN CHINA Miao, W., Moran, A., Liu, J., Coxson, P., Heidenreich, P., Gu, D., He, J., Goldman, L., Zhao, D. BMJ PUBLISHING GROUP. 2013: E127

  View details for DOI 10.1136/heartjnl-2013-304613.345

  View details for Web of Science ID 000331272900343

• Improvement of Guideline Beta-Blocker Prescribing in Heart Failure: A Cluster-Randomized Pragmatic Trial of a Pharmacy Intervention JOURNAL OF CARDIAC FAILURE McCarren, M., Furmaga, E., Jackevicius, C. A., Sahay, A., Coppler, T. L., Katzianer, J., Griffiths, R. L., Tonnu-Mihara, I., Heidenreich, P. 2013; 19 (8): 525-532

  Abstract

  Treatment with specific beta-blockers and doses recommended by guidelines is often not achieved in practice. We evaluated an intervention directed to the pharmacy to improve prescribing.We conducted a pragmatic cluster-randomized trial, where facilities (n = 12) with patients (n = 220) were the clusters. Eligible patients had a beta-blocker prescription that was not guideline concordant. Level 1 intervention included information to a pharmacist on facility guideline concordance. Level 2 also provided a list of patients not meeting guideline goals. Intervention and follow-up periods were each 6 months. Achievement of full concordance with recommendations was low (4%-5%) in both groups, primarily due to lack of tolerability. However, compared with level 1, the level 2 intervention was associated with 1.9-fold greater odds of improvement in prescribing (95% confidence interval [CI] 1.1-3.2). Level 2 patients also had greater odds of a higher dose (1.9, 95% CI 1.1-3.3). The intervention was aided by the patient lists provided, the electronic medical record system, and staff support.In actual practice, full achievement of guideline goals was low. However, a simple intervention targeting pharmacy moved patients toward guideline goals. As health care systems incorporate electronic medical records, this intervention should have broader feasibility.

  View details for DOI 10.1016/j.cardfail.2013.06.004

  View details for Web of Science ID 000323142400001

  View details for PubMedID 23910580

• Expert consensus for multi-modality imaging evaluation of cardiovascular complications of radiotherapy in adults: a report from the European Association of Cardiovascular Imaging and the American Society of Echocardiography EUROPEAN HEART JOURNAL-CARDIOVASCULAR IMAGING Lancellotti, P., Nkomo, V. T., Badano, L. P., Bergler, J., Bogaert, J., Davin, L., Cosyns, B., Coucke, P., Dulgheru, R., Edvardsen, T., Gaemperli, O., Galderisi, M., Griffin, B., Heidenreich, P. A., Nieman, K., Plana, J. C., Port, S. C., Scherrer-Crosbie, M., Schwartz, R. G., Sebag, I. A., Voigt, J., Wann, S., Yang, P. C. 2013; 14 (8): 721-740

  Abstract

  Cardiac toxicity is one of the most concerning side effects of anti-cancer therapy. The gain in life expectancy obtained with anti-cancer therapy can be compromised by increased morbidity and mortality associated with its cardiac complications. While radiosensitivity of the heart was initially recognized only in the early 1970s, the heart is regarded in the current era as one of the most critical dose-limiting organs in radiotherapy. Several clinical studies have identified adverse clinical consequences of radiation-induced heart disease (RIHD) on the outcome of long-term cancer survivors. A comprehensive review of potential cardiac complications related to radiotherapy is warranted. An evidence-based review of several imaging approaches used to detect, evaluate, and monitor RIHD is discussed. Recommendations for the early identification and monitoring of cardiovascular complications of radiotherapy by cardiac imaging are also proposed.

  View details for DOI 10.1093/ehjci/jet123

  View details for Web of Science ID 000321833100001

  View details for PubMedID 23847385

• Association of age and packed red blood cell transfusion to 1-year survival - an observational study of ICU patients TRANSFUSION MEDICINE Mudumbai, S. C., Cronkite, R., Hu, K. U., Heidenreich, P. A., Gonzalez, C., Bertaccini, E., Stafford, R. S., Cason, B. A., Mariano, E. R., Wagner, T. 2013; 23 (4): 231-237

  Abstract

  OBJECTIVES: To compare the 1-year survival for different age strata of intensive care unit (ICU) patients after receipt of packed red blood cell (PRBC) transfusions. BACKGROUND: Despite guidelines documenting risks of PRBC transfusion and data showing that increasing age is associated with ICU mortality, little data exist on whether age alters the transfusion-related risk of decreased survival. METHODS: We retrospectively examined data on 2393 consecutive male ICU patients admitted to a tertiary-care hospital from 2003 to 2009 in age strata: 21-50, 51-60, 61-70, 71-80 and >80 years. We calculated Cox regression models to determine the modifying effect of age on the impact of PRBC transfusion on 1-year survival by using interaction terms between receipt of transfusion and age strata, controlling for type of admission and Charlson co-morbidity indices. We also examined the distribution of admission haematocrit and whether transfusion rates differed by age strata. RESULTS: All age strata experienced statistically similar risks of decreased 1-year survival after receipt of PRBC transfusions. However, patients age >80 were more likely than younger cohorts to have haematocrits of 25-30% at admission and were transfused at approximately twice the rate of each of the younger age strata. DISCUSSION: We found no significant interaction between receipt of red cell transfusion and age, as variables, and survival at 1 year as an outcome.

  View details for DOI 10.1111/tme.12010

  View details for Web of Science ID 000321975300005

  View details for PubMedID 23480030

• Patient-centered disease management (PCDM) for heart failure: study protocol for a randomised controlled trial BMC CARDIOVASCULAR DISORDERS Bekelman, D. B., Plomondon, M. E., Sullivan, M. D., Nelson, K., Hattler, B., McBryde, C., Lehmann, K. G., Potfay, J., Heidenreich, P., Rumsfeld, J. S. 2013; 13

  Abstract

  Chronic heart failure (HF) disease management programs have reported inconsistent results and have not included comorbid depression management or specifically focused on improving patient-reported outcomes. The Patient Centered Disease Management (PCDM) trial was designed to test the effectiveness of collaborative care disease management in improving health status (symptoms, functioning, and quality of life) in patients with HF who reported poor HF-specific health status.Patients with a HF diagnosis at four VA Medical Centers were identified through population-based sampling. Patients with a Kansas City Cardiomyopathy Questionnaire (KCCQ, a measure of HF-specific health status) score of < 60 (heavy symptom burden and impaired quality of life) were invited to enroll in the PCDM trial. Enrolled patients were randomized to receive usual care or the PCDM intervention, which included: (1) collaborative care management by VA clinicians including a nurse, cardiologist, internist, and psychiatrist, who worked with patients and their primary care providers to provide guideline-concordant care management, (2) home telemonitoring and guided patient self-management support, and (3) screening and treatment for comorbid depression. The primary study outcome is change in overall KCCQ score. Secondary outcomes include depression, medication adherence, guideline-based care, hospitalizations, and mortality.The PCDM trial builds on previous studies of HF disease management by prioritizing patient health status, implementing a collaborative care model of health care delivery, and addressing depression, a key barrier to optimal disease management. The study has been designed as an 'effectiveness trial' to support broader implementation in the healthcare system if it is successful.Unique identifier: NCT00461513.

  View details for DOI 10.1186/1471-2261-13-49

  View details for Web of Science ID 000322037600001

  View details for PubMedID 23837415

  View details for PubMedCentralID PMC3718720

• Transitional adherence and persistence in the use of aldosterone antagonist therapy in patients with heart failure. American heart journal Curtis, L. H., Mi, X., Qualls, L. G., Check, D. K., Hammill, B. G., Hammill, S. C., Heidenreich, P. A., Masoudi, F. A., Setoguchi, S., Hernandez, A. F., Fonarow, G. C. 2013; 165 (6): 979-986 e1

  Abstract

  Aldosterone antagonist therapy is recommended for selected patients with heart failure and reduced ejection fraction. Adherence to therapy in the transition from hospital to home is not well understood.We identified patients with heart failure and reduced ejection fraction who were ≥65 years old, eligible for aldosterone antagonist therapy, and discharged home from hospitals in the Get With the Guidelines-Heart Failure registry between January 1, 2005, and December 31, 2008. We used Medicare prescription drug event data to measure adherence. Main outcome measures were prescription at discharge, outpatient prescription claim within 90 days, discontinuation, and adherence as measured with the medication possession ratio. We used the cumulative incidence function to estimate rates of initiation and discontinuation.Among 2,086 eligible patients, 561 (26.9%) were prescribed an aldosterone antagonist at discharge. Within 90 days, 78.6% of eligible patients with a discharge prescription filled a prescription for the therapy, compared with 13.0% of eligible patients without a discharge prescription (P < .001). The median medication possession ratio was 0.63 over 1 year of follow-up. Among 634 patients who filled a prescription within 90 days of discharge, 7.9% discontinued therapy within 1 year.Most eligible patients were not prescribed aldosterone antagonist therapy at discharge from a heart failure hospitalization. Eligible patients without a discharge prescription seldom initiated therapy as outpatients. Most patients who were prescribed an aldosterone antagonist at discharge filled the prescription within 90 days and remained on therapy.

  View details for DOI 10.1016/j.ahj.2013.03.007

  View details for PubMedID 23708170

• PILOT CLINICAL TRIAL OF A COLLABORATIVE CARE INTERVENTION TO IMPROVE SYMPTOMS AND QUALITY OF LIFE IN CHRONIC HEART FAILURE Bekelman, D., Nowels, C. T., Main, D., Heidenreich, P., Hattler, B., Lorenz, K., Meek, P., McBryde, C., Hooker, S. SPRINGER. 2013: S149

  View details for Web of Science ID 000331939301113

• Validated, Electronic Health Record Deployable Prediction Models for Assessing Patient Risk of 30-Day Rehospitalization and Mortality in Older Heart Failure Patients JACC-HEART FAILURE Eapen, Z. J., Liang, L., Fonarow, G. C., Heidenreich, P. A., Curtis, L. H., Peterson, E. D., Hernandez, A. F. 2013; 1 (3): 245-251

  Abstract

  The study sought to derive and validate risk-prediction tools from a large nationwide registry linked with Medicare claims data.Few clinical models have been developed utilizing data elements readily available in electronic health records (EHRs) to facilitate "real-time" risk estimation.Heart failure (HF) patients ≥ 65 years of age hospitalized in the GWTG-HF (Get With The Guidelines-Heart Failure) program were linked with Medicare claims from January 2005 to December 2009. Multivariable models were developed for 30-day mortality after admission, 30-day rehospitalization after discharge, and 30-day mortality/rehospitalization after discharge. Candidate variables were selected based on availability in EHRs and prognostic value. The models were validated in a 30% random sample and separately in patients with reduced and preserved ejection fraction (EF).Among 33,349 patients at 160 hospitals, 3,002 (9.1%) died within 30 days of admission, 7,020 (22.8%) were rehospitalized within 30 days of discharge, and 8,374 (27.2%) died or were rehospitalized within 30 days of discharge. Compared with patients classified as low risk, high-risk patients had significantly higher odds of death (odds ratio [OR]: 8.82, 95% confidence interval [CI]: 7.58 to 10.26), rehospitalization (OR: 1.99, 95% CI: 1.86 to 2.13), and death/rehospitalization (OR: 2.65, 95% CI: 2.44 to 2.89). The 30-day mortality model demonstrated good discrimination (c-index 0.75) while the rehospitalization and death/rehospitalization models demonstrated more modest discrimination (c-indices of 0.59 and 0.62), with similar performance in the validation cohort and for patients with preserved and reduced EF.These predictive models allow for risk stratification of 30-day outcomes for patients hospitalized with HF and may provide a validated, point-of-care tool for clinical decision making.

  View details for DOI 10.1016/j.jchf.2013.01.008

  View details for Web of Science ID 000209535500010

• Validated, electronic health record deployable prediction models for assessing patient risk of 30-day rehospitalization and mortality in older heart failure patients. JACC. Heart failure Eapen, Z. J., Liang, L., Fonarow, G. C., Heidenreich, P. A., Curtis, L. H., Peterson, E. D., Hernandez, A. F. 2013; 1 (3): 245-251

  Abstract

  The study sought to derive and validate risk-prediction tools from a large nationwide registry linked with Medicare claims data.Few clinical models have been developed utilizing data elements readily available in electronic health records (EHRs) to facilitate "real-time" risk estimation.Heart failure (HF) patients ≥ 65 years of age hospitalized in the GWTG-HF (Get With The Guidelines-Heart Failure) program were linked with Medicare claims from January 2005 to December 2009. Multivariable models were developed for 30-day mortality after admission, 30-day rehospitalization after discharge, and 30-day mortality/rehospitalization after discharge. Candidate variables were selected based on availability in EHRs and prognostic value. The models were validated in a 30% random sample and separately in patients with reduced and preserved ejection fraction (EF).Among 33,349 patients at 160 hospitals, 3,002 (9.1%) died within 30 days of admission, 7,020 (22.8%) were rehospitalized within 30 days of discharge, and 8,374 (27.2%) died or were rehospitalized within 30 days of discharge. Compared with patients classified as low risk, high-risk patients had significantly higher odds of death (odds ratio [OR]: 8.82, 95% confidence interval [CI]: 7.58 to 10.26), rehospitalization (OR: 1.99, 95% CI: 1.86 to 2.13), and death/rehospitalization (OR: 2.65, 95% CI: 2.44 to 2.89). The 30-day mortality model demonstrated good discrimination (c-index 0.75) while the rehospitalization and death/rehospitalization models demonstrated more modest discrimination (c-indices of 0.59 and 0.62), with similar performance in the validation cohort and for patients with preserved and reduced EF.These predictive models allow for risk stratification of 30-day outcomes for patients hospitalized with HF and may provide a validated, point-of-care tool for clinical decision making.

  View details for DOI 10.1016/j.jchf.2013.01.008

  View details for PubMedID 24621877

• Are we targeting the right metric for heart failure? Comparison of hospital 30-day readmission rates and total episode of care inpatient days. American heart journal Kociol, R. D., Liang, L., Hernandez, A. F., Curtis, L. H., Heidenreich, P. A., Yancy, C. W., Fonarow, G. C., Peterson, E. D. 2013; 165 (6): 987-994 e1

  Abstract

  Hospitals are challenged to reduce length of stay (LOS), yet simultaneously reduce readmissions for patients with heart failure (HF). This study investigates whether 30-day rehospitalization or an alternative measure of total inpatient days over an episode of care (EOC) is the best indicator of resource use, HF quality, and outcomes.Using data from the American Heart Association's Get With The Guidelines-Heart Failure Registry linked to Medicare claims, we ranked and compared hospitals by LOS, 30-day readmission rate, and overall EOC metric, defined as all hospital days for an HF admission and any subsequent admissions within 30 days. We divided hospitals into quartiles by 30-day EOC and 30-day readmission rates. We compared performance by EOC and readmission rate quartiles with respect to quality of care indicators and 30-day postdischarge mortality.The population had a mean age of 80 ± 7.95 years, 45% were male, and 82% were white. Hospital-level unadjusted median index LOS and overall EOC were 4.9 (4.2-5.6) and 6.2 (5.3-7.4) days, respectively. Median 30-day readmission rate was 23.2%. Hospital HF readmission rate was not associated with initial hospital LOS, only slightly associated with total EOC rank (r = 0.26, P = .001), and inversely related to HF performance measures. After adjustment, there was no association between 30-day readmission and decreased 30-day mortality. In contrast, better performance on the EOC metric was associated with decreased odds of 30-day mortality.Although hospital 30-day readmission rate was poorly correlated with LOS, quality measures, and 30-day mortality, better performance on the EOC metric was associated with better 30-day survival. Total inpatient days during a 30-day EOC may more accurately reflect overall resource use and better serve as a target for quality improvement efforts.

  View details for DOI 10.1016/j.ahj.2013.02.006

  View details for PubMedID 23708171

• The National ICD Registry Report: version 2.1 including leads and pediatrics for years 2010 and 2011. Heart rhythm Kremers, M. S., Hammill, S. C., Berul, C. I., Koutras, C., Curtis, J. S., Wang, Y., Beachy, J., Blum Meisnere, L., Conyers, D. M., Reynolds, M. R., Heidenreich, P. A., Al-Khatib, S. M., Pina, I. L., Blake, K., Norine Walsh, M., Wilkoff, B. L., Shalaby, A., Masoudi, F. A., Rumsfeld, J. 2013; 10 (4): e59-65

  View details for DOI 10.1016/j.hrthm.2013.01.035

  View details for PubMedID 23403056

• The National ICD Registry Report: Version 2.1 including leads and pediatrics for years 2010 and 2011 HEART RHYTHM Kremers, M. S., Hammill, S. C., Berul, C. I., Koutras, C., Curtis, J. S., Wang, Y., Beachy, J., Meisnere, L. B., Conyers, D. M., Reynolds, M. R., Heidenreich, P. A., Al-Khatib, S. M., Pina, I. L., Blake, K., Walsh, M. N., Wilkoff, B. L., Shalaby, A., Masoudi, F. A., Rumsfeld, J. 2013; 10 (4): E59-E65

  View details for DOI 10.1016/j.hrthm.2013.01.035

  View details for Web of Science ID 000317277700002

• ACCF/HRS/AHA/ASE/HFSA/SCAI/SCCT/SCMR 2013 appropriate use criteria for implantable cardioverter-defibrillators and cardiac resynchronization therapy: a report of the American College of Cardiology Foundation appropriate use criteria task force, Heart Rhythm Society, American Heart Association, American Society of Echocardiography, Heart Failure Society of America, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance. Heart rhythm Russo, A. M., Stainback, R. F., Bailey, S. R., Epstein, A. E., Heidenreich, P. A., Jessup, M., Kapa, S., Kremers, M. S., Lindsay, B. D., Stevenson, L. W. 2013; 10 (4): e11-58

  View details for DOI 10.1016/j.hrthm.2013.01.008

  View details for PubMedID 23473952

• ACCF/HRS/AHA/ASE/HFSA/SCAI/SCCT/SCMR 2013 appropriate use criteria for implantable cardioverter-defibrillators and cardiac resynchronization therapy: a report of the American College of Cardiology Foundation appropriate use criteria task force, Heart Rhythm Society, American Heart Association, American Society of Echocardiography, Heart Failure Society of America, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance. Journal of the American College of Cardiology Russo, A. M., Stainback, R. F., Bailey, S. R., Epstein, A. E., Heidenreich, P. A., Jessup, M., Kapa, S., Kremers, M. S., Lindsay, B. D., Stevenson, L. W. 2013; 61 (12): 1318-1368

  View details for DOI 10.1016/j.jacc.2012.12.017

  View details for PubMedID 23453819

• INCREMENTAL COST-EFFECTIVENESS OF GUIDELINE-DIRECTED MEDICAL THERAPIES FOR HEART FAILURE Banka, G., Heidenreich, P., Fonarow, G. ELSEVIER SCIENCE INC. 2013: E1538

  View details for DOI 10.1016/S0735-1097(13)61538-7

  View details for Web of Science ID 000316555201643

• OUTCOMES OF MEDICARE BENEFICIARIES WITH HEART FAILURE AND ATRIAL FIBRILLATION Khazanie, P., Liang, L., Qualls, L., Curtis, L., Fonarow, G., Hammill, B., Hammill, S., Heidenreich, P., Masoudi, F., Hernandez, A., Piccini, J. ELSEVIER SCIENCE INC. 2013: E733

  View details for DOI 10.1016/S0735-1097(13)60733-0

  View details for Web of Science ID 000316555200733

• CARDIAC RESYNCHRONIZATION THERAPY IN THE ELDERLY Heidenreich, P. A., Tsai, V., Bao, H., Curtis, J., Goldstein, M., Curtis, L., Hernandez, A., Peterson, P., Masoudi, F. ELSEVIER SCIENCE INC. 2013: E1477

  View details for DOI 10.1016/S0735-1097(13)61477-1

  View details for Web of Science ID 000316555201582

• Effects of mineralocorticoid receptor antagonists on the risk of sudden cardiac death in patients with left ventricular systolic dysfunction: a meta-analysis of randomized controlled trials. Circulation. Heart failure Bapoje, S. R., Bahia, A., Hokanson, J. E., Peterson, P. N., Heidenreich, P. A., Lindenfeld, J., Allen, L. A., Masoudi, F. A. 2013; 6 (2): 166-173

  Abstract

  Sudden cardiac death (SCD) is an important cause of death in patients with left ventricular systolic dysfunction. Mineralocorticoid receptor antagonists (MRAs) may attenuate this risk. The objective of this meta-analysis was to assess the impact of MRAs on SCD in patients with left ventricular systolic dysfunction.We systematically searched PubMed, EMBASE, Cochrane, and other databases through March 30, 2012, without language restrictions. We included trials that enrolled patients with left ventricular ejection fraction of ≤45%, randomized subjects to MRAs versus control and reported outcomes on SCD, total and cardiovascular mortality. Eight published trials that enrolled 11 875 patients met inclusion criteria. Of these, 6 reported data on SCD and cardiovascular mortality, and 7 reported data on total mortality. No heterogeneity was observed among the trials. Patients treated with MRAs had 23% lower odds of experiencing SCD compared with controls (odds ratio, 0.77; 95% confidence interval, 0.66-0.89; P=0.001). Similar reductions were observed in cardiovascular (0.75; 95% confidence interval, 0.68-0.84; P<0.001) and total mortality (odds ratio, 0.74; 95% confidence interval, 0.63-0.86; P<0.001). Although publication bias was observed, the results did not change after a trim and fill test, suggesting that the impact of this bias was likely insignificant.MRAs reduce the risk of SCD in patients with left ventricular systolic dysfunction. Comparative effectiveness studies of MRAs on SCD in usual care as well as studies evaluating the efficacy of other therapies to prevent SCD in patients receiving optimal MRA therapy are needed to guide clinical decision-making.

  View details for DOI 10.1161/CIRCHEARTFAILURE.112.000003

  View details for PubMedID 23403436

• Severe obstructive sleep apnea increases mortality in patients with ischemic heart disease and myocardial injury SLEEP AND BREATHING Won, C. H., Chun, H. J., Chandra, S. M., Sarinas, P. S., Chitkara, R. K., Heidenreich, P. A. 2013; 17 (1): 85-91

  Abstract

  We hypothesized that obstructive sleep apnea(OSA) has a dose-dependent impact on mortality in those with ischemic heart disease or previous myocardial injury.We performed a retrospective cohort study of 281 consecutive OSA patients with a history of myocardial injury as determined by elevated troponin levels or with known existing ischemic heart disease. We compared survival between those with severe OSA [apnea–hypopneaindex (AHI) ≥30] and those with mild to moderate OSA(AHI >5 and <30).Of the 281 patients (mean age 65 years, mean BMI34, 98% male, 58% with diabetes), 151 patients had mild moderate OSA and 130 had severe OSA. During a mean follow-up of 4.1 years, there were significantly greater deaths in the severe OSA group compared to the mild moderate OSA group [53 deaths (41%) vs. 44 deaths(29%), respectively, p00.04]. The adjusted hazard ratio for mortality with severe OSA was 1.72 (95% confidence interval1.01–2.91, p00.04).The severity of obstructive sleep apnea is associated with increased risk of death, and risk stratification based on OSA severity is relevant even in the diseased cardiac patient.

  View details for DOI 10.1007/s11325-012-0653-y

  View details for Web of Science ID 000315167200019

  View details for PubMedID 22294346

• Differences and trends in stroke prevention anticoagulation in primary care vs cardiology specialty management of new atrial fibrillation: The Retrospective Evaluation and Assessment of Therapies in AF (TREAT-AF) study. American heart journal Turakhia, M. P., Hoang, D. D., Xu, X., Frayne, S., Schmitt, S., Yang, F., Phibbs, C. S., Than, C. T., Wang, P. J., Heidenreich, P. A. 2013; 165 (1): 93-101 e1

  Abstract

  Atrial fibrillation and flutter (AF, collectively) cause stroke. We evaluated whether treating specialty influences warfarin prescription in patients with newly diagnosed AF.In the TREAT-AF study, we used Veterans Health Administration health record and claims data to identify patients with newly diagnosed AF between October 2004 and November 2008 and at least 1 internal medicine/primary care or cardiology outpatient encounter within 90 days after diagnosis. The primary outcome was prescription of warfarin.In 141,642 patients meeting the inclusion criteria, the mean age was 72.3 ± 10.2 years, 1.48% were women, and 25.8% had cardiology outpatient care. Cardiology-treated patients had more comorbidities and higher mean CHADS2 scores (1.8 vs 1.6, P < .0001). Warfarin use was higher in cardiology-treated vs primary care only-treated patients (68.6% vs 48.9%, P < .0001). After covariate and site-level adjustment, cardiology care was significantly associated with warfarin use (odds ratio [OR] 2.05, 95% CI 1.99-2.11). These findings were consistent across a series of adjusted models (OR 2.05-2.20), propensity matching (OR 1.98), and subgroup analyses (OR 1.58-2.11). Warfarin use in primary-care-only patients declined from 2004 to 2008 (51.6%-44.0%, P < .0001), whereas the adjusted odds of warfarin receipt with cardiology care (vs primary care) increased from 2004 to 2008 (1.88-2.24, P < .0001).In patients with newly diagnosed AF, we found large differences in anticoagulation use by treating specialty. A divergent 5-year trend of risk-adjusted warfarin use was observed. Treating specialty influences stroke prevention care and may impact clinical outcomes.

  View details for DOI 10.1016/j.ahj.2012.10.010

  View details for PubMedID 23237139

• Differences and trends in stroke prevention anticoagulation in primary care vs cardiology specialty management of new atrial fibrillation: The Retrospective Evaluation and Assessment of Therapies in AF (TREAT-AF) study AMERICAN HEART JOURNAL Turakhia, M. P., Hoang, D. D., Xu, X., Frayne, S., Schmitt, S., Yang, F., Phibbs, C. S., Than, C. T., Wang, P. J., Heidenreich, P. A. 2013; 165 (1): 93-?

  Abstract

  Atrial fibrillation and flutter (AF, collectively) cause stroke. We evaluated whether treating specialty influences warfarin prescription in patients with newly diagnosed AF.In the TREAT-AF study, we used Veterans Health Administration health record and claims data to identify patients with newly diagnosed AF between October 2004 and November 2008 and at least 1 internal medicine/primary care or cardiology outpatient encounter within 90 days after diagnosis. The primary outcome was prescription of warfarin.In 141,642 patients meeting the inclusion criteria, the mean age was 72.3 ± 10.2 years, 1.48% were women, and 25.8% had cardiology outpatient care. Cardiology-treated patients had more comorbidities and higher mean CHADS2 scores (1.8 vs 1.6, P < .0001). Warfarin use was higher in cardiology-treated vs primary care only-treated patients (68.6% vs 48.9%, P < .0001). After covariate and site-level adjustment, cardiology care was significantly associated with warfarin use (odds ratio [OR] 2.05, 95% CI 1.99-2.11). These findings were consistent across a series of adjusted models (OR 2.05-2.20), propensity matching (OR 1.98), and subgroup analyses (OR 1.58-2.11). Warfarin use in primary-care-only patients declined from 2004 to 2008 (51.6%-44.0%, P < .0001), whereas the adjusted odds of warfarin receipt with cardiology care (vs primary care) increased from 2004 to 2008 (1.88-2.24, P < .0001).In patients with newly diagnosed AF, we found large differences in anticoagulation use by treating specialty. A divergent 5-year trend of risk-adjusted warfarin use was observed. Treating specialty influences stroke prevention care and may impact clinical outcomes.

  View details for DOI 10.1016/j.ahj.2012.10.010

  View details for Web of Science ID 000312272900017

  View details for PubMedID 23237139

• Time for a Thorough Evaluation of Patient-Centered Care CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES Heidenreich, P. A. 2013; 6 (1): 2-4

  View details for DOI 10.1161/CIRCOUTCOMES.112.970194

  View details for Web of Science ID 000313637500003

  View details for PubMedID 23322803

• Are Racial/Ethnic Gaps in the Use of Cardiac Resynchronization Therapy Narrowing? An Analysis of 107,096 Patients From the National Cardiovascular Data Registry's ICD Registry. (vol 60, pg 1577, 2012) JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Eapen, Z. J., Lopes, R. D., Al-Khatib, S. M., Wang, Y., Bao, H., Curtis, J., Heidenreich, P. A., Hernandez, A. F., Peterson, E. D., Hammill, S. C. 2012; 60 (24): 2605

  View details for DOI 10.1016/j.jacc.2012.10.004

  View details for Web of Science ID 000312198000022

• Racial Differences in Atrial Fibrillation Prevalence and Anticoagulation Use Thomas, K. L., Piccini, J. P., Liang, L., Heidenreich, P., Fonarow, G., Peterson, E., Yancy, C., Hernandez, A. LIPPINCOTT WILLIAMS & WILKINS. 2012

  View details for Web of Science ID 000208885006304

• Center for Medicare and Medicaid Services Reimbursement Criteria Concordant Primary Prevention ICD Implantation in the Outcomes Among Veterans with Implantable Defibrillators (OVID) Registry Katz, D. F., Pellegrini, C. N., Heidenreich, P. A., Keung, E. C., Peterson, P., Rumsfeld, J. S., Massie, B. M., Varosy, P. D. LIPPINCOTT WILLIAMS & WILKINS. 2012

  View details for Web of Science ID 000208885001139

• Do Patients with Heart Failure and Atrial Fibrillation Adhere to Warfarin After Hospital Discharge? Findings from the Get With The Guidelines-Heart Failure Registry and Medicare Linked Database Eapen, Z., Mi, X., Fonarow, G. C., Heidenreich, P. A., Curtis, L. H., Hernandez, A. F., Al-Khatib, S. M. LIPPINCOTT WILLIAMS & WILKINS. 2012

  View details for Web of Science ID 000208885008228

• Impact of Baseline Stroke Risk and Bleeding Risk on INR Control among Patients with Atrial Fibrillation on Warfarin: the TREAT-AF Study Turakhia, M. P., Than, C. T., Xu, X., Schmitt, S. K., Yang, F., Frayne, S. M., Phibbs, C. S., Holmes, T. H., Heidenreich, P. A. LIPPINCOTT WILLIAMS & WILKINS. 2012

  View details for Web of Science ID 000208885006200

• National Survey of Hospital Strategies to Reduce Heart Failure Readmissions Findings From the Get With the Guidelines-Heart Failure Registry CIRCULATION-HEART FAILURE Kociol, R. D., Peterson, E. D., Hammill, B. G., Flynn, K. E., Heidenreich, P. A., Pina, I. L., Lytle, B. L., Albert, N. M., Curtis, L. H., Fonarow, G. C., Hernandez, A. F. 2012; 5 (6): 680-687

  Abstract

  Reducing 30-day heart failure readmission rates is a national priority. Yet, little is known about how hospitals address the problem and whether hospital-based processes of care are associated with reductions in readmission rates.We surveyed 100 randomly selected hospitals participating in the Get With the Guidelines-Heart Failure quality improvement program regarding common processes of care aimed at reducing readmissions. We grouped processes into 3 domains (ie, inpatient care, discharge and transitional care, and general quality improvement) and scored hospitals on the basis of survey responses using processes selected a priori. We used linear regression to examine associations between these domain scores and 30-day risk-standardized readmission rates. Of the 100 participating sites, 28% were academic centers and 64% were community hospitals. The median readmission rate among participating sites (24.0%; 95% CI, 22.6%-25.7%) was comparable with the national average (24.6%; 23.5-25.9). Sites varied substantially in care processes used for inpatient care, education, discharge process, care transitions, and quality improvement. Overall, neither inpatient care nor general quality improvement domains were associated with 30-day readmission rates. Hospitals in the lowest readmission rate quartile had modestly higher discharge and transitional care domain scores (P=0.03).A variety of strategies are used by hospitals in an attempt to improve 30-day readmission rates for patients hospitalized with heart failure. Although more complete discharge and transitional care processes may be modestly associated with lower 30-day readmission rates, most current strategies are not associated with lower readmission rates.

  View details for DOI 10.1161/CIRCHEARTFAILURE.112.967406

  View details for Web of Science ID 000313580100013

  View details for PubMedID 22933525

• FACILITATING HEALTH BEHAVIORS AND HEALTH LITERACY IN DISEASE SELF-CARE IN OLDER ADULTS Oliva, N., Gaskin, L., Heidenreich, P. OXFORD UNIV PRESS INC. 2012: 137

  View details for Web of Science ID 000312888201624

• HFSA and AAHFN joint position statement: advocating for a full scope of nursing practice and leadership in heart failure. Journal of cardiac failure Lee, C. S., Greenberg, B. H., Laramee, A. S., Ammon, S. E., Prasun, M., Galvao, M., Doering, L. V., Sherman, M. E., Stevenson, L. W., Gregory, D. D., Heidenreich, P. A., Kapur, N. K., O'Connell, J. B., Taylor, A. L., Hill, J. A., Baas, L., Gibbs, A., Rasmusson, K., Lewis, C., Kirkwood, P., Reigle, J., Rathman, L., Bither, C. 2012; 18 (11): 811-812

  View details for DOI 10.1016/j.cardfail.2012.09.001

  View details for PubMedID 23141852

• HFSA and AAHFN joint position statement: Advocating for a full scope of nursing practice and leadership in heart failure HEART & LUNG Lee, C. S., Greenberg, B. H., Laramee, A. S., Ammon, S. E., Prasun, M., Galvao, M., Doering, L. V., Sherman, M. E., Stevenson, L. W., Gregory, D. D., Heidenreich, P. A., Kapur, N. K., O'Connell, J. B., Taylor, A. L., Hill, J. A., Baas, L., Gibbs, A., Rasmusson, K., Lewis, C., Kirkwood, P., Reigle, J., Rathman, L., Bither, C. 2012; 41 (6): 531-533

  View details for DOI 10.1016/j.hrtlng.2012.10.002

  View details for Web of Science ID 000311011300002

  View details for PubMedID 23121831

• Are Racial/Ethnic Gaps in the Use of Cardiac Resynchronization Therapy Narrowing? An Analysis of 107,096 Patients From the National Cardiovascular Data Registry's ICD Registry JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Eapen, Z. J., Al-Khatib, S., Lopes, R. D., Wang, Y., Bao, H., Curtis, J., Heidenreich, P. A., Hernandez, A. F., Peterson, E. D., Hammill, S. C. 2012; 60 (16): 1577-1578

  View details for DOI 10.1016/j.jacc.2012.06.024

  View details for Web of Science ID 000310198200019

  View details for PubMedID 22958954

• Automated extraction of ejection fraction for quality measurement using regular expressions in Unstructured Information Management Architecture (UIMA) for heart failure JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION Garvin, J. H., DuVall, S. L., South, B. R., Bray, B. E., Bolton, D., Heavirland, J., Pickard, S., Heidenreich, P., Shen, S., Weir, C., Samore, M., Goldstein, M. K. 2012; 19 (5): 859-866

  Abstract

  Left ventricular ejection fraction (EF) is a key component of heart failure quality measures used within the Department of Veteran Affairs (VA). Our goals were to build a natural language processing system to extract the EF from free-text echocardiogram reports to automate measurement reporting and to validate the accuracy of the system using a comparison reference standard developed through human review. This project was a Translational Use Case Project within the VA Consortium for Healthcare Informatics.We created a set of regular expressions and rules to capture the EF using a random sample of 765 echocardiograms from seven VA medical centers. The documents were randomly assigned to two sets: a set of 275 used for training and a second set of 490 used for testing and validation. To establish the reference standard, two independent reviewers annotated all documents in both sets; a third reviewer adjudicated disagreements.System test results for document-level classification of EF of <40% had a sensitivity (recall) of 98.41%, a specificity of 100%, a positive predictive value (precision) of 100%, and an F measure of 99.2%. System test results at the concept level had a sensitivity of 88.9% (95% CI 87.7% to 90.0%), a positive predictive value of 95% (95% CI 94.2% to 95.9%), and an F measure of 91.9% (95% CI 91.2% to 92.7%).An EF value of <40% can be accurately identified in VA echocardiogram reports.An automated information extraction system can be used to accurately extract EF for quality measurement.

  View details for DOI 10.1136/amiajnl-2011-000535

  View details for Web of Science ID 000307934600025

  View details for PubMedID 22437073

  View details for PubMedCentralID PMC3422820

• Self-Reported Awareness of Chronic Heart Failure (CHF) in a VA Population Diagnosed With CHF: Implications for Individual Patients, Caregivers, Providers, and Organizations Oliva, N. L., Gaskin, L., Sahay, A., Gholami, P., Heidenreich, P. CHURCHILL LIVINGSTONE INC MEDICAL PUBLISHERS. 2012: S107–S108

  View details for DOI 10.1016/j.cardfail.2012.06.410

  View details for Web of Science ID 000307679700355

• Trends in Patients Hospitalized With Heart Failure and Preserved Left Ventricular Ejection Fraction Prevalence, Therapies, and Outcomes CIRCULATION Steinberg, B. A., Zhao, X., Heidenreich, P. A., Peterson, E. D., Bhatt, D. L., Cannon, C. P., Hernandez, A. F., Fonarow, G. C. 2012; 126 (1): 65-?

  Abstract

  Heart failure with preserved ejection fraction (EF) is a common syndrome, but trends in treatments and outcomes are lacking.We analyzed data from 275 hospitals in Get With the Guidelines-Heart Failure from January 2005 to October 2010. Patients were stratified by EF as reduced EF (EF <40% [HF-reduced EF]), borderline EF (40%≤EF<50% [HF-borderline EF]), or preserved (EF ≥50% [HF-preserved EF]). Using multivariable models, we examined trends in therapies and outcomes. Among 110 621 patients, 50% (55 083) had HF-reduced EF, 14% (15 184) had HF-borderline EF, and 36% (40 354) had HF-preserved EF. From 2005 to 2010, the proportion of hospitalizations for HF-preserved EF increased from 33% to 39% (P<0.0001). In multivariable analyses, use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers at discharge decreased in all EF groups, and β-blocker use increased. Patients with HF-preserved EF less frequently achieved blood pressure control (adjusted odds ratio, 0.44 versus HF-reduced EF; P<0.001) and were more likely discharged to skilled nursing (adjusted odds ratio, 1.16 versus HF-reduced EF; P<0.001). In-hospital mortality for HF-preserved EF decreased from 3.32% in 2005 to 2.35% in 2010 (adjusted odds ratio, 0.89 per year; P=0.01) but was stable for patients with HF-reduced EF (3.03%-2.83%; adjusted odds ratio, 0.93 per year; P=0.10).Hospitalization for HF-preserved EF is increasing relative to HF-reduced EF. Although in-hospital mortality for patients with HF-preserved EF declined over the study period, an important opportunity remains for identifying evidence-based therapies in patients with HF-preserved EF.

  View details for DOI 10.1161/CIRCULATIONAHA.111.080770

  View details for Web of Science ID 000306977100025

  View details for PubMedID 22615345

• Utilization of Hospice and Predicted Mortality Risk Among Older Patients Hospitalized With Heart Failure: Findings From GWTG-HF JOURNAL OF CARDIAC FAILURE Whellan, D. J., Cox, M., Hernandez, A. F., Heidenreich, P. A., Curtis, L. H., Peterson, E. D., Fonarow, G. C. 2012; 18 (6): 471-477

  Abstract

  Guidelines recommend hospice care as a treatment option for end-stage heart failure (HF) patients. Little is known regarding utilization of hospice care in a contemporary cohort of patients hospitalized with HF and how this may vary by estimated mortality risk.We analyzed HF patients ≥65 years (n = 58,330) from 214 hospitals participating in the Get With the Guidelines-HF program. Univariate analysis comparing patients discharged to hospice versus other patients was performed. Hospice utilization was evaluated for deciles of estimated 90-day mortality risk using a validated model. Multivariate analysis using admission patient and hospital characteristics was also performed to determine factors associated with hospice discharge.There were 1,442 patients discharged to hospice, and rates of referral varied widely by hospital (interquartile range 0-3.7%) as shown in the univariate analysis. Patients discharged to hospice were significantly older and more often white, had lower left ventricular ejection fraction, higher B-type natriuretic peptide, and lower systolic blood pressure on admission. Utilization rates for each decile of 90-day estimated mortality risk ranged from 0.3% to 8.6%. Multivariable analysis found that factors associated with hospice utilization included increased age, low systolic blood pressure on admission, and increased blood urea nitrogen.Hospice utilization remains low among HF patients, even those with the highest predicted risk of death.

  View details for DOI 10.1016/j.cardfail.2012.02.006

  View details for Web of Science ID 000305166400005

  View details for PubMedID 22633304

• Design and rationale of a retrospective clinical effectiveness study of aldosterone antagonist therapy in patients with heart failure AMERICAN HEART JOURNAL Curtis, L. H., Mi, X., Qualls, L. G., Hammill, B. G., Hammill, S. C., Heidenreich, P. A., Masoudi, F. A., Setoguchi, S., Hernandez, A. F., Fonarow, G. C. 2012; 163 (6): 946-?

  Abstract

  Despite demonstrated efficacy in randomized trials, aldosterone antagonist therapy is not used in many eligible patients with heart failure. Questions remain about its clinical effectiveness and safety for patients who are underrepresented in randomized trials and those at risk for hyperkalemia.The proposed study will evaluate the effectiveness of aldosterone antagonist therapy in eligible Medicare beneficiaries ≥ 65 years old hospitalized for heart failure between 2005 and 2008. Data are from the GWTG-HF registry linked with Medicare inpatient and prescription drug event files. We will use inverse probability-weighted estimators to assess differences in mortality, cardiovascular readmission, and readmission for hyperkalemia between patients who receive or do not receive aldosterone antagonist therapy.The initial data set included 33,652 patients; 5,463 (16.2%) met all inclusion criteria. Compared with patients who did not meet the inclusion criteria, patients in the final cohort were more likely to be younger (77.3 vs 80.3 years) and male (63.8% vs 41.3%) and to have ischemic heart failure (74.2% vs 59.5%) (all P < .001). Mortality rates were 24.7% at 1 year and 50.7% at 3 years; cardiovascular readmission rates were 50.1% at 1 year and 65.2% at 3 years.The proposed study will evaluate the clinical effectiveness of aldosterone antagonist therapy in Medicare beneficiaries hospitalized for heart failure with reduced ejection fraction, an underrepresented population in clinical trials. By addressing this evidence gap, the study has the potential to inform clinical decision making and improve patient outcomes.

  View details for DOI 10.1016/j.ahj.2012.03.007

  View details for Web of Science ID 000305428200005

  View details for PubMedID 22709746

• Vascular Surgery Patients Prescribed Preoperative beta-Blockers Experienced a Decrease in the Maximal Heart Rate Observed During Induction of General Anesthesia JOURNAL OF CARDIOTHORACIC AND VASCULAR ANESTHESIA Mudumbai, S. C., Wagner, T., Mahajan, S., King, R., Heidenreich, P. A., Hlatky, M., Wallace, A., Mariano, E. R. 2012; 26 (3): 414-419

  Abstract

  To investigate the association of preoperative β-blocker usage and maximal heart rates observed during the induction of general anesthesia.Retrospective descriptive, univariate, and multivariate analyses of electronic hospital and anesthesia medical records.A tertiary-care medical center within the Veterans Health Administration.Consecutive adult elective and emergent patients presenting for vascular surgery during calendar years 2005 to 2011.None.Of the 430 eligible cases, 218 were prescribed β-blockers, and 212 were not taking β-blockers. The two groups were comparable across baseline patient factors (ie, demographic, morphometric, surgical duration, and surgical procedures) and induction medication doses. The β-blocker group experienced a lower maximal heart rate during the induction of general anesthesia compared with the non-β-blocker group (105 ± 41 beats/min v 115 ± 45 beats/min, respectively; p < 0.01). Adjusted linear regression found a statistically significant association between lower maximal heart rate and the use of β-blockers (β = -11.1 beats/min, p < 0.01). There was no difference between groups in total intraoperative β-blocker administration.Preoperative β-blockade of vascular surgery patients undergoing general anesthesia is associated with a lower maximal heart rate during anesthetic induction. There may be potential benefits in administering β-blockers to reduce physiologic stress in this surgical population at risk for perioperative cardiac morbidity. Future research should further explore intraoperative hemodynamic effects in light of existing practice guidelines for optimal medication selection, dosage, and heart rate control.

  View details for DOI 10.1053/j.jvca.2011.09.027

  View details for Web of Science ID 000304215800011

  View details for PubMedID 22138312

• Role of heart rate as a marker and mediator of poor outcome for patients with heart failure. Current heart failure reports Kapoor, J. R., Heidenreich, P. A. 2012; 9 (2): 133-138

  Abstract

  Tachycardia has been associated with worse outcomes for patients with heart failure and is also thought to have a direct adverse impact on the myocardium. This report highlights the current evidence for heart rate as both a risk factor and mediator for poor outcome for patients with heart failure. We summarize the large number of studies evaluating heart rate in patients with systolic dysfunction and newer studies that examine patients with preserved systolic function. The effect on outcomes in heart failure of medications known to slow the heart rate such as β-blockers and the more recently developed drug ivabradine are discussed. The data clearly show that a high heart rate is a marker of increased mortality. There is also a strong suggestion that a higher heart rate directly worsens outcome and that this can be mitigated by heart rate-reducing medications.

  View details for DOI 10.1007/s11897-012-0086-8

  View details for PubMedID 22351045

• ACCF/AHA/AMA-PCPI 2011 Performance Measures for Adults With Heart Failure JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Bonow, R. O., Ganiats, T. G., Beam, C. T., Blake, K., Casey, D. E., Goodlin, S. J., Grady, K. L., Hundley, R. F., Jessup, M., Lynn, T. E., Masoudi, F. A., Nilasena, D., Pina, I. L., Rockswold, P. D., Sadwin, L. B., Sikkema, J. D., Sincak, C. A., Spertus, J., Torcson, P. J., Torres, E., Williams, M. V., Wong, J. B., Peterson, E. D., Masoudi, F. A., DeLong, E., Erwin, J. P., Fonarow, G. C., Goff, D. C., Grady, K. L., Green, L. A., Heidenreich, P. A., Jenkins, K. J., Loth, A., Shahian, D. M. 2012; 59 (20): 1812-1832

  View details for DOI 10.1016/j.jacc.2012.03.013

  View details for Web of Science ID 000304007000015

• ACCF/AHA/AMA-PCPI 2011 performance measures for adults with heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures and the American Medical Association-Physician Consortium for Performance Improvement. Journal of the American College of Cardiology Bonow, R. O., Ganiats, T. G., Beam, C. T., Blake, K., Casey, D. E., Goodlin, S. J., Grady, K. L., Hundley, R. F., Jessup, M., Lynn, T. E., Masoudi, F. A., Nilasena, D., Piña, I. L., Rockswold, P. D., Sadwin, L. B., Sikkema, J. D., Sincak, C. A., Spertus, J., Torcson, P. J., Torres, E., Williams, M. V., Wong, J. B., Peterson, E. D., Masoudi, F. A., DeLong, E., Erwin, J. P., Fonarow, G. C., Goff, D. C., Grady, K. L., Green, L. A., Heidenreich, P. A., Jenkins, K. J., Loth, A., Shahian, D. M. 2012; 59 (20): 1812-1832

  View details for DOI 10.1016/j.jacc.2012.03.013

  View details for PubMedID 22534627

• The Effect of Angiotensin-Converting Enzyme Inhibitors and Statins on the Progression of Aortic Sclerosis and Mortality JOURNAL OF HEART VALVE DISEASE Ardehali, R., Leeper, N. J., Wilson, A. M., Heidenreich, P. A. 2012; 21 (3): 337-343

  Abstract

  Although aortic sclerosis has been associated with an increase in adverse cardiovascular outcomes, no proven therapy has been shown to slow its progression to overt aortic stenosis (AS). Thus, the hypothesis was assessed that treatment with angiotensin-converting enzyme inhibitors (ACE-Is), angiotensin receptor blockers (ARBs) or statins may be associated with an improvement in the clinical outcome of these patients.A total of 4,105 patients with evidence of aortic sclerosis seen on transthoracic echocardiography (defined as thickening or calcification with a mean valve gradient < or = 15 mmHg) was identified. Patients with a sclerotic valve who were treated with ACE-Is/ARBs or statins were followed for a mean period of 1,078 +/- 615 days. After adjustment for the propensity to receive ACE-Is/ARBs or statins, mortality, hemodynamic progression to AS, hospitalization for ischemic heart disease (IHD), and congestive heart failure (CHF) were assessed and related to the medical treatment.At baseline, patients with aortic sclerosis who were treated with an ACE-I/ARB or a statin suffered significantly more from comorbidities such as IHD, CHF, hypertension, diabetes, and peripheral arterial disease, when compared to subjects with sclerotic valves not treated with these drugs. After adjustment for confounding factors, treatment with statins was associated with a significant reduction in mortality (odds ratio [OR] 0.73, 95% CI 0.56-0.98, p = 0.001), admission for IHD (OR 0.81, 95% CI 0.66-0.99, p = 0.03), admission for CHF (OR 0.68, 95% CI 0.55-0.85, p = 0.01) and progression to AS (OR 0.64, 95% CI 0.42-0.97, p = 0.03). While ACE-I treatment resulted in a significant reduction in admission for IHD (OR 0.80, 95% CI 0.65-0.98, p = 0.03) and CHF (OR 0.76, 95% CI 0.62-0.94, p = 0.01), the beneficial trend towards reduced mortality and delayed progression to AS was not significant.Treatment of this patient population with statins led to a significant reduction in mortality and also slowed the progression to AS--an effect that was not statistically significant with ACE-I treatment.

  View details for Web of Science ID 000306675500011

  View details for PubMedID 22808835

• CLINICAL EXPERIENCE AND DIAGNOSTIC YIELD FROM A NATIONAL REGISTRY OF 14-DAY AMBULATORY ECG PATCH MONITORING Turakhia, M., Hoang, D., Zimetbaum, P., Yang, F., Froelicher, V., Heidenreich, P. ELSEVIER SCIENCE INC. 2012: E646

  View details for DOI 10.1016/S0735-1097(12)60647-0

  View details for Web of Science ID 000302326700648

• Trends in Use of Implantable Cardioverter-Defibrillator Therapy Among Patients Hospitalized for Heart Failure Have the Previously Observed Sex and Racial Disparities Changed Over Time? CIRCULATION Al-Khatib, S. M., Hellkamp, A. S., Hernandez, A. F., Fonarow, G. C., Thomas, K. L., Al-Khalidi, H. R., Heidenreich, P. A., Hammill, S., Yancy, C., Peterson, E. D. 2012; 125 (9): 1094-1101

  Abstract

  Prior studies have demonstrated low use of implantable cardioverter defibrillators (ICDs) as primary prevention, particularly among women and blacks. The degree to which the overall use of ICD therapy and disparities in use have changed is unclear.We examined 11 880 unique patients with a history of heart failure and left ventricular ejection fraction ≤35% who were ≥65 years old and enrolled in the Get With the Guidelines-Heart Failure (GWTG-HF) program from January 2005 through December 2009. We determined the rate of ICD use by year for the overall population and for sex and race groups. From 2005 to 2007, overall ICD use increased from 30.2% to 42.4% and then remained unchanged in 2008 to 2009. After adjustment for potential confounders, ICD use increased significantly in the overall study population during 2005 to 2007 (odds ratio, 1.28; 95% confidence interval, 1.11-1.48 per year; P=0.0008) and in black women (odds ratio, 1.82; 95% confidence interval, 1.28-2.58 per year; P=0.0008), white women (odds ratio, 1.30; 95% confidence interval, 1.06-1.59 per year; P=0.010), black men (odds ratio, 1.54; 95% confidence interval, 1.19-1.99 per year; P=0.0009), and white men (odds ratio, 1.25; 95% confidence interval, 1.06-1.48 per year; P=0.0072). The increase in ICD use was greatest among blacks.In the GWTG-HF quality improvement program, a significant increase in ICD therapy use was observed over time in all sex and race groups. The previously described racial disparities in ICD use were no longer present by the end of the study period; however, sex differences persisted.

  View details for DOI 10.1161/CIRCULATIONAHA.111.066605

  View details for Web of Science ID 000301197700016

  View details for PubMedID 22287589

  View details for PubMedCentralID PMC3670671

• Ability of microvolt T-wave alternans to modify risk assessment of ventricular tachyarrhythmic events: A meta-analysis AMERICAN HEART JOURNAL Gupta, A., Hoang, D. D., Karliner, L., Tice, J. A., Heidenreich, P., Wang, P. J., Turakhia, M. P. 2012; 163 (3): 354-364

  Abstract

  Prior studies have indicated that the magnitude of risk association of microvolt T-wave alternans (MTWA) testing appears to vary with the population studied. We performed a meta-analysis to determine the ability of MTWA to modify risk assessment of ventricular tachyarrhythmic events (VTEs) and sudden cardiac death (SCD) across a series of patient risk profiles using likelihood ratio (LR) testing, a measure of test performance independent of disease prevalence.We identified original research articles published from January 1990 to January 2011 that investigate spectrally derived MTWA. Ventricular tachyarrhythmic event was defined as the total and arrhythmic mortality and nonfatal sustained or implantable cardioverter-defibrillator-treated ventricular tachyarrhythmias. Summary estimates were created for positive and nonnegative MTWA results using a random-effects model and were expressed as positive (LR+) and negative (LR-) LRs.Of 1,534 articles, 20 prospective cohort studies met our inclusion criteria, consisting of 5,945 subjects predominantly with prior myocardial infarction or left ventricular dysfunction. Although there was a modest association between positive MTWA and VTE (relative risk 2.45, 1.58-3.79) and nonnegative MTWA and VTE (3.68, 2.23-6.07), test performance was poor (positive MTWA: LR+ 1.78, LR- 0.43; nonnegative MTWA: LR+ 1.38, LR- 0.56). Subgroup analyses of subjects classified as prior VTE, post-myocardial infarction, SCD-HeFT type, and MADIT-II type had a similar poor test performance. A negative MTWA result would decrease the annualized risk of VTE from 8.85% to 6.37% in MADIT-II-type patients and from 5.91% to 2.60% in SCD-HeFT-type patients.Despite a modest association, results of spectrally derived MTWA testing do not sufficiently modify the risk of VTE to change clinical decisions.

  View details for DOI 10.1016/j.ahj.2011.11.021

  View details for PubMedID 22424005

• Patient and hospital characteristics associated with traditional measures of inpatient quality of care for patients with heart failure AMERICAN HEART JOURNAL Heidenreich, P. A., Zhao, X., Hernandez, A. F., Yancy, C. W., Fonarow, G. C. 2012; 163 (2): 239-U337

  Abstract

  The purpose of this study was to determine patient and hospital characteristics associated with 4 measures of quality of inpatient heart failure care used by both the primary payer of heart failure care in the United States (Center for Medicare and Medicaid Services) and the main hospital accrediting organization (The Joint Commission).We used data from Get With The Guidelines Program for patients hospitalized with heart failure. Eligibility for receiving care based on the Center for Medicare and Medicaid Services performance measures was determined for assessment of left ventricular ejection fraction (LVEF; n = 60,601), use of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) if LVEF<40% and no contraindications (24,130), discharge instructions (49,383), and smoking cessation counseling (10,152). Patient and hospital characteristics that were significantly associated with performance measures in univariate analyses were entered into multivariate logistic regression models.Overall, documentation for LVEF assessment was noted in 95%, ACEi/ARB use in 87%, discharge instruction in 82%, and smoking cessation counseling in 91% of eligible patients. In adjusted analyses, older patients and those with evidence of renal failure were significantly less likely to receive each care measure except for discharge instructions (no age effect). Patients with higher body mass index were more likely to receive ACEi/ARB and discharge instructions but less likely to have LVEF documented or to receive smoking cessation counseling. Small hospitals (<200 beds) were less likely to provide each of the performance measures compared with larger hospitals.Recommended heart failure care is less likely in patients with certain characteristics (older age and abnormal renal function) and those cared for in smaller hospitals. Programs to improve evidence-based care for heart failure should consider interventions specifically targeting and tailored to smaller facilities and patients who are older with comorbidities.

  View details for DOI 10.1016/j.ahj.2011.10.008

  View details for Web of Science ID 000300226600016

  View details for PubMedID 22305842

• Cost-effectiveness of pharmacologic and invasive therapies for stroke prophylaxis in atrial fibrillation JOURNAL OF CARDIOVASCULAR MEDICINE Solomon, M. D., Ullal, A. J., Hoang, D. D., Freeman, J. V., Heidenreich, P., Turakhia, M. P. 2012; 13 (2): 86-96

  Abstract

  Atrial fibrillation is an abnormal heart rhythm characterized by rapid, disorganized activation (fibrillation) of the left and right atria of the heart, and is responsible for 15% of 700,000 strokes in the United States each year. There are multiple pharmacologic and nonpharmacologic therapies used for stroke prevention in atrial fibrillation, including vitamin K antagonists such as warfarin, antiplatelet agents such as aspirin and clopidogrel, and newer agents such as dabigatran, rivaroxaban and apixaban. Nonpharmacologic therapies involve excluding the left atrial appendage from the systemic circulation by surgical ligation or excision, percutaneous ligation, or endovascular implantation of a left atrial occlusion device. Because atrial fibrillation-related stroke is preventable, a comparison of the value of these interventions by cost-effectiveness analysis (CEA) could inform clinical and health policy recommendations. In this article, we review the principles of CEA and identify 11 articles that examine CEA of stroke prophylaxis strategies in atrial fibrillation. Although most studies evaluate aspirin and warfarin across a variety of atrial fibrillation stroke risk profiles, we also review new literature on new pharmacologic therapies such as direct thrombin inhibitors and discuss the potential value of device-based therapies.

  View details for DOI 10.2459/JCM.0b013e32834f23cf

  View details for Web of Science ID 000299652200002

  View details for PubMedID 22193838

• Using Stress Testing to Guide Primary Prevention of Coronary Heart Disease Among Intermediate-Risk Patients A Cost-Effectiveness Analysis CIRCULATION Galper, B. Z., Moran, A., Coxson, P. G., Pletcher, M. J., Heidenreich, P., Lazar, L. D., Rodondi, N., Wang, Y. C., Goldman, L. 2012; 125 (2): 260-U205

  Abstract

  Noninvasive stress testing might guide the use of aspirin and statins for primary prevention of coronary heart disease, but it is unclear if such a strategy would be cost effective.We compared the status quo, in which the current national use of aspirin and statins was simulated, with 3 other strategies: (1) full implementation of Adult Treatment Panel III guidelines, (2) a treat-all strategy in which all intermediate-risk persons received statins (men and women) and aspirin (men only), and (3) a test-and-treat strategy in which all persons with an intermediate risk of coronary heart disease underwent stress testing and those with a positive test were treated with high-intensity statins (men and women) and aspirin (men only). Healthcare costs, coronary heart disease events, and quality-adjusted life years from 2011 to 2040 were projected. Under a variety of assumptions, the treat-all strategy was the most effective and least expensive strategy. Stress electrocardiography was more effective and less expensive than other test-and-treat strategies, but it was less expensive than treat all only if statin cost exceeded $3.16/pill or if testing increased adherence from <22% to >75%. However, stress electrocardiography could be cost effective in persons initially nonadherent to the treat-all strategy if it raised their adherence to 5% and cost saving if it raised their adherence to 13%.When generic high-potency statins are available, noninvasive cardiac stress testing to target preventive medications is not cost effective unless it substantially improves adherence.

  View details for DOI 10.1161/CIRCULATIONAHA.111.041293

  View details for Web of Science ID 000299321600015

  View details for PubMedID 22144567

  View details for PubMedCentralID PMC3265963

• Physician Procedure Volume and Complications of Cardioverter-Defibrillator Implantation CIRCULATION Freeman, J. V., Wang, Y., Curtis, J. P., Heidenreich, P. A., Hlatky, M. A. 2012; 125 (1): 57-64

  Abstract

  The outcomes of procedures are often better when they are performed by more experienced physicians. We assessed whether the rate of complications after implantable cardioverter-defibrillator (ICD) placement varied with the volume of procedures a physician performed.We studied 356 515 initial ICD implantations in the National Cardiovascular Data Registry-ICD Registry, performed by 4011 physicians in 1463 hospitals. We examined the relationship between physician annual ICD implantation volume and in-hospital complications, using hierarchical logistic regression to adjust for patient characteristics, implanting physician certification, hospital characteristics, hospital annual procedure volume, and the clustering of patients within hospitals and by physician. We repeated this analysis for ICD subtypes: single chamber, dual chamber, and biventricular. There were 10 994 patients (3.1%) with a complication after ICD implantation, and 1375 died (0.39%). The complication rate decreased with increasing physician procedure volume from 4.6% in the lowest quartile to 2.9% in the highest quartile (P<0.0001), and the mortality rate decreased from 0.72% to 0.36% (P<0.0001). The inverse relationship between physician procedure volume and complications remained significant after adjusting for patient, physician, and hospital characteristics (OR 1.55 for complications in lowest-volume quartile compared with highest; 95% confidence interval, 1.34-1.79; P<0.0001). This inverse relationship was independent of physician specialty and of hospital volume, was consistent across ICD subtypes, and was also evident for in-hospital mortality.Physicians who implant more ICDs have lower rates of procedural complications and in-hospital mortality, independent of hospital procedure volume, physician specialty, and ICD type.

  View details for DOI 10.1161/CIRCULATIONAHA.111.046995

  View details for Web of Science ID 000299169100019

  View details for PubMedID 22095828

• Cost Effectiveness of Improved Acute Myocardial Infarction Treatment in China: Projections From the Coronary Heart Disease Policy Model-China Wang, M., Moran, A., Liu, J., Coxson, P., Heidenreich, P., Gu, D., He, J., Goldman, L., Zhao, D. LIPPINCOTT WILLIAMS & WILKINS. 2011

  View details for Web of Science ID 000299738702174

• Hospitalist Care and Associated Outcomes for Patients Hospitalized with Heart Failure: Insights from Get With The Guidelines-Heart Failure Kociol, R. D., Hammill, B. G., Fonarow, G. C., Heidenreich, P. A., Peterson, E. D., Curtis, L. H., Hernandez, A. F. LIPPINCOTT WILLIAMS & WILKINS. 2011

  View details for Web of Science ID 000299738705240

• National Survey of Care Processes to Reduce Readmission in Patients Hospitalized for Heart Failure: Factors Associated with Lower Readmission Rates Kociol, R. D., Flynn, K. E., Hammill, B. G., Heidenreich, P. A., Pina, I. L., Lytle, B. L., Albert, N. M., Curtis, L. H., Fonarow, G. C., Peterson, E. D., Hernandez, A. F. LIPPINCOTT WILLIAMS & WILKINS. 2011

  View details for Web of Science ID 000299738705300

• Adherence to Guideline-Based Indications and Prevalence of Optimal Medical Therapy Among Patients Receiving Cardiac Resynchronization Therapy Defibrillators in the Outcomes Among Veterans with Implantable Devices Registry Schneider, P. M., Pelligrini, C. N., Yang, Y., Heidenreich, P. A., Rumsfeld, J. S., Masoudi, F. A., Massie, B. M., Varosy, P. D. LIPPINCOTT WILLIAMS & WILKINS. 2011

  View details for Web of Science ID 000299738702306

• Is Cardiac Resynchronization Therapy Use Improving Among Racial/Ethnic Minorities? An Analysis of 107,096 Patients from the NCDR-ICD Registry Eapen, Z., Al-Khatib, S. M., Wang, Y., Lopes, R. D., Bao, H., Curtis, J. P., Heidenreich, P. A., Hernandez, A. F., Hammill, S. C. LIPPINCOTT WILLIAMS & WILKINS. 2011

  View details for Web of Science ID 000299738705122

• Comparison of Composite Measure Methodologies for Rewarding Quality of Care An Analysis From the American Heart Association's Get With The Guidelines Program CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES Eapen, Z. J., Fonarow, G. C., Dai, D., O'Brien, S. M., Schwamm, L. H., Cannon, C. P., Heidenreich, P. A., Bhatt, D. L., Peterson, E. D., Hernandez, A. F. 2011; 4 (6): 610-618

  Abstract

  Composite indices of health care performance are an aggregation of underlying individual performance measures and are increasingly being used to rank hospitals. We sought to conduct an observational analysis to determine the influence of the opportunity-based and all-or-none composite performance measures on hospital rankings.We examined 194 245 patients hospitalized with acute myocardial infarction between July 2006 and June 2009 from 334 hospitals participating in the Get With The Guidelines--Coronary Artery Disease (GWTG-CAD) quality improvement program. We analyzed hospital opportunity-based and all-or-none composite scores and 30-day risk-standardized all-cause mortality and readmission rates. We found that the median calculated opportunity-based score for these hospitals was 95.5 (interquartile range, 90.4, 98.0). The median all-or-none score was 88.9 (interquartile range, 79.7, 94.4). The 2 scoring methods were significantly correlated with one another (r=0.98, P<0.001). Rankings generated by the two methods were significantly correlated (r=0.93, P<0.001). The two methods had a modest correlation with the 30-day risk-standardized mortality rate (opportunity-based score: r=-0.25, P<0.001; all-or-none score: r=-0.24, P<0.001). Neither composite measure correlated with the 30-day risk-standardized readmission rate. Over time, the number of hospitals new to the top and bottom quintiles of hospital rankings diminished similarly for both composite measures. When including additional performance measures into the composite score, the two methods produced similar changes in hospital rankings.The opportunity-based and all-or-none coronary artery disease composite indices are highly correlated and yield similar ranking of the top and bottom quintiles of hospitals. The two methods provide similarly modest correlations with 30-day mortality, but not readmission.

  View details for DOI 10.1161/CIRCOUTCOMES.111.961391

  View details for Web of Science ID 000297168400007

  View details for PubMedID 22010200

• Association of admission hematocrit with 6-month and 1-year mortality in intensive care unit patients TRANSFUSION Mudumbai, S. C., Cronkite, R., Hu, K. U., Wagner, T., Hayashi, K., Ozanne, G. M., Davies, M. F., Heidenreich, P., Bertaccini, E. 2011; 51 (10): 2148-2159

  Abstract

  This study examined the association of hematocrit (Hct) levels measured upon intensive care unit (ICU) admission and red blood cell transfusions to long-term (1-year or 180-day) mortality for both surgical and medical patients.Administrative and laboratory data were collected retrospectively on 2393 consecutive medical and surgical male patients admitted to the ICU between 2003 and 2009. We stratified patients based on their median Hct level during the first 24 hours of their ICU stay (Hct < 25.0%, 25% ≤ Hct < 30%, 30% ≤ Hct < 39%, and 39.0% and higher). An extended Cox regression analysis was conducted to identify the time period after ICU admission (0 to <180, 180 to 365 days) when low Hct (<25.0) was most strongly associated with mortality. The unadjusted and adjusted relationship between admission Hct level, receipt of a transfusion, and 180-day mortality was assessed using Cox proportional hazards regression modeling.Patients with an Hct level of less than 25% who were not transfused had the worst mortality risk overall (hazard ratio [HR], 6.26; 95% confidence interval [CI], 3.05-12.85; p < 0.001) during the 6 months after ICU admission than patients with a Hct level of 39.0% or more who were not transfused. Within the subgroup of patients with a Hct level of less than 25% only, receipt of a transfusion was associated with a significant reduction in the risk of mortality (HR, 0.40; 95% CI, 0.19-0.85; p = 0.017).Anemia of a Hct level of less than 25% upon admission to the ICU, in the absence of a transfusion, is associated with long-term mortality. Our study suggests that there may be Hct levels below which the transfusion risk-to-benefit imbalance reverses.

  View details for DOI 10.1111/j.1537-2995.2011.03134.x

  View details for Web of Science ID 000295917700014

  View details for PubMedID 21985048

• Associations of Patient Demographic Characteristics and Regional Physician Density With Early Physician Follow-Up Among Medicare Beneficiaries Hospitalized With Heart Failure AMERICAN JOURNAL OF CARDIOLOGY Kociol, R. D., Greiner, M. A., Fonarow, G. C., Hammill, B. G., Heidenreich, P. A., Yancy, C. W., Peterson, E. D., Curtis, L. H., Hernandez, A. F. 2011; 108 (7): 985-991

  Abstract

  Early physician follow-up after a heart failure (HF) hospitalization is associated with lower risk of readmission. However, factors associated with early physician follow-up are not well understood. We identified 30,136 patients with HF ≥65 years at 225 hospitals participating in the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE) registry or the Get With The Guidelines-Heart Failure (GWTG-HF) registry from January 1, 2003 through December 31, 2006. We linked these clinical data to Medicare claims data for longitudinal follow-up. Using logistic regression models with site-level random effects, we identified predictors of physician follow-up within 7 days of hospital discharge. Overall 11,420 patients (37.9%) had early physician follow-up. Patients residing in hospital referral regions with higher physician concentration were significantly more likely to have early follow-up (odds ratio 1.29, 95% confidence interval 1.12 to 1.48, for highest vs lowest quartile). Patients in rural areas (0.84, 0.78 to 0.91) and patients with lower socioeconomic status (0.79, 0.74 to 0.85) were less likely to have early follow-up. Women (0.87, 0.83 to 0.91) and black patients (0.84, 0.77 to 0.92) were less likely to receive early follow-up. Patients with greater co-morbidity were less likely to receive early follow-up. In conclusion, physician follow-up within 7 days after discharge from a HF hospitalization varied according to regional physician density, rural location, socioeconomic status, gender, race, and co-morbid conditions. Strategies are needed to ensure access among vulnerable populations to this supply-sensitive resource.

  View details for DOI 10.1016/j.amjcard.2011.05.032

  View details for Web of Science ID 000295863200015

  View details for PubMedID 21791327

• Payment Source, Quality of Care, and Outcomes in Patients Hospitalized With Heart Failure JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Kapoor, J. R., Kapoor, R., Hellkamp, A. S., Hernandez, A. F., Heidenreich, P. A., Fonarow, G. C. 2011; 58 (14): 1465-1471

  Abstract

  The aim of this study was to analyze the relationship between payment source and quality of care and outcomes in heart failure (HF).HF is a major cause of morbidity and mortality. There is a lack of studies assessing the association of payment source with HF quality of care and outcomes.A total of 99,508 HF admissions from 244 sites between January 2005 and September 2009 were analyzed. Patients were grouped on the basis of payer status (private/health maintenance organization, no insurance, Medicare, or Medicaid) with private/health maintenance organization as the reference group.The no-insurance group was less likely to receive evidence-based beta-blockers (adjusted odds ratio [OR]: 0.73; 95% confidence interval [CI]: 0.62 to 0.86), implantable cardioverter-defibrillator (OR: 0.59; 95% CI: 0.50 to 0.70), or anticoagulation for atrial fibrillation (OR: 0.73; 95% CI: 0.61 to 0.87). Similarly, the Medicaid group was less likely to receive evidence-based beta-blockers (OR: 0.86; 95% CI: 0.78 to 0.95) or implantable cardioverter-defibrillators (OR: 0.86; 95% CI: 0.78 to 0.96). Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and beta-blockers were prescribed less frequently in the Medicare group (OR: 0.89; 95% CI: 0.81 to 0.98). The Medicare, Medicaid, and no-insurance groups had longer hospital stays. Higher adjusted rates of in-hospital mortality were seen in patients with Medicaid (OR: 1.22; 95% CI: 1.06 to 1.41) and in patients with reduced systolic function with no insurance.Decreased quality of care and outcomes for patients with HF were observed in the no-insurance, Medicaid, and Medicare groups compared with the private/health maintenance organization group.

  View details for DOI 10.1016/j.jacc.2011.06.034

  View details for Web of Science ID 000295213900011

  View details for PubMedID 21939830

• ACCF/AHA Methodology for the Development of Quality Measures for Cardiovascular Technology A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Bonow, R. O., Douglas, P. S., Buxton, A. E., Cohen, D. J., Curtis, J. P., DeLong, E., Drozda, J. P., Ferguson, T. B., Heidenreich, P. A., Hendel, R. C., Masoudi, F. A., Peterson, E. D., Taylor, A. J., Erwin, J. P., Fonarow, G. C., Goff, D. C., Grady, K., Green, L. A., Jenkins, K. J., Loth, A., Shahian, D. M. 2011; 58 (14): 1517-1538

  Abstract

  Consistent with the growing national focus on healthcare quality, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have taken a leadership role over the past decade in developing measures of the quality of cardiovascular care by convening a joint ACCF/AHA Task Force on Performance Measures. The Task Force is charged with identifying the clinical topics appropriate for the development of performance measures and with assembling writing committees composed of clinical and methodological experts in collaboration with appropriate subspecialty societies. The Task Force has also created methodology documents that offer guidance in the development of process, outcome, composite, and efficiency measures. Cardiovascular performance measures using existing ACCF/AHA methodology are based on Class I or Class III guidelines recommendations, usually with Level A evidence. These performance measures, based on evidence-based ACCF/AHA guidelines, remain the most rigorous quality measures for both internal quality improvement and public reporting. However, many of the tools for diagnosis and treatment of cardiovascular disease involve advanced technologies, such as cardiac imaging, for which there are often no underlying guideline documents. Because these technologies affect the quality of cardiovascular care and also have the potential to contribute to cardiovascular health expenditures, there is a need for more critical assessment of the use of technology, including the development of quality and performance measures in areas in which guideline recommendations are absent. The evaluation of quality in the use of cardiovascular technologies requires consideration of multiple parameters that differ from other healthcare processes. The present document describes methodology for development of 2 new classes of quality measures in these situations, appropriate use measures and structure/safety measures. Appropriate use measures are based on specific indications, processes, or parameters of care for which high level of evidence data and Class I or Class III guideline recommendations may be lacking but are addressed in ACCF appropriate use criteria documents. Structure/safety measures represent measures developed to address structural aspects of the use of healthcare technology (e.g., laboratory accreditation, personnel training, and credentialing) or quality issues related to patient safety when there are neither guidelines recommendations nor appropriate use criteria. Although the strength of evidence for appropriate use measures and structure/safety measures may not be as strong as that for formal performance measures, they are quality measures that are otherwise rigorously developed, reviewed, tested, and approved in the same manner as ACCF/AHA performance measures. The ultimate goal of the present document is to provide direction in defining and measuring the appropriate use-avoiding not only underuse but also overuse and misuse-and proper application of cardiovascular technology and to describe how such appropriate use measures and structure/safety measures might be developed for the purposes of quality improvement and public reporting. It is anticipated that this effort will help focus the national dialogue on the use of cardiovascular technology and away from the current concerns about volume and cost alone to a more holistic emphasis on value.

  View details for DOI 10.1016/j.jacc.2011.07.007

  View details for Web of Science ID 000295213900020

• ACCF/AHA Methodology for the Development of Quality Measures for Cardiovascular Technology A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures CIRCULATION Bonow, R. O., Douglas, P. S., Buxton, A. E., Cohen, D. J., Curtis, J. P., DeLong, E., Drozda, J. P., Ferguson, T. B., Heidenreich, P. A., Hendel, R. C., Masoudi, F. A., Peterson, E. D., Taylor, A. J., Erwin, J. P., Fonarow, G. C., Goff, D. C., Grady, K., Green, L. A., Jenkins, K. J., Loth, A., Shahian, D. M. 2011; 124 (13): 1483-U255

  Abstract

  Consistent with the growing national focus on healthcare quality, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have taken a leadership role over the past decade in developing measures of the quality of cardiovascular care by convening a joint ACCF/AHA Task Force on Performance Measures. The Task Force is charged with identifying the clinical topics appropriate for the development of performance measures and with assembling writing committees composed of clinical and methodological experts in collaboration with appropriate subspecialty societies. The Task Force has also created methodology documents that offer guidance in the development of process, outcome, composite, and efficiency measures. Cardiovascular performance measures using existing ACCF/AHA methodology are based on Class I or Class III guidelines recommendations, usually with Level A evidence. These performance measures, based on evidence-based ACCF/AHA guidelines, remain the most rigorous quality measures for both internal quality improvement and public reporting. However, many of the tools for diagnosis and treatment of cardiovascular disease involve advanced technologies, such as cardiac imaging, for which there are often no underlying guideline documents. Because these technologies affect the quality of cardiovascular care and also have the potential to contribute to cardiovascular health expenditures, there is a need for more critical assessment of the use of technology, including the development of quality and performance measures in areas in which guideline recommendations are absent. The evaluation of quality in the use of cardiovascular technologies requires consideration of multiple parameters that differ from other healthcare processes. The present document describes methodology for development of 2 new classes of quality measures in these situations, appropriate use measures and structure/safety measures. Appropriate use measures are based on specific indications, processes, or parameters of care for which high level of evidence data and Class I or Class III guideline recommendations may be lacking but are addressed in ACCF appropriate use criteria documents. Structure/safety measures represent measures developed to address structural aspects of the use of healthcare technology (e.g., laboratory accreditation, personnel training, and credentialing) or quality issues related to patient safety when there are neither guidelines recommendations nor appropriate use criteria. Although the strength of evidence for appropriate use measures and structure/safety measures may not be as strong as that for formal performance measures, they are quality measures that are otherwise rigorously developed, reviewed, tested, and approved in the same manner as ACCF/AHA performance measures. The ultimate goal of the present document is to provide direction in defining and measuring the appropriate use-avoiding not only underuse but also overuse and misuse-and proper application of cardiovascular technology and to describe how such appropriate use measures and structure/safety measures might be developed for the purposes of quality improvement and public reporting. It is anticipated that this effort will help focus the national dialogue on the use of cardiovascular technology and away from the current concerns about volume and cost alone to a more holistic emphasis on value.

  View details for DOI 10.1161/CIR.0b013e31822935fc

  View details for Web of Science ID 000295218000023

• ACCF/AHA methodology for the development of quality measures for cardiovascular technology: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures. Journal of the American College of Cardiology Bonow, R. O., Douglas, P. S., Buxton, A. E., Cohen, D. J., Curtis, J. P., DeLong, E., Drozda, J. P., Ferguson, T. B., Heidenreich, P. A., Hendel, R. C., Masoudi, F. A., Peterson, E. D., Taylor, A. J. 2011; 58 (14): 1517-1538

  Abstract

  Consistent with the growing national focus on healthcare quality, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have taken a leadership role over the past decade in developing measures of the quality of cardiovascular care by convening a joint ACCF/AHA Task Force on Performance Measures. The Task Force is charged with identifying the clinical topics appropriate for the development of performance measures and with assembling writing committees composed of clinical and methodological experts in collaboration with appropriate subspecialty societies. The Task Force has also created methodology documents that offer guidance in the development of process, outcome, composite, and efficiency measures. Cardiovascular performance measures using existing ACCF/AHA methodology are based on Class I or Class III guidelines recommendations, usually with Level A evidence. These performance measures, based on evidence-based ACCF/AHA guidelines, remain the most rigorous quality measures for both internal quality improvement and public reporting. However, many of the tools for diagnosis and treatment of cardiovascular disease involve advanced technologies, such as cardiac imaging, for which there are often no underlying guideline documents. Because these technologies affect the quality of cardiovascular care and also have the potential to contribute to cardiovascular health expenditures, there is a need for more critical assessment of the use of technology, including the development of quality and performance measures in areas in which guideline recommendations are absent. The evaluation of quality in the use of cardiovascular technologies requires consideration of multiple parameters that differ from other healthcare processes. The present document describes methodology for development of 2 new classes of quality measures in these situations, appropriate use measures and structure/safety measures. Appropriate use measures are based on specific indications, processes, or parameters of care for which high level of evidence data and Class I or Class III guideline recommendations may be lacking but are addressed in ACCF appropriate use criteria documents. Structure/safety measures represent measures developed to address structural aspects of the use of healthcare technology (e.g., laboratory accreditation, personnel training, and credentialing) or quality issues related to patient safety when there are neither guidelines recommendations nor appropriate use criteria. Although the strength of evidence for appropriate use measures and structure/safety measures may not be as strong as that for formal performance measures, they are quality measures that are otherwise rigorously developed, reviewed, tested, and approved in the same manner as ACCF/AHA performance measures. The ultimate goal of the present document is to provide direction in defining and measuring the appropriate use-avoiding not only underuse but also overuse and misuse-and proper application of cardiovascular technology and to describe how such appropriate use measures and structure/safety measures might be developed for the purposes of quality improvement and public reporting. It is anticipated that this effort will help focus the national dialogue on the use of cardiovascular technology and away from the current concerns about volume and cost alone to a more holistic emphasis on value.

  View details for DOI 10.1016/j.jacc.2011.07.007

  View details for PubMedID 21880456

• ACCF/AHA methodology for the development of quality measures for cardiovascular technology: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures. Circulation Bonow, R. O., Douglas, P. S., Buxton, A. E., Cohen, D. J., Curtis, J. P., DeLong, E., Drozda, J. P., Ferguson, T. B., Heidenreich, P. A., Hendel, R. C., Masoudi, F. A., Peterson, E. D., Taylor, A. J. 2011; 124 (13): 1483-1502

  Abstract

  Consistent with the growing national focus on healthcare quality, the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have taken a leadership role over the past decade in developing measures of the quality of cardiovascular care by convening a joint ACCF/AHA Task Force on Performance Measures. The Task Force is charged with identifying the clinical topics appropriate for the development of performance measures and with assembling writing committees composed of clinical and methodological experts in collaboration with appropriate subspecialty societies. The Task Force has also created methodology documents that offer guidance in the development of process, outcome, composite, and efficiency measures. Cardiovascular performance measures using existing ACCF/AHA methodology are based on Class I or Class III guidelines recommendations, usually with Level A evidence. These performance measures, based on evidence-based ACCF/AHA guidelines, remain the most rigorous quality measures for both internal quality improvement and public reporting. However, many of the tools for diagnosis and treatment of cardiovascular disease involve advanced technologies, such as cardiac imaging, for which there are often no underlying guideline documents. Because these technologies affect the quality of cardiovascular care and also have the potential to contribute to cardiovascular health expenditures, there is a need for more critical assessment of the use of technology, including the development of quality and performance measures in areas in which guideline recommendations are absent. The evaluation of quality in the use of cardiovascular technologies requires consideration of multiple parameters that differ from other healthcare processes. The present document describes methodology for development of 2 new classes of quality measures in these situations, appropriate use measures and structure/safety measures. Appropriate use measures are based on specific indications, processes, or parameters of care for which high level of evidence data and Class I or Class III guideline recommendations may be lacking but are addressed in ACCF appropriate use criteria documents. Structure/safety measures represent measures developed to address structural aspects of the use of healthcare technology (e.g., laboratory accreditation, personnel training, and credentialing) or quality issues related to patient safety when there are neither guidelines recommendations nor appropriate use criteria. Although the strength of evidence for appropriate use measures and structure/safety measures may not be as strong as that for formal performance measures, they are quality measures that are otherwise rigorously developed, reviewed, tested, and approved in the same manner as ACCF/AHA performance measures. The ultimate goal of the present document is to provide direction in defining and measuring the appropriate use-avoiding not only underuse but also overuse and misuse-and proper application of cardiovascular technology and to describe how such appropriate use measures and structure/safety measures might be developed for the purposes of quality improvement and public reporting. It is anticipated that this effort will help focus the national dialogue on the use of cardiovascular technology and away from the current concerns about volume and cost alone to a more holistic emphasis on value.

  View details for DOI 10.1161/CIR.0b013e31822935fc

  View details for PubMedID 21875906

• Collaborative Care Intervention for Stable Ischemic Heart Disease ARCHIVES OF INTERNAL MEDICINE Fihn, S. D., Bucher, J. B., McDonell, M., Diehr, P., Rumsfeld, J. S., Doak, M., Dougherty, C., Gerrity, M., Heidenreich, P., Larsen, G., Lee, P. I., Lucas, L., McBryde, C., Nelson, K., Plomondon, M. E., Stadius, M., Bryson, C. 2011; 171 (16): 1471-1479

  Abstract

  Accumulating evidence suggests that collaborative models of care enhance communication among primary care providers, improving quality of care and outcomes for patients with chronic conditions. We sought to determine whether a multifaceted intervention that used a collaborative care model and was directed through primary care providers would improve symptoms of angina, self-perceived health, and concordance with practice guidelines for managing chronic stable angina.We conducted a prospective trial, cluster randomized by provider, involving patients with symptomatic ischemic heart disease recruited from primary care clinics at 4 academically affiliated Department of Veterans Affairs health care systems. Primary end points were changes over 12 months in symptoms on the Seattle Angina Questionnaire, self-perceived health, and concordance with practice guidelines.In total, 183 primary care providers and 703 patients participated in the study. Providers accepted and implemented 91.6% of 701 recommendations made by collaborative care teams. Almost half were related to medications, including adjustments to β-blockers, long-acting nitrates, and statins. The intervention did not significantly improve symptoms of angina or self-perceived health, although end points favored collaborative care for 10 of 13 prespecified measures. While concordance with practice guidelines improved 4.5% more among patients receiving collaborative care than among those receiving usual care (P < .01), this was mainly because of increased use of diagnostic testing rather than increased use of recommended medications.A collaborative care intervention was well accepted by primary care providers and modestly improved receipt of guideline-concordant care but not symptoms or self-perceived health in patients with stable angina.

  View details for Web of Science ID 000294825100011

  View details for PubMedID 21911632

• Diabetes, quality of care, and in-hospital outcomes in patients hospitalized with heart failure AMERICAN HEART JOURNAL Kapoor, J. R., Fonarow, G. C., Zhao, X., Kapoor, R., Hernandez, A. F., Heidenreich, P. A. 2011; 162 (3): 480-U95

  Abstract

  Diabetes mellitus is frequently comorbid with heart failure (HF). It is unclear if comorbid diabetes is associated with quality of care and in-hospital mortality.We analyzed 133,971 HF admissions from 431 hospitals between January 2005 and January 2010 comparing patients with and without diabetes.There were 54,352 (41%) patients hospitalized with HF with a history or newly diagnosed diabetes. After adjustment, patients with diabetes were as likely as patients without diabetes to appropriately receive the composite of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and β-blockers (odds ratio [OR] 0.99, 95% CI 0.94-1.04), angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (OR 0.98, 95% CI 0.92-1.05), evidence-based β-blockers (OR 1.04, 95% CI 0.98-1.1), and hydralazine/nitrates (OR 1.09, 95% CI 0.99-1.2). However, patients with diabetes were less likely to receive smoking cessation counseling (OR 0.89, 95% CI 0.81-0.98) and blood pressure control (OR 0.81, 95% CI 0.78-0.84) and to attain the all-or-none composite measure (OR 0.96, 95% CI 0.93-0.99). Patients with diabetes were more likely to receive an aldosterone antagonist for reduced left ventricular ejection fraction (OR 1.05, 95% CI 1.00-1.11), lipid-lowering agent (OR 1.33, 95% CI 1.26-1.41), and influenza vaccination (OR 1.05, 95% CI 1.01-1.09). Diabetes was independently associated with longer hospital stay but not within-hospital mortality.With few exceptions, the application of evidence-based care and in-hospital outcomes were similar whether or not diabetes was present in this large contemporary cohort of patients hospitalized with HF.

  View details for DOI 10.1016/j.ahj.2011.06.008

  View details for Web of Science ID 000294447400010

  View details for PubMedID 21884864

• Mental Illness and Warfarin Use in Atrial Fibrillation AMERICAN JOURNAL OF MANAGED CARE Walker, G. A., Heidenreich, P. A., Phibbs, C. S., Go, A. S., Chiu, V. Y., Schmitt, S. K., Ananth, L., Frayne, S. M. 2011; 17 (9): 617-624

  Abstract

  To determine whether atrial fibrillation (AF) patients with mental health conditions (MHCs) were less likely than AF patients without MHCs to be prescribed warfarin and, if receiving warfarin, to maintain an International Normalized Ratio (INR) within the therapeutic range.Detailed chart review of AF patients using a Veterans Health Administration (VHA) facility in 2003.For a random sample of 296 AF patients, records identified clinician-diagnosed MHCs (independent variable) and AF-related care in 2003 (dependent variables), receipt of warfarin, INR values below/above key thresholds, and time spent within the therapeutic range (2.0-3.0) or highly out of range. Differences between the MHC and comparison groups were examined using X2 tests and logistic regression controlling for age and comorbidity.Among warfarin-eligible AF patients (n = 246), 48.5% of those with MHCs versus 28.9% of those without MHCs were not treated with warfarin (P = .004). Among those receiving warfarin and monitored in VHA, highly supratherapeutic INRs were more common in the MHC group; for example, 27.3% versus 1.6% had any INR >5.0 (P <.001). Differences persisted after adjusting for age and comorbidity.MHC patients with AF were less likely than those without MHC to have adequate management of their AF care. Interventions directed at AF patients with MHC may help to optimize their outcomes.

  View details for Web of Science ID 000295129700008

  View details for PubMedID 21902447

• Cardiac resynchronization therapy and the relationship of percent biventricular pacing to symptoms and survival HEART RHYTHM Hayes, D. L., Boehmer, J. P., Day, J. D., Gilliam, F. R., Heidenreich, P. A., Seth, M., Jones, P. W., Saxon, L. A. 2011; 8 (9): 1469-1475

  Abstract

  With the advent of cardiac resynchronization therapy, it was unclear what percentage of biventricular pacing would be required to obtain maximal symptomatic and mortality benefit from the therapy. The optimal percentage of biventricular pacing and the association between the amount of continuous pacing and survival is unknown.The purpose of this study was to assess the optimal percentage of biventricular pacing and any association with survival in a large cohort of networked patients.A large cohort of 36,935 patients followed up in a remote-monitoring network, the LATITUDE Patient Management system (Boston Scientific Corp., Natick, Massachusetts), was assessed to determine the association between the percentage of biventricular pacing and mortality.The greatest magnitude of reduction in mortality was observed with a biventricular pacing achieved in excess of 98% of all ventricular beats. Atrial fibrillation and native atrial ventricular condition can limit a high degree of biventricular pacing. Incremental increases in mortality benefit are observed with an increasing percentage of biventricular pacing.Every effort should be made to reduce native atrioventricular conduction with cardiac resynchronization therapy systems in an attempt to achieve biventricular pacing as close to 100% as possible.

  View details for DOI 10.1016/j.hrthm.2011.04.015

  View details for Web of Science ID 000294249200021

  View details for PubMedID 21699828

• Real World Evaluation of Dual-Zone ICD and CRT-D Programming Compared to Single-Zone Programming: The ALTITUDE REDUCES Study JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY Gilliam, F. R., Hayes, D. L., Boehmer, J. P., Day, J., Heidenreich, P. A., Seth, M., Jones, P. W., Stein, K. M., Saxon, L. A. 2011; 22 (9): 1023-1029

  Abstract

  We evaluated the frequency of appropriate and inappropriate shocks and survival in patients using dual-zone programming versus single-zone programming.For the ALTITUDE REDUCES study, patients were followed for 1.6 ± 1.1 years. The 12-month incidence of any shock was lower for dual-versus single-zone programmed detection at rates ≤170 bpm and between 170-200 bpm (P < 0.001). Appropriate shock rates at 1 year were also lower with dual-zone programming in these rate intervals (single zone 9.1%, 5.4%, P < 0.001, dual zone 6.7%, 4.7%, P < 0.02). There were no detectable differences between single- and dual-zone shock incidence at detection rates ≥ 200 bpm (P = 0.14). Inappropriate shock incidence was less with dual- versus single-zone detection at all detect rates <200 bpm, but not at rates ≥200 bpm (P < 0.001, P = 0.37). The lowest risk of appropriate and inappropriate shock was associated with dual-zone programming and detection rates ≥200 bpm (2.1%). Dual-zone detection was associated with more nonsustained and diverted therapy episodes but these patients did not have an increased risk of death compared to patients with single-zone programming. Patients programmed to low detection rate, single-zone detection and shock-only therapy also had the highest preshock mortality risk (P = 0.05).Shock incidence is lowest with either single- or dual-zone detection ≥200 bpm. For detection rates <200 bpm, dual-zone programming is associated with a reduction in the incidence of total shocks, appropriate shocks, and inappropriate shocks. 

  View details for DOI 10.1111/j.1540-8167.2011.02086.x

  View details for Web of Science ID 000295131200012

  View details for PubMedID 21627705

• The Need for Multiple Measures of Hospital Quality Results From the Get With The Guidelines-Heart Failure Registry of the American Heart Association CIRCULATION Hernandez, A. F., Fonarow, G. C., Liang, L., Heidenreich, P. A., Yancy, C., Peterson, E. D. 2011; 124 (6): 712-719

  Abstract

  Process and outcome measures are often used to quantify quality of care in hospitals. Whether these quality measures correlate with one another and the degree to which hospital provider rankings shift on the basis of the performance metric is uncertain.Heart failure patients ≥ 65 years of age hospitalized in the Get With the Guidelines-Heart Failure registry of the American Heart Association were linked to Medicare claims from 2005 to 2006. Hospitals were ranked by (1) composite adherence scores for 5 heart failure process measures, (2) composite adherence scores for emerging quality measures, (3) risk-adjusted 30-day death after admission, and (4) risk-adjusted 30-day readmission after discharge. Hierarchical models using shrinkage estimates were performed to adjust for case mix and hospital volume. There were 19 483 patients hospitalized from 2005 to 2006 from 153 hospitals. The overall median composite adherence rate to heart process measures was 85.8% (25th, 75th percentiles 77.5, 91.4). Median 30-day risk-adjusted mortality was 9.0% (7.9, 10.4). Median risk-adjusted 30-day readmission was 22.9% (22.1, 23.5). The weighted κ for remaining within the top 20th percentile or bottom 20th percentile was ≤ 0.15 and the Spearman correlation overall was ≤ 0.21 between the different measures of quality of care. The average shift in ranks was 33 positions (13, 68) when criteria were changed from 30-day mortality to readmission and 51 positions (22, 76) when ranking metric changed from 30-day mortality to composite process adherence.Agreement between different methods of ranking hospital-based quality of care and 30-day mortality or readmission rankings was poor. Profiling quality of care will require multidimensional ranking methods and/or additional measures.

  View details for DOI 10.1161/CIRCULATIONAHA.111.026088

  View details for Web of Science ID 000293624800017

  View details for PubMedID 21788585

• The Importance of Consistent, High-Quality Acute Myocardial Infarction and Heart Failure Care Results From the American Heart Association's Get With The Guidelines Program JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Wang, T. Y., Dai, D., Hernandez, A. F., Bhatt, D. L., Heidenreich, P. A., Fonarow, G. C., Peterson, E. D. 2011; 58 (6): 637-644

  Abstract

  This study examined the degree to which hospital performance for acute myocardial infarction (AMI) and heart failure (HF) care processes are correlated.Although AMI and HF care processes may be amenable to similar quality improvement interventions, whether these are indeed correlated and whether hospitals with consistently superior performance for both care metrics have the best outcomes remains unknown.We compared hospital performance of the Centers for Medicare & Medicaid Services AMI and HF core measures in 283 hospitals submitting 10 or more patients to the Get With The Guidelines AMI and HF programs between January 2005 and April 2009.Median hospital adherence to AMI and HF composite measures were 93% (interquartile range: 87% to 97%) and 92% (interquartile range: 85% to 96%), respectively, with only a modest correlation between hospital performance on these 2 composite metrics (r = 0.50; 95% confidence interval: 0.41 to 0.58). Hospitals with superior performance to both AMI and HF processes had significantly longer duration of Get With The Guidelines participation and lower adjusted in-hospital mortality (odds ratio: 0.79; 95% confidence interval: 0.63 to 0.99) for AMI and HF patients, whereas hospitals with superior adherence to either alone had similar mortality rates as hospitals with superior adherence to neither measure.Hospitals that had consistent, superior performance for both AMI and HF care had significantly lower risk-adjusted mortality than those with superior performance either alone or for neither measure. Whether a single scoring system to assess global, rather than condition-specific, quality of cardiovascular care would facilitate care quality improvement more consistently and would optimize patient outcomes merits further investigation.

  View details for DOI 10.1016/j.jacc.2011.05.012

  View details for Web of Science ID 000293167200014

  View details for PubMedID 21798428

• Predictors of Hospital Length of Stay in Heart Failure: Findings from Get With the Guidelines JOURNAL OF CARDIAC FAILURE Whellan, D. J., Zhao, X., Hernandez, A. F., Liang, L., Peterson, E. D., Bhatt, D. L., Heidenreich, P. A., Schwamm, L. H., Fonarow, G. C. 2011; 17 (8): 649-656

  Abstract

  This study was undertaken to identify predictors of hospital length of stay (LOS) for heart failure (HF) patients using clinical variables available at the time of admission and hospital characteristics.A cohort of 70,094 HF patients discharged to home from 246 hospitals participating in the Get With the Guidelines-Heart Failure was analyzed for admission predictors for LOS. The analysis incorporated patient characteristics (PC) first, then added hospital characteristics (HC) followed by standard laboratory evaluations (SL), including troponin and brain natriuretic peptide (BNP). There were 31,995 patients (45.6%) with LOS < 4 days, 26,750 (38.2%) with LOS 4 to 7 days, and 11,349 (16.2%) with LOS > 7 days. Patients with longer LOS had more comorbidities and a higher severity of disease on admission. Overall models explained a modest amount of LOS variation, with an r(2) of 4.8%, with PC responsible for 1.3% of variation and together with SL explained 2.2% of variation. HC did not change the variation.Based on admission vital signs and BNP levels, patients with longer LOS have more comorbidities and a higher disease severity. The ability to risk stratify for LOS based on patient admission and hospital characteristics is limited.

  View details for DOI 10.1016/j.cardfail.2011.04.005

  View details for Web of Science ID 000293938600006

  View details for PubMedID 21807326

• Heart Failure Diagnostic Parameters and Symptoms: Observations from the ALTITUDE Study Boehmer, J. P., Day, J. D., Gilliam, F. R., Heidenreich, P. A., Hayes, D. L., Roy, K., Jiang, S., Saxon, L. A. CHURCHILL LIVINGSTONE INC MEDICAL PUBLISHERS. 2011: S44

  View details for DOI 10.1016/j.cardfail.2011.06.148

  View details for Web of Science ID 000293938700140

• A Blended Facilitation To Implement the VA Hospital-to-Home (H2H) Initiative: CHF QUERI Sahay, A., Heidenreich, P. A. CHURCHILL LIVINGSTONE INC MEDICAL PUBLISHERS. 2011: S77

  View details for DOI 10.1016/j.cardfail.2011.06.259

  View details for Web of Science ID 000293938700245

• Association of Heart Failure Symptoms Identified by Home Monitoring with Long-Term Mortality and Shock Incidence Heidenreich, P. A., Boehmer, J. P., Hayes, D. L., Gilliam, F. R., Day, J. D., Seth, M., Saxon, L. A. CHURCHILL LIVINGSTONE INC MEDICAL PUBLISHERS. 2011: S77

  View details for DOI 10.1016/j.cardfail.2011.06.260

  View details for Web of Science ID 000293938700246

• Successful Facilitation of the Save 5 Million Lives Campaign at VA VISNs (Regions): CHF QUERI Sahay, A., Heidenreich, P. A. CHURCHILL LIVINGSTONE INC MEDICAL PUBLISHERS. 2011: S84

  View details for DOI 10.1016/j.cardfail.2011.06.283

  View details for Web of Science ID 000293938700269

• Characteristics of Implantable Cardioverter-defibrillator Recipients for the Primary and Secondary Prevention of Sudden Cardiac Death in the Outcomes Among Veterans With Implantable Defibrillators (OVID) Registry Katz, D. F., Aleong, R. G., Pointer, L., Pelligrini, C. N., Sauer, W. H., Heath, R. R., Schuller, J., Nguyen, D. T., Heidenreich, P. A., Massie, B. M., Varosy, P. D. CHURCHILL LIVINGSTONE INC MEDICAL PUBLISHERS. 2011: S52–S53

  View details for DOI 10.1016/j.cardfail.2011.06.177

  View details for Web of Science ID 000293938700168

• Barriers and Facilitators to Implementing the 2010 Veteran's Administration (VA) CHF QUERI Hospital to Home (H2H) Initiative Oliva, N. L., Sahay, A., Gholami, P., Heidenreich, P. A. CHURCHILL LIVINGSTONE INC MEDICAL PUBLISHERS. 2011: S75–S76

  View details for DOI 10.1016/j.cardfail.2011.06.253

  View details for Web of Science ID 000293938700239

• ACCF/AHA 2011 key data elements and definitions of a base cardiovascular vocabulary for electronic health records: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Data Standards. Circulation Weintraub, W. S., Karlsberg, R. P., Tcheng, J. E., Boris, J. R., Buxton, A. E., Dove, J. T., Fonarow, G. C., Goldberg, L. R., Heidenreich, P., Hendel, R. C., Jacobs, A. K., Lewis, W., Mirro, M. J., Shahian, D. M., Hendel, R. C., Bozkurt, B., Jacobs, J. P., Peterson, P. N., Roger, V. L., Smith, E. E., Tcheng, J. E., Wang, T. 2011; 124 (1): 103-123

  View details for DOI 10.1161/CIR.0b013e31821ccf71

  View details for PubMedID 21646493

• ACCF/AHA 2011 Key Data Elements and Definitions of a Base Cardiovascular Vocabulary for Electronic Health Records A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Data Standards CIRCULATION Weintraub, W. S., Karlsberg, R. P., Tcheng, J. E., Boris, J. R., Buxton, A. E., Dove, J. T., Fonarow, G. C., Goldberg, L. R., Heidenreich, P., Hendel, R. C., Jacobs, A. K., Lewis, W., Mirro, M. J., Shahian, D. M. 2011; 124 (1): 103-U220

  View details for DOI 10.1161/CIR.0b013e31821ccf71

  View details for Web of Science ID 000292375200026

• ACCF/AHA 2011 Key Data Elements and Definitions of a Base Cardiovascular Vocabulary for Electronic Health Records A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Data Standards JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Weintraub, W. S., Karlsberg, R. P., Tcheng, J. E., Boris, J. R., Buxton, A. E., Dove, J. T., Fonarow, G. C., Goldberg, L. R., Heidenreich, P., Hendel, R. C., Jacobs, A. K., Lewis, W., Mirro, M. J., Shahian, D. M. 2011; 58 (2): 202-222

  View details for DOI 10.1016/j.jacc.2011.05.001

  View details for Web of Science ID 000292189300025

  View details for PubMedID 21652161

• Patterns and Predictors of Evidence-Based Medication Continuation Among Hospitalized Heart Failure Patients (from Get With the Guidelines-Heart Failure) AMERICAN JOURNAL OF CARDIOLOGY Krantz, M. J., Ambardekar, A. V., Kaltenbach, L., Hernandez, A. F., Heidenreich, P. A., Fonarow, G. C. 2011; 107 (12): 1818-1823

  Abstract

  Hospitalized patients with heart failure and decreased ejection fraction are at substantial risk for mortality and rehospitalization, yet no acute therapies are proven to decrease this risk. Therefore, in-hospital use of medications proved to decrease long-term mortality is a critical strategy to improve outcomes. Although endorsed in guidelines, predictors of initiation and continuation of angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), β blockers, and aldosterone antagonists have not been well studied. We assessed noncontraindicated use patterns for the 3 medications using the Get With the Guidelines-Heart Failure (GWTG-HF) registry from February 2009 through March 2010. Medication continuation was defined as treatment on admission and discharge. Multivariable logistic regression using generalized estimating equations was used to determine factors associated with discharge use. In total 9,474 patients were enrolled during the study period. Of those treated before hospitalization, overall continuation rates were 88.5% for ACE inhibitors/ARBs, 91.6% for β blockers, and 71.9% for aldosterone-antagonists. Of patients untreated before admission, 87.4% had ACE inhibitors/ARBs and 90.1% had β blocker initiated during hospitalization or at discharge, whereas only 25.2% were started on an aldosterone antagonist. In multivariate analysis, admission therapy was most strongly associated with discharge use (adjusted odds ratios 7.4, 6.0, and 20.9 for ACE inhibitors/ARBs, β blockers, and aldosterone antagonists, respectively). Western region, younger age, and academic affiliation were also associated with higher discharge use. Although ACE inhibitor/ARB and β-blocker continuation rates were high, aldosterone antagonist use was lower despite potential eligibility. In conclusion, being admitted on evidence-based medications is the most powerful, independent predictor of discharge use.

  View details for DOI 10.1016/j.amjcard.2011.02.322

  View details for Web of Science ID 000291754900021

  View details for PubMedID 21482418

• Potential impact of optimal implementation of evidence-based heart failure therapies on mortality AMERICAN HEART JOURNAL Fonarow, G. C., Yancy, C. W., Hernandez, A. F., Peterson, E. D., Spertus, J. A., Heidenreich, P. A. 2011; 161 (6): 1024-U244

  Abstract

  Although multiple therapies have been shown to lower mortality in patients with heart failure (HF) and reduced left ventricular ejection fraction, their application in clinical practice has been less than ideal. To date, empiric estimation of the potential benefits that could be gained from eliminating these existing treatment gaps with optimal implementation has not been quantified.Eligibility criteria for each evidence-based HF therapy, the estimated frequency of use/nonuse of specific treatments, the case fatality rates, and the risk reductions due to treatment were obtained from published sources. The numbers of deaths prevented or postponed because of each guideline-recommended therapy and overall were determined.Among patients with HF with reduced left ventricular ejection fraction in the United States (n = 2,644,800), the number eligible but not currently treated ranged from 139,749 for hydralazine/isorbide dinitrate to 852,512 for implantable cardioverter defibrillators. The comparative number of deaths that could potentially be prevented per year with optimal implementation of angiotensin-converting enzyme inhibitor/angiotensin receptor antagonist is 6,516; β-blockers, 12,922; aldosterone antagonists, 21,407; hydralazine/isorbide dinitrate, 6,655; cardiac resynchronization therapy, 8,317; and implantable cardioverter defibrillators, 12,179. If these treatment benefits were additive, optimal implementation of all 6 therapies could potentially prevent 67,996 deaths a year.A substantial number of HF deaths in this country could potentially be prevented by optimal implementation of evidence-based therapies. These data may underscore the importance of performance improvement efforts to translate evidence-based therapy to routine clinical practice so as to reduce contemporary HF mortality.

  View details for DOI 10.1016/j.ahj.2011.01.027

  View details for Web of Science ID 000291343000003

  View details for PubMedID 21641346

• The Year in Quality of Care in Heart Failure JOURNAL OF CARDIAC FAILURE Rich, M. W., Heart Failure Soc Amer 2011; 17 (6): 443-450

  View details for DOI 10.1016/j.cardfail.2011.04.003

  View details for Web of Science ID 000291624000002

  View details for PubMedID 21624731

• The Year in Epidemiology, Health Services Research, and Outcomes Research JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Hlatky, M. A., Heidenreich, P. A. 2011; 57 (19): 1859-1866

  View details for DOI 10.1016/j.jacc.2011.01.020

  View details for Web of Science ID 000290210100003

  View details for PubMedID 21545941

• Discharge to a Skilled Nursing Facility and Subsequent Clinical Outcomes Among Older Patients Hospitalized for Heart Failure CIRCULATION-HEART FAILURE Allen, L. A., Hernandez, A. F., Peterson, E. D., Curtis, L. H., Dai, D., Masoudi, F. A., Bhatt, D. L., Heidenreich, P. A., Fonarow, G. C. 2011; 4 (3): 293-300

  Abstract

  Heart failure (HF) is the leading cause of hospitalization among older Americans. Subsequent discharge to skilled nursing facilities (SNF) is not well described.We performed an observational analysis of Medicare beneficiaries ≥65 years of age, discharged alive to SNF or home after ≥3-day hospitalization for HF in 2005 and 2006 within the Get With The Guidelines-HF Program. Among 15 459 patients from 149 hospitals, 24.1% were discharged to an SNF, 22.3% to home with home health service, and 53.6% to home with self-care. SNF use varied significantly among hospitals (median, 10.2% versus 33.9% in low versus high tertiles), with rates highest in the Northeast. Patient factors associated with discharge to SNF included longer length of stay, advanced age, female sex, hypotension, higher ejection fraction, absence of ischemic heart disease, and a variety of comorbidities. Performance measures were modestly lower for patients discharged to SNF. Unadjusted absolute event rates were higher at 30 days (death, 14.4% versus 4.1%; rehospitalization, 27.0% versus 23.5%) and 1 year (death, 53.5% versus 29.1%; rehospitalization, 76.1% versus 72.2%) after discharge to SNF versus home, respectively (P<0.0001 for all). After adjustment for measured patient characteristics, discharge to SNF remained associated with increased death (hazard ratio, 1.76; 95% confidence interval, 1.66 to 1.87) and rehospitalization (hazard ratio, 1.08; 95% confidence interval, 1.03 to 1.14).Discharge to SNF is common among Medicare patients hospitalized for HF, and these patients face substantial risk for adverse events, with more than half dead within 1 year. These findings highlight the need to better characterize this unique patient population and understand the SNF care they receive.

  View details for DOI 10.1161/CIRCHEARTFAILURE.110.959171

  View details for Web of Science ID 000292869800013

  View details for PubMedID 21447803

• Procedure Volume and Outcome You Should Take Into Account Each Hospital Reply JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Freeman, J. V., Wang, Y., Curtis, J. P., Heidenreich, P. A., Hlatky, M. A. 2011; 57 (16): 1714-1714

  View details for DOI 10.1016/j.jacc.2010.12.023

  View details for Web of Science ID 000289460800015

• GENETIC DETERMINANTS OF DRAMATIC IMPROVEMENT IN LEFT VENTRICULAR FUNCTION IN PATIENTS WITH HEART FAILURE 60th Annual Scientific Session and Expo of the American-College-of-Cardiology (ACC) / I2 Summit / ACCF/Herman K. Gold Young Investigator's Award in Molecular and Cellular Cardiology Perez, M. V., Pavlovic, A., Wheeler, M. T., Dewey, F. E., Bernstein, D., Fowler, M. B., Robbins, R. C., Quertermous, T., Chan, K., Absher, D., Ho, M., Cretti, E., Southwick, A., Rosenthal, D., Myers, R. M., Heidenreich, P., Garrett, L., Sedehi, D., Kao, D., Salisbury, H., Ashley, E. A. ELSEVIER SCIENCE INC. 2011: E2041–E2041

  View details for Web of Science ID 000291695102046

• CARDIOLOGY PRACTICE IMPROVEMENT PATHWAY: HOW DO WE MEASURE QUALITY IN CARDIOVASCULAR CARE? Russo, A. M., Hagan, E., Biga, C., Cacchione, J. G., Drozda, J., Duffy, P. L., Gillam, L., Heidenreich, P. A., Jenkins, K., Kennett, J. D., Loth, A., Mirro, M., Newhall, C., Oetgen, W., Smith, S., Weiner, B. H., Windle, J., Wright, J. ELSEVIER SCIENCE INC. 2011: E1219

  View details for DOI 10.1016/S0735-1097(11)61219-9

  View details for Web of Science ID 000291695101222

• Association of race/ethnicity with clinical risk factors, quality of care, and acute outcomes in patients hospitalized with heart failure AMERICAN HEART JOURNAL Thomas, K. L., Hernandez, A. F., Dai, D., Heidenreich, P., Fonarow, G. C., Peterson, E. D., Yancy, C. W. 2011; 161 (4): 746-754

  Abstract

  Black and Hispanic populations are at increased risk for developing heart failure (HF) at a younger age and experience differential morbidity and possibly differential mortality compared with whites. Yet, there have been insufficient data characterizing the clinical presentation, quality of care, and outcomes of patients hospitalized with HF as a function of race/ethnicity.We analyzed 78,801 patients from 257 hospitals voluntarily participating in the American Heart Association's Get With The Guidelines-HF Program from January 2005 thru December 2008. There were 56,266 (71.4%) white, 17,775 (22.6%) black, and 4,760 (6.0%) Hispanic patients. In patients hospitalized with HF, we sought to assess clinical characteristics, adherence to core and other guideline-based HF care measures, and in-hospital mortality as a function of race and ethnicity.Relative to white patients, Hispanic and black patients were significantly younger (median age 78.0, 63.0, 64.0 years, respectively), had lower left ventricular ejection fractions, and had more diabetes mellitus and hypertension. With few exceptions, the provision of guideline-based care was comparable for black, Hispanic, and white patients. Black and Hispanic patients had lower in-hospital mortality than white patients: black/white odds ratio 0.69, 95% CI 0.62-0.78, P < .001 and Hispanic/white odds ratio 0.81, 95% CI 0.67-0.98, P = .03.Hispanic and black patients hospitalized with HF have more cardiovascular risk factors than white patients; however; they have similar or better in-hospital mortality rates. Within the context of a national HF quality improvement program, HF care was equitable and improved in all racial/ethnic groups over time.

  View details for DOI 10.1016/j.ahj.2011.01.012

  View details for Web of Science ID 000289190500019

  View details for PubMedID 21473975

• Developing Heart Failure (HF) Clinical Decision Support for Patients with Comorbidities. Goldstein, M. K., Martins, S. B., Tu, S. W., Heidenreich, P., Massie, B., Furmaga, E. WILEY-BLACKWELL. 2011: S146

  View details for Web of Science ID 000289524600424

• A comparison of echocardiographic measures of diastolic function for predicting all-cause mortality in a predominantly male population AMERICAN HEART JOURNAL Nguyen, P. K., Schnittger, I., Heidenreich, P. A. 2011; 161 (3): 530-537

  Abstract

  Prior studies demonstrating the prognostic value of echocardiographic measures of diastolic function have been limited by sample size, have included only select clinical populations, and have not incorporated newer measures of diastolic function nor determined their independent prognostic value. The objective of this study is to determine the independent prognostic value of established and new echocardiographic parameters of diastolic function.We included 3,604 consecutive patients referred to 1 of 3 echocardiography laboratories over a 2-year period. We obtained measurements of mitral inflow velocities, pulmonary vein filling pattern, mitral annulus motion (e'), and propagation velocity (V(p)). The primary end point was 1-year all-cause mortality.The mean age of the patients was 68 years, and 95% were male. There were 277 deaths during a mean follow-up of 248 ± 221 days. For patients with reduced left ventricular ejection fraction (LVEF), all measured parameters except for e' were associated with mortality (P < .05) on univariate analysis. For patients with preserved LVEF, the E-wave velocity was significantly associated with mortality (P < .05) on univariate analysis. The deceleration time/E-wave velocity ratio, V(p), and pulmonary vein filling pattern were borderline significant (P < .10). With multivariate analysis, only V(p) was associated with survival for both reduced (P = .02) and preserved LVEF groups (P = .01).In a large, clinically diverse population, most measures of diastolic function were predictive of all-cause mortality without adjustment for patient characteristics. On multivariate analysis, only V(p) was independently associated with total mortality. This association with mortality may be related to factors other than diastolic function and warrants further investigation.

  View details for DOI 10.1016/j.ahj.2010.12.010

  View details for Web of Science ID 000288156400018

  View details for PubMedID 21392608

• ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Douglas, P. S., Garcia, M. J., Haines, D. E., Lai, W. W., Manning, W. J., Patel, A. R., Picard, M. H., Polk, D. M., Ragosta, M., Ward, R., Weiner, R. B. 2011; 57 (9): 1126-1166

  View details for DOI 10.1016/j.jacc.2010.11.002

  View details for Web of Science ID 000287652000014

  View details for PubMedID 21349406

• ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance American College of Chest Physicians. Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American College of Chest Physicians, Douglas, P. S., Garcia, M. J., Haines, D. E., Lai, W. W., Manning, W. J., Patel, A. R., Picard, M. H., Polk, D. M., Ragosta, M., Parker Ward, R., Weiner, R. B., Bailey, S. R., Weiner, R. B., Alagona, P. J., Anderson, J. L., DeCara, J. M., Dolor, R. J., Fazel, R., Gillespie, J. A., Heidenreich, P. A., Leykum, L. K., Marine, J. E., Mishkel, G. J., Pellikka, P. A., Raff, G. L., Vijayaraghavan, K., Weissman, N. J., Wu, K. C., Wolk, M. J., Bailey, S. R., Douglas, P. S., Hendel, R. C., Kramer, C. M., Min, J. K., Patel, M. R., Shaw, L., Stainback, R. F., Allen, J. M., Baldwin, D., Behrenbeck, T., Blaivas, M., Bonow, R. O., DeCara, J. M., Duffy, P. L., Fleischmann, K. E., Gregory, S. A., Jerome, S. D., Kushner, F. G., Lesser, J., Levitov, A. B., Lotun, K., Mieres, J. H., Miller, T. D., Nixon, J. V., Porembka, D. T., Powell, B. D., Raman, S., Thomas, G. S., Thomas, J. D., Vashist, A., Walsh, M. N., Warnes, C. A., Wight, J. N., Williams, K. A., Wu, K. C., Wolk, M. J., Bailey, S. R., Douglas, P. S., Hendel, R. C., Kramer, C. M., Min, J. K., Patel, M. R., Shaw, L., Stainback, R. F., Allen, J. M. 2011; 24 (3): 229-67

  Abstract

  The American College of Cardiology Foundation (ACCF), in partnership with the American Society of Echocardiography (ASE) and along with key specialty and subspecialty societies, conducted a review of common clinical scenarios where echocardiography is frequently considered. This document combines and updates the original transthoracic and transesophageal echocardiography appropriateness criteria published in 2007 (1) and the original stress echocardiography appropriateness criteria published in 2008 (2). This revision reflects new clinical data, reflects changes in test utilization patterns,and clarifies echocardiography use where omissions or lack of clarity existed in the original criteria.The indications (clinical scenarios)were derived from common applications or anticipated uses, as well as from current clinical practice guidelines and results of studies examining the implementation of the original appropriate use criteria (AUC).The 202 indications in this document were developed by a diverse writing group and scored by a separate independent technical panel on a scale of 1 to 9,to designate appropriate use(median 7 to 9), uncertain use(median 4 to 6), and inappropriate use (median 1 to 3). Ninety-seven indications were rated as appropriate, 34 were rated as uncertain, and 71 were rated as inappropriate. In general,the use of echocardiography for initial diagnosis when there is a change in clinical status or when the results of the echocardiogram are anticipated to change patient management were rated appropriate. Routine testing when there was no change in clinical status or when results of testing were unlikely to modify management were more likely to be inappropriate than appropriate/uncertain.The AUC for echocardiography have the potential to impact physician decision making,healthcare delivery, and reimbursement policy. Furthermore,recognition of uncertain clinical scenarios facilitates identification of areas that would benefit from future research.

  View details for DOI 10.1016/j.echo.2010.12.008

  View details for PubMedID 21338862

• Non-Evidence-Based ICD Implantations in the United States JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Al-Khatib, S. M., Hellkamp, A., Curtis, J., Mark, D., Peterson, E., Sanders, G. D., Heidenreich, P. A., Hernandez, A. F., Curtis, L. H., Hammill, S. 2011; 305 (1): 43-49

  Abstract

  Practice guidelines do not recommend use of an implantable cardioverter-defibrillator (ICD) for primary prevention in patients recovering from a myocardial infarction or coronary artery bypass graft surgery and those with severe heart failure symptoms or a recent diagnosis of heart failure.To determine the number, characteristics, and in-hospital outcomes of patients who receive a non-evidence-based ICD and examine the distribution of these implants by site, physician specialty, and year of procedure.Retrospective cohort study of cases submitted to the National Cardiovascular Data Registry-ICD Registry between January 1, 2006, and June 30, 2009.In-hospital outcomes.Of 111,707 patients, 25,145 received non-evidence-based ICD implants (22.5%). Patients who received a non-evidence-based ICD compared with those who received an evidence-based ICD had a significantly higher risk of in-hospital death (0.57% [95% confidence interval {CI}, 0.48%-0.66%] vs 0.18% [95% CI, 0.15%-0.20%]; P <.001) and any postprocedure complication (3.23% [95% CI, 3.01%-3.45%] vs 2.41% [95% CI, 2.31%-2.51%]; P <.001). There was substantial variation in non-evidence-based ICDs by site. The rate of non-evidence-based ICD implants was significantly lower for electrophysiologists (20.8%; 95% CI, 20.5%-21.1%) than nonelectrophysiologists (24.8% [95% CI, 24.2%-25.3%] for nonelectrophysiologist cardiologists; 36.1% [95% CI, 34.3%-38.0%] for thoracic surgeons; and 24.9% [95% CI, 23.8%-25.9%] for other specialties) (P<.001 for all comparisons). There was no clear decrease in the rate of non-evidence-based ICDs over time (24.5% [6908/28,233] in 2006, 21.8% [7395/33,965] in 2007, 22.0% [7245/32,960] in 2008, and 21.7% [3597/16,549] in 2009; P <.001 for trend from 2006-2009 and P = .94 for trend from 2007-2009).Among patients with ICD implants in this registry, 22.5% did not meet evidence-based criteria for implantation.

  View details for Web of Science ID 000285924100023

  View details for PubMedID 21205965

  View details for PubMedCentralID PMC3432303

• Incremental Value of Clinical Data Beyond Claims Data in Predicting 30-Day Outcomes After Heart Failure Hospitalization CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES Hammill, B. G., Curtis, L. H., Fonarow, G. C., Heidenreich, P. A., Yancy, C. W., Peterson, E. D., Hernandez, A. F. 2011; 4 (1): 60-67

  Abstract

  Administrative claims data are used routinely for risk adjustment and hospital profiling for heart failure outcomes. As clinical data become more readily available, the incremental value of adding clinical data to claims-based models of mortality and readmission is unclear.We linked heart failure hospitalizations from the Get With The Guidelines-Heart Failure registry with Medicare claims data for patients discharged between January 1, 2004, and December 31, 2006. We evaluated the performance of claims-only and claims-clinical regression models for 30-day mortality and readmission, and compared hospital rankings from both models. There were 25 766 patients from 308 hospitals in the mortality analysis, and 24 163 patients from 307 hospitals in the readmission analysis. The claims-clinical mortality model (area under the curve [AUC], 0.761; generalized R(2)=0.172) had better fit than the claims-only mortality model (AUC, 0.718; R(2)=0.113). The claims-only readmission model (AUC, 0.587; R(2)=0.025) and the claims-clinical readmission model (AUC, 0.599; R(2)=0.031) had similar performance. Among hospitals ranked as top or bottom performers by the claims-only mortality model, 12% were not ranked similarly by the claims-clinical model. For the claims-only readmission model, 3% of top or bottom performers were not ranked similarly by the claims-clinical model.Adding clinical data to claims data for heart failure hospitalizations significantly improved prediction of mortality, and shifted mortality performance rankings for a substantial proportion of hospitals. Clinical data did not meaningfully improve the discrimination of the readmission model, and had little effect on performance rankings.

  View details for DOI 10.1161/CIRCOUTCOMES.110.954693

  View details for Web of Science ID 000286311700012

  View details for PubMedID 21139093

• A small pericardial effusion is a marker of increased mortality AMERICAN HEART JOURNAL Mitiku, T. Y., Heidenreich, P. A. 2011; 161 (1)

  Abstract

  the study aimed to evaluate the prognostic importance of an incidental small pericardial effusion found on echocardiography.we identified 10,067 consecutive patients undergoing echocardiography at 1 of 3 laboratories. Patients were excluded if they were referred for evaluation of the pericardium (n = 133), had cardiac surgery within the previous 60 days (n = 393), had a moderate or greater pericardial effusion (>1 cm if circumferential, n = 29), had no follow-up (n = 153), or had inadequate visualization of the pericardial space (n = 9). The Social Security Death Index was used to determine survival.a small pericardial effusion was noted in 534 (5.7%) of 9,350 patients. Compared to patients without a small effusion, those with an effusion were slightly older (68 ± 13 vs 67 ± 12 years, P = .02) and had a lower ejection fraction (52% vs 55%, P < .0001). Mortality at 1 year was greater for patients with a small effusion (26%) compared to those without an effusion (11%, P < .0001). After adjustment for demographics, medical history, patient location, and other echocardiographic findings, small pericardial effusion remained associated with higher mortality (hazard ratio 1.17, 95% CI 1.09-1.28, P = .0002). Of 211 with an effusion and follow-up echocardiography (mean 547 days), 136 (60%) had resolution, 63 (28%) showed no change, and 12 (5%) had an increase in size, although no patient developed a large effusion or cardiac tamponade.the presence of a small asymptomatic pericardial effusion is associated with increased mortality.

  View details for DOI 10.1016/j.ahj.2010.10.007

  View details for Web of Science ID 000285376200018

  View details for PubMedID 21167348

• Measuring Value From the Patient's Perspective CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES Heidenreich, P. A. 2011; 4 (1): 9-10

  View details for DOI 10.1161/CIRCOUTCOMES.110.959171

  View details for Web of Science ID 000286311700004

  View details for PubMedID 21245459

• Regional Variation in the Use of Implantable Cardioverter-Defibrillators for Primary Prevention Results From the National Cardiovascular Data Registry CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES Matlock, D. D., Peterson, P. N., Heidenreich, P. A., Lucas, F. L., Malenka, D. J., Wang, Y., Curtis, J. P., Kutner, J. S., Fisher, E. S., Masoudi, F. A. 2011; 4 (1): 114-121

  Abstract

  Although the use of implantable cardioverter-defibrillators (ICDs) for the primary prevention of sudden cardiac death varies by sex, race, and hospital, geographic variation in ICD use remains unexplored. Our objective was to quantify regional variations in the utilization of primary prevention ICDs in the United States, and to evaluate if an association exists between utilization and physician supply or the proportion of patients meeting the trial inclusion criteria.This is a cross-sectional analysis among the Medicare, fee-for-service population from the National Cardiovascular Data Registry. Using hospital referral regions, we calculated the age-, sex-, and race-adjusted rates of ICD placement for each region and assessed the correlation between these rates and (1) physician supply and (2) the proportion of patients meeting trial inclusion criteria. Substantial variation was found across quintiles of rate ratios of ICD implantation, ranging from 0.39 to 1.77 (compared with a national mean rate of 1.0). This ratio was not correlated with the supply of cardiologists (R(2)=0.01), electrophysiologists (R(2)=0.01), or with the proportion of patients meeting trial inclusion criteria (R(2)<0.01). Over all, 13% of all patients receiving ICDs did not meet trial criteria.Marked geographic variation in the use of primary prevention ICDs exists across the United States that is not correlated with physician supply. Although >1 in 10 patients received ICDs outside of trial criteria, this potential overuse did not explain the variation. Future studies should consider underuse or misuse of primary prevention ICDs as causes of geographic variation.

  View details for DOI 10.1161/CIRCOUTCOMES.110.958264

  View details for Web of Science ID 000286311700019

  View details for PubMedID 21139094

• ACCF/AHA/ACR/SCAI/SIR/SVM/SVN/SVS 2010 Performance Measures for Adults With Peripheral Artery Disease A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures, the American College of Radiology, the Society for Cardiac Angiography and Interventions, the Society for Interventional Radiology, the Society for Vascular Medicine, the Society for Vascular Nursing, and the Society for Vascular Surgery (Writing Committee to Develop Clinical Performance Measures for Peripheral Artery Disease) CIRCULATION Olin, J. W., Allie, D. E., Belkin, M., Bonow, R. O., Casey, D. E., Creager, M. A., Gerber, T. C., Hirsch, A. T., Jaff, M. R., Kaufman, J. A., Lewis, C. A., Martin, E. T., Martin, L. G., Sheehan, P., Stewart, K. J., Treat-Jacobson, D., White, C. J., Zheng, Z., Masoudi, F. A., DeLong, E., Erwin, J. P., Goff, D. C., Grady, K., Green, L. A., Heidenreich, P. A., Jenkins, K. J., Loth, A. R., Peterson, E. D., Shahian, D. M., Brindis, R. G., Lewin, J. C., May, C., Shahriary, M., Chiu, J. S., Barrett, E. A., Brown, N., Robertson, R. M., Whitman, G. R., Randle, D. 2010; 122 (24): 2583-2618

  View details for DOI 10.1161/CIR.0b013e3182031a3c

  View details for Web of Science ID 000285243200018

• Using Restriction to Minimize Bias in Observational Studies JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Turakhia, M. P., Heidenreich, P. A. 2010; 304 (21): 2359-2359

  View details for Web of Science ID 000284763900014

  View details for PubMedID 21119082

• ACCF/AHA New Insights Into the Methodology of Performance Measurement JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Spertus, J. A., Bonow, R. O., Chan, P., Diamond, G. A., Drozda, J. P., Kaul, S., Krumholz, H. M., Masoudi, F. A., Normand, S. T., Peterson, E. D., Radford, M. J., Rumsfeld, J. S. 2010; 56 (21): 1767-1782

  View details for DOI 10.1016/j.jacc.2010.09.009

  View details for Web of Science ID 000284062800020

  View details for PubMedID 21070935

• Economic Impact of Monitoring Heart Transplant Recipients With Gene Expression Profiling to Detect Rejection an IMAGE Analysis Heidenreich, P. A., Pham, M. X., Teuteberg, J. J., Kfoury, A. G., Starling, R. C., Deng, M. C., Cappola, T. P., Kao, A., Anderson, A. S., Cotts, W. G., Ewald, G. A., Baran, D. A., Bogaev, R. C., Elashoff, B., Baron, H., Yee, J., Valantine, H. A. CHURCHILL LIVINGSTONE INC MEDICAL PUBLISHERS. 2010: 911-912

  View details for DOI 10.1016/j.cardfail.2010.09.008

  View details for Web of Science ID 000284247600011

• ACP Journal Club. CT coronary angiography was more accurate than stress testing for diagnosing CAD, especially in patients at intermediate risk. Annals of internal medicine Heidenreich, P. 2010; 153 (8): JC4-9

  View details for DOI 10.1059/0003-4819-153-8-201010190-02009

  View details for PubMedID 20956705

• Reprint--AACVPR/ACCF/AHA 2010 update: performance measures on cardiac rehabilitation for referral to cardiac rehabilitation/secondary prevention services: a report of the American Association of Cardiovascular and Pulmonary Rehabilitation and the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Clinical Performance Measures for Cardiac Rehabilitation). Physical therapy Thomas, R. J., King, M., Lui, K., Oldridge, N., Piña, I. L., Spertus, J., Masoudi, F. A., DeLong, E., Erwin, J. P., Goff, D. C., Grady, K., Green, L. A., Heidenreich, P. A., Jenkins, K. J., Loth, A. R., Peterson, E. D., Shahian, D. M. 2010; 90 (10): 1373-1382

  View details for PubMedID 20889928

• Heart Rate Predicts Mortality in Patients With Heart Failure and Preserved Systolic Function JOURNAL OF CARDIAC FAILURE Kapoor, J. R., Heidenreich, P. A. 2010; 16 (10): 806-811

  Abstract

  Elevated resting heart rates have been associated with increased mortality and morbidity in patients with heart failure and decreased left ventricular ejection fraction (EF). It is unclear, though, if this association applies to those with heart failure and preserved EF.We determined outcome for 685 consecutive patients with a prior diagnosis of heart failure and a preserved EF (>50%) documented on echocardiography at 1 of 3 laboratories. Patients with non-sinus rhythm were excluded from the analysis. We determined adjusted mortality rates at 1 year after the echocardiogram. The mean age of the cohort was 70 ± 11 years. Of the 685 included patients, 87% had a history of hypertension, 50% had diabetes, and the mean EF was 60% ± 6%. All-cause mortality at 1 year was significantly lower in the group with heart rate below 60 beats/min (10%) when compared with the group with heart rates between 60 and 70 beats/min (18%), 71-90 beats/min (20%), and >90 beats/min (35%) (P < .0001). After adjustment for patient history, demographics, laboratory values, and echocardiographic findings, the hazard ratios for total mortality (relative to a heart rate of <60) were 1.26 (95% CI, 0.88-1.80) for HR 60-69, 1.47 (95% CI, 1.02-2.07) for HR 70-90, and 2.00 (95% CI, 1.31-3.04) for HR>90 (P = .01 across all groups).These data suggest that an elevated resting heart rate is a marker for increased mortality in patients with heart failure and preserved systolic function. Heart rate may be useful in these patients for improved cardiovascular risk assessment.

  View details for DOI 10.1016/j.cardfail.2010.04.013

  View details for Web of Science ID 000282997500002

  View details for PubMedID 20932462

• The Relation Between Hospital Procedure Volume and Complications of Cardioverter-Defibrillator Implantation From the Implantable Cardioverter-Defibrillator Registry JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Freeman, J. V., Wang, Y., Curtis, J. P., Heidenreich, P. A., Hlatky, M. A. 2010; 56 (14): 1133-1139

  Abstract

  We sought to examine the relationship between hospital implantable cardioverter-defibrillator (ICD) implantation volume and procedural complications in a contemporary, representative population.Hospitals that perform higher volumes of procedures generally have better clinical outcomes.We examined initial ICD implantations between January 2006 and December 2008 at hospitals participating in the NCDR (National Cardiovascular Data Registry) ICD Registry and evaluated the relationship between hospital annual implant volume and in-hospital adverse outcomes.The rate of adverse events declined progressively with increasing procedure volume (p trend < 0.0001). This relationship remained significant (p trend < 0.0001) after adjustment for patient clinical characteristics, operator characteristics, and hospital characteristics. The volume-outcome relationship was evident for all ICD subtypes, including single-chamber (p trend = 0.004), dual-chamber (p trend < 0.0001), and biventricular ICDs (p trend = 0.02).Patients who have an ICD implanted at a high-volume hospital are less likely to have an adverse event associated with the procedure than patients who have an ICD implanted at a low-volume hospital.

  View details for DOI 10.1016/j.jacc.2010.07.007

  View details for Web of Science ID 000282144700007

  View details for PubMedID 20863954

• Review of the Registry's Fourth Year, Incorporating Lead Data and Pediatric ICD Procedures, and Use as a National Performance Measure HEART RHYTHM Hammill, S. C., Kremers, M. S., Stevenson, L. W., Heidenreich, P. A., Lang, C. M., Curtis, J. P., Wang, Y., Berul, C. I., Kadish, A. H., Al-Khatib, S. M., Pina, I. L., Walsh, M. N., Mirro, M. J., Lindsay, B. D., Reynolds, M. R., Pontzer, K., Blum, L., Masoudi, F., Rumsfeld, J., Brindis, R. G. 2010; 7 (9): 1340-1345

  View details for DOI 10.1016/j.hrthm.2010.07.015

  View details for Web of Science ID 000281444100034

  View details for PubMedID 20647056

• History of Heart Failure and Mortality among Veterans With Implantable Cardioverter-Defibrillators Varosy, P. D., Pellegrini, C. N., Yang, Y., Keung, E., Heidenreich, P., Rumsfeld, J. S., Massie, B. M. CHURCHILL LIVINGSTONE INC MEDICAL PUBLISHERS. 2010: S95–S96

  View details for DOI 10.1016/j.cardfail.2010.06.335

  View details for Web of Science ID 000281501800314

• Clinical Subtype of Atrial Fibrillation at the Time of Implantation and Subsequent Mortality among Veterans With Implantable Defibrillators Aleong, R., Sauer, W. H., Pellegnni, C. N., Yang, Y., Keung, E., Heidenreich, P., Rumsfeld, J. S., Massie, B. M., Varosy, P. D. CHURCHILL LIVINGSTONE INC MEDICAL PUBLISHERS. 2010: S58

  View details for DOI 10.1016/j.cardfail.2010.06.201

  View details for Web of Science ID 000281501800186

• Heart Failure Symptoms Identified With Home Monitoring Predict Subsequent Shock and Death Heidenreich, P. A., Boehmer, J. P., Hayes, D. L., Gilliam, F. R., Day, J. D., Jones, P. W., Seth, M., Saxon, L. A. CHURCHILL LIVINGSTONE INC MEDICAL PUBLISHERS. 2010: S85

  View details for DOI 10.1016/j.cardfail.2010.06.299

  View details for Web of Science ID 000281501800278

• Handheld Ultrasound, B-Natriuretic Peptide for Screening Stage B Heart Failure SOUTHERN MEDICAL JOURNAL Hebert, K., Horswell, R., Heidenreich, P., Miranda, J., Arcement, L. 2010; 103 (7): 616-622

  Abstract

  To determine if B-natriuretic peptide (BNP), handheld ultrasound, and echo interpretation was an accurate and reliable screening for stage B heart failure.One hundred and forty-five indigent diabetic patients were prospectively enrolled, and their BNP levels were measured. Each patient underwent a handheld echo.BNP was correlated with ejection fraction, but not with diastolic dysfunction. The area under the receiver-operator characteristic was 0.77. Kappa statistics for reliability in interpreting handheld echoes was 1.0.Results from this study suggested that BNP may be able to serve as a reliable screening tool for stage B heart failure in diabetic populations. Because BNP is an inexpensive blood test, it could be incorporated into the congestive heart failure diagnostic algorithm to determine which patients need imaging studies, namely echocardiography. Handheld echocardiography had interobserver reliability and is a promising alternative screening method.

  View details for DOI 10.1097/SMJ.0b013e3181e1ffec

  View details for Web of Science ID 000279397000007

  View details for PubMedID 20531053

• Reply to the letter to the editor for Obesity and survival in patients with heart failure and preserved systolic function: A U-shaped relationship AMERICAN HEART JOURNAL Kapoor, J. R., Heidenreich, P. A. 2010; 159 (6)

  View details for DOI 10.1016/j.ahj.2010.03.015

  View details for Web of Science ID 000278533200038

• Age and receipt of guideline-recommended care for heart failure: a nationwide study. Steinman, M. A., Fung, K., Boscardin, J., Heidenreich, P. A. WILEY-BLACKWELL PUBLISHING, INC. 2010: 113-114

  View details for Web of Science ID 000276247100326

• COMPARISON OF HOSPITAL PERFORMANCE OF ACUTE MYOCARDIAL INFARCTION AND HEART FAILURE QUALITY MEASURES: FINDINGS FROM THE GET WITH THE GUIDELINES REGISTRY Wang, T., Dai, D., Hernandez, A., Bhatt, D., Heidenreich, P., Fonarow, G., Peterson, E. ELSEVIER SCIENCE INC. 2010

  View details for Web of Science ID 001045644801438

• THE RELATION BETWEEN HOSPITAL PROCEDURE VOLUME AND COMPLICATIONS OF CARDIOVERTER-DEFIBRILLATOR IMPLANTATION FROM THE NATIONAL CARDIOVASCULAR DATA REGISTRY Freeman, J. V., Wang, Y., Curtis, J., Heidenreich, P. A., Hlatky, M. ELSEVIER SCIENCE INC. 2010

  View details for Web of Science ID 001045644801305

• COST-EFFECTIVE PRIMARY PREVENTION OF CORONARY HEART DISEASE IN INTERMEDIATE RISK PATIENTS: UNIVERSAL ASPIRIN AND STATINS IS SUPERIOR TO PREVENTION GUIDED BY STRESS TESTING Galper, B. Z., Moran, A., Pletcher, M. J., Coxson, P., Lazar, L., Wang, Y., Heidenreich, P., Goldman, L. ELSEVIER SCIENCE INC. 2010

  View details for Web of Science ID 001045644801345

• Are quality improvements associated with the Get With the Guidelines-Coronary Artery Disease (GWTG-CAD) program sustained over time?: A longitudinal comparison of GWTG-CAD hospitals versus non-GWTG-CAD hospitals AMERICAN HEART JOURNAL Xian, Y., Pan, W., Peterson, E. D., Heidenreich, P. A., Cannon, C. P., Hernandez, A. F., Friedman, B., Holloway, R. G., Fonarow, G. C. 2010; 159 (2)

  Abstract

  Previous reports have demonstrated that participation in GWTG-CAD, a national quality initiative of the American Heart Association, is associated with improved guideline adherence for patients hospitalized with CAD. We sought to establish whether these benefits from participation in GWTG-CAD were sustained over time.We used the Centers for Medicare and Medicaid Services Hospital Compare database to examine 6 performance measures and one composite score for 3 consecutive 12-month periods including aspirin and beta-blocker on arrival/discharge, angiotensin-converting enzyme inhibitor (ACE-I) for left ventricular systolic dysfunction (LVSD), and adult smoking cessation counseling. The differences in guideline adherence between the GWTG-CAD hospitals (n = 440, 439, 429) and non-GWTG-CAD hospitals (n = 2,438, 2,268, 2,140) were evaluated for each 12-month period. A multivariate mixed-effects model was used to estimate the independent effect of GWTG-CAD over time adjusting for hospital characteristics.Compared with non-GWTG hospitals, the GWTG-CAD hospitals demonstrated higher guideline adherence for 6 performance measures. The largest differences existed for (1) aspirin at arrival (2.3%, 2.1%, and 1.6% for each 12-month period, respectively), (2) aspirin at discharge (3.4%, 2.2%, and 2.3%), (3) beta-blocker at arrival (3.4%, 2.9%, and 2.6%), and (4) beta-blocker at discharge (2.8%, 1.8%, and 1.5%). In multivariate analysis, the GWTG-CAD hospitals were independently associated with better adherence for 4 of the 6 measures (the exceptions were ACE-I for LVSD and smoking cessation counseling). Superior performance was also found for the composite measures. Although there was some narrowing between groups, GWTG-CAD hospitals maintained superior guideline adherence than non-GWTG-CAD hospitals for the entire 3-year period (adjusted differences 1.8%, 1.6%, and 1.4%).Hospitals participating in GWTG-CAD had modestly superior acute cardiac care and secondary prevention measures performance relative to non-GWTG-CAD. These benefits of GWTG-CAD participation were sustained over time and independent of hospital characteristics.

  View details for DOI 10.1016/j.ahj.2009.11.002

  View details for Web of Science ID 000274287200007

  View details for PubMedID 20152218

• Obesity and survival in patients with heart failure and preserved systolic function: A U-shaped relationship AMERICAN HEART JOURNAL Kapoor, J. R., Heidenreich, P. A. 2010; 159 (1): 75-80

  Abstract

  Studies document better survival in heart failure patients with decreased left ventricular ejection fraction (EF) and higher body mass index (BMI; kg/m(2)) compared to those with a lower BMI. However, it is unknown if this "obesity paradox" applies to heart failure patients with preserved EF or if it extends to the very obese (BMI >35).We determined all-cause mortality for 1,236 consecutive patients with a prior diagnosis of heart failure and a preserved EF (> or =50%).Obesity (BMI>30) was noted in 542 patients (44%). The mean age was 71 +/- 12 years, but this varied depending on BMI. One-year all-cause mortality decreased with increasing BMI, except at BMI >45 where mortality began to increase (55% if BMI <20, 38% if BMI 20-25, 26% if BMI 26-30, 25% if BMI 31-35, 17% if BMI 36-40, 18% if BMI 41-45, and 25% if BMI>45, P < .001). After adjustment for patient age, history, medications, and laboratory and echocardiographic parameters, the hazard ratios for total mortality (relative to BMI 26-30) were 1.68 (95% CI, 1.04-2.69) for BMI <20, 1.25 (95% CI, 0.92-1.68) for BMI 20 to 25, 0.99 (95% CI, 0.71-1.36) for BMI 31-35, 0.58 (95% CI, 0.35-0.97) for BMI 36 to 40, 0.79 (95% CI, 0.44-1.4) for BMI 41 to 45, and 1.38 (95% CI 0.74-2.6) for BMI >45 (P < .0001).Low BMI is associated with increased mortality in patients with heart failure and preserved systolic function. However, with a BMI of >45, mortality increased, raising the possibility of a U-shaped relationship between BMI and survival.

  View details for DOI 10.1016/j.ahj.2009.10.026

  View details for Web of Science ID 000273051300011

  View details for PubMedID 20102870

• The Year in Epidemiology, Health Services Research, and Outcomes Research JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Hlatky, M. A., Heidenreich, P. 2009; 54 (25): 2343-2351

  View details for DOI 10.1016/j.jacc.2009.10.013

  View details for Web of Science ID 000272768600001

  View details for PubMedID 20082921

• The Impact of Different Ranking Methods for Hospital's Heart Failure Quality of Care: Results From the AHA' s Get With the Guidelines-Heart Failure Registry Hernandez, A. F., Liang, L., O'Brien, S. M., Heidenreich, P. A., Yancy, C. W., Fonarow, G. C., Peterson, E. D. LIPPINCOTT WILLIAMS & WILKINS. 2009: S471

  View details for Web of Science ID 000271831500686

• Incremental Value of Clinical Data Beyond Claims to Predict 30-Day Outcomes Following Heart Failure Admission: Results From the AHA's Get With the Guidelines-Heart Failure Registry Hammill, B. G., Curtis, L. H., Fonarow, G. C., Heidenreich, P. A., Yancy, C. W., Peterson, E. D., Hernandez, A. F. LIPPINCOTT WILLIAMS & WILKINS. 2009: S394-S395

  View details for Web of Science ID 000271831500377

• Home Blood Pressure Monitoring Provides Important Prognostic Information in Patients Treated With a Cardiac Resynchronization Therapy Defibrillator Boehmer, J. P., Day, J., Gilliam, F. R., Heidenreich, P. A., Hayes, D. L., Seth, M., Jones, P. W., Meyer, T. E., Saxon, L. A. LIPPINCOTT WILLIAMS & WILKINS. 2009: S440

  View details for Web of Science ID 000271831500556

• Clinical characteristics and in-hospital outcome of patients with end-stage renal disease on dialysis referred for implantable cardioverter-defibrillator implantation HEART RHYTHM Aggarwal, A., Wang, Y., Rumsfeld, J. S., Curtis, J. P., Heidenreich, P. A. 2009; 6 (11): 1565-1571

  Abstract

  Little is known about the clinical profile of end-stage renal disease (ESRD) patients who undergo implantable cardioverter-defibrillator (ICD) implantation.This study sought to analyze the risk profile of ESRD patients admitted for ICD implantation.Patients undergoing first-time device implantation in National Cardiovascular Data Registry/ICD registry from 01/01/06 to 12/31/07 were analyzed (n = 164,069). Patients with ESRD (defined as those requiring dialysis) were compared with patients without ESRD. Primary outcome was in-hospital complications. Because length of hospital stay for ERSD patients was significantly longer (8 vs. 4 days), complications within 2 days of ICD implantation were also examined. The proportion of patients meeting approved indications for ICD implantation was evaluated.ESRD patients (n = 6,851, 4.4%) had higher rates of comorbid medical conditions, major complications, and total complications, and were less likely to receive an ICD for primary prevention. ESRD patients who received ICD implantation for primary prevention were more likely to meet trial criteria. ESRD patients were less likely to receive beta-blockers and angiotensin inhibitors (P <.0001). Unadjusted in-hospital mortality was almost 5-fold among patients with ESRD (1.9% vs. 0.4%, P <.0001). Multivariable analysis confirmed that ESRD was independently associated with total in-hospital complications (odds ratio [OR] = 1.38, 95% confidence interval: 1.23 to 1.54, P <.0001), and total complications at 2 days (OR = 1.20, 95% confidence interval: 1.05 to 1.36, P = .006).ESRD patients presenting for ICD implantation are sicker, and have higher rates of in-hospital complications even when accounting for overall longer length of hospital stay. Strategies to decrease complications among ESRD patients who undergo ICD implantation need exploration.

  View details for DOI 10.1016/j.hrthm.2009.08.006

  View details for Web of Science ID 000271817100005

  View details for PubMedID 19879533

• National ICD Registry Annual Report 2008: Review of the ICD Registry's Third Year, Expansion to include Lead Data and Pediatric ICD Procedures, and Role for Measuring Performance (vol 6, pg 1397, 2009) HEART RHYTHM Hammill, S. C., Berul, C., Kremers, M. S., Kadish, A. H., Stevenson, L., Heidenreich, P. A., Lindsay, B. D., Mirro, M. J., Radford, M. J., McKay, C., Wang, Y., Lang, C. M., Pontzer, K., Rumsfeld, J., Phurrough, S. E., Curtis, J. P., Brindis, R. G. 2009; 6 (11): 1698

  View details for Web of Science ID 000271817100031

• THE INFLUENCE OF ECONOMIC INCENTIVES AND REGULATORY FACTORS ON THE ADOPTION OF TREATMENT TECHNOLOGIES: A CASE STUDY OF TECHNOLOGIES USED TO TREAT HEART ATTACKS HEALTH ECONOMICS Bech, M., Christiansen, T., Dunham, K., Lauridsen, J., Lyttkens, C. H., McDonald, K., McGuire, A. 2009; 18 (10): 1114-1132

  Abstract

  The Technological Change in Health Care Research Network collected unique patient-level data on three procedures for treatment of heart attack patients (catheterization, coronary artery bypass grafts and percutaneous transluminal coronary angioplasty) for 17 countries over a 15-year period to examine the impact of economic and institutional factors on technology adoption. Specific institutional factors are shown to be important to the uptake of these technologies. Health-care systems characterized as public contract systems and reimbursement systems have higher adoption rates than public-integrated health-care systems. Central control of funding of investments is negatively associated with adoption rates and the impact is of the same magnitude as the overall health-care system classification. GDP per capita also has a strong role in initial adoption. The impact of income and institutional characteristics on the utilization rates of the three procedures diminishes over time.

  View details for DOI 10.1002/hec.1417

  View details for Web of Science ID 000269942100002

  View details for PubMedID 18972326

  View details for PubMedCentralID PMC2740812

• Survival among patients with left ventricular systolic dysfunction treated with atenolol. Congestive heart failure (Greenwich, Conn.) Kapoor, J. R., Heidenreich, P. A. 2009; 15 (5): 213-217

  Abstract

  Metoprolol succinate, carvedilol, and bisoprolol are approved for use in heart failure. Other beta-blockers have been found to be inferior (metoprolol tartrate) or have not been studied (atenolol). The authors compared all-cause mortality following treatment with either atenolol, carvedilol, or metoprolol tartrate for 974 patients with left ventricular function < or =40%. The unadjusted mortality at 6 months was lower with atenolol (3.2%) and carvedilol (4.2%) when compared with metoprolol tartrate (7.5%, P< or =.039). However, patients with atenolol were older but had less prior heart failure. After adjustment for the propensity to be treated with atenolol, patients actually treated with atenolol had a significantly lower risk of death compared with treatment with metoprolol tartrate and comparable outcome to those treated with carvedilol. These results suggest that atenolol may be useful for patients with heart failure treatment and highlight the need for a randomized trial comparing atenolol with established beta-blockers.

  View details for DOI 10.1111/j.1751-7133.2009.00096.x

  View details for PubMedID 19751421

• NATIONAL ICD REGISTRY ANNUAL REPORT 2008 Review of the ICD Registry's Third Year, Expansion to include Lead Data and Pediatric ICD Procedures, and Role for Measuring Performance HEART RHYTHM Hammill, S. C., Kremers, M. S., Kadish, A. H., Stevenson, L. W., Heidenreich, P. A., Lindsay, B. D., Mirro, M. J., Radford, M. J., McKay, C., Wang, Y., Lang, C. M., Pontzer, K., Rumsfed, J., Phurrough, S. E., Curtis, J. P., Brindis, R. G. 2009; 6 (9): 1397-1401

  View details for DOI 10.1016/j.hrthm.2009.07.015

  View details for Web of Science ID 000269615100032

• Review of the ICD Registry's third year, expansion to include lead data and pediatric ICD procedures, and role for measuring performance. Heart rhythm Hammill, S. C., Kremers, M. S., Kadish, A. H., Stevenson, L. W., Heidenreich, P. A., Lindsay, B. D., Mirro, M. J., Radford, M. J., McKay, C., Wang, Y., Lang, C. M., Pontzer, K., Rumsfeld, J., Phurrough, S. E., Curtis, J. P., Brindis, R. G. 2009; 6 (9): 1397-1401

  View details for DOI 10.1016/j.hrthm.2009.07.015

  View details for PubMedID 19716099

• Use of implantable cardioverter defibrillators for primary prevention in the community: Do women and men equally meet trial enrollment criteria? AMERICAN HEART JOURNAL Daugherty, S. L., Peterson, P. N., Wang, Y., Curtis, J. P., Heidenreich, P. A., Lindenfeld, J., Vidaillet, H. J., Masoudi, F. A. 2009; 158 (2): 224-229

  Abstract

  Fewer women than men undergo implantable cardioverter defibrillator (ICD) implantation for the primary prevention of sudden cardiac death. The criteria used to select patients for ICD implantation may be more permissive among men than for women. We hypothesized that women who undergo primary prevention ICD implantation more often meet strict trial enrollment criteria for this therapy.We studied 59,812 patients in the National Cardiovascular Data Registry ICD registry undergoing initial primary prevention ICD placement between January 2005 and April 2007. Patients were classified as meeting or not meeting enrollment criteria of either the MADIT-II or SCD-HeFT trials. Multivariable analyses assessed the association between gender and concordance with trial criteria adjusting for demographic, clinical, and system characteristics.Among the cohort, 27% (n = 16,072) were women. Overall, 85.2% of women and 84.5% of men met enrollment criteria of either trial (P = .05). In multivariable analyses, women were equally likely to meet trial criteria (OR 1.04, 95% CI 0.99-1.10) than men. Significantly more women than men met the trial enrollment criteria among patients older than age 65 (86.6% of women vs 85.3% of men, OR 1.11, 95% CI 1.03-1.19), but this difference was not found among younger patients (82.5% of women vs 83.0% of men, OR 0.97, 95% CI 0.89-1.07).In a national cohort undergoing primary prevention ICD implantation, older women were only slightly more likely then men to meet the enrollment criteria for MADIT II or SCD-HeFT. Relative overutilization in men is not an important explanation for gender differences in ICD implantation.

  View details for DOI 10.1016/j.ahj.2009.05.018

  View details for Web of Science ID 000268749000012

  View details for PubMedID 19619698

• Does Participation in the HF Network Indicate Better Practices of Care for Heart Failure Patients: CHF QUERI Sahay, A., Heidenreich, P. A. CHURCHILL LIVINGSTONE INC MEDICAL PUBLISHERS. 2009: S97

  View details for DOI 10.1016/j.cardfail.2009.06.105

  View details for Web of Science ID 000268897500318

• Inequality in treatment use among elderly patients with acute myocardial infarction: USA, Belgium and Quebec BMC HEALTH SERVICES RESEARCH Perelman, J., Shmueli, A., McDonald, K. M., Pilote, L., Saynina, O., Closon, M. 2009; 9

  Abstract

  Previous research has provided evidence that socioeconomic status has an impact on invasive treatments use after acute myocardial infarction. In this paper, we compare the socioeconomic inequality in the use of high-technology diagnosis and treatment after acute myocardial infarction between the US, Quebec and Belgium paying special attention to financial incentives and regulations as explanatory factors.We examined hospital-discharge abstracts for all patients older than 65 who were admitted to hospitals during the 1993-1998 period in the US, Quebec and Belgium with a primary diagnosis of acute myocardial infarction. Patients' income data were imputed from the median incomes of their residential area. For each country, we compared the risk-adjusted probability of undergoing each procedure between socioeconomic categories measured by the patient's area median income.Our findings indicate that income-related inequality exists in the use of high-technology treatment and diagnosis techniques that is not justified by differences in patients' health characteristics. Those inequalities are largely explained, in the US and Quebec, by inequalities in distances to hospitals with on-site cardiac facilities. However, in both Belgium and the US, inequalities persist among patients admitted to hospitals with on-site cardiac facilities, rejecting the hospital location effect as the single explanation for inequalities. Meanwhile, inequality levels diverge across countries (higher in the US and in Belgium, extremely low in Quebec).The findings support the hypothesis that income-related inequality in treatment for AMI exists and is likely to be affected by a country's system of health care.

  View details for DOI 10.1186/1472-6963-9-130

  View details for Web of Science ID 000269526100002

  View details for PubMedID 19643011

  View details for PubMedCentralID PMC3277323

• ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 Appropriate Use Criteria for Cardiac Radionuclide Imaging A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine Endorsed by the American College of Emergency Physicians JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Hendel, R. C., Berman, D. S., Di Carli, M. F., Heidenreich, P. A., Henkin, R. E., Pellikka, P. A., Pohost, G. M., Williams, K. A. 2009; 53 (23): 2201-2229

  View details for DOI 10.1016/j.jacc.2009.02.013

  View details for Web of Science ID 000266568200018

  View details for PubMedID 19497454

• ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. Circulation Hendel, R. C., Berman, D. S., Di Carli, M. F., Heidenreich, P. A., Henkin, R. E., Pellikka, P. A., Pohost, G. M., Williams, K. A. 2009; 119 (22): e561-87

  Abstract

  The American College of Cardiology Foundation (ACCF), along with key specialty and subspecialty societies, conducted an appropriate use review of common clinical scenarios where cardiac radionuclide imaging (RNI) is frequently considered. This document is a revision of the original Single-Photon Emission Computed Tomography Myocardial Perfusion Imaging (SPECT MPI) Appropriateness Criteria, published 4 years earlier, written to reflect changes in test utilization and new clinical data, and to clarify RNI use where omissions or lack of clarity existed in the original criteria. This is in keeping with the commitment to revise and refine appropriate use criteria (AUC) on a frequent basis. The indications for this review were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Sixty-seven clinical scenarios were developed by a writing group and scored by a separate technical panel on a scale of 1 to 9 to designate appropriate use, inappropriate use, or uncertain use. In general, use of cardiac RNI for diagnosis and risk assessment in intermediate- and high-risk patients with coronary artery disease (CAD) was viewed favorably, while testing in low-risk patients, routine repeat testing, and general screening in certain clinical scenarios were viewed less favorably. Additionally, use for perioperative testing was found to be inappropriate except for high selected groups of patients. It is anticipated that these results will have a significant impact on physician decision making, test performance, and reimbursement policy, and will help guide future research.

  View details for DOI 10.1161/CIRCULATIONAHA.109.192519

  View details for PubMedID 19451357

• The Year in Epidemiology, Health Services Research, and Outcomes Research JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Hlatky, M. A., Heidenreich, P. A. 2009; 53 (16): 1459-1466

  View details for DOI 10.1016/j.jacc.2009.01.038

  View details for Web of Science ID 000265160200010

  View details for PubMedID 19371831

• EFFECT OF A COLLABORATIVE CARE INTERVENTION ON PATIENTS WITH ISCHEMIC HEART DISEASE Fihn, S. D., Rumsfeld, J., Diehr, P. H., Mcdonell, M., Stadius, M., Gerrity, M., Larsen, G., Heidenreich, P. A., Bryson, C. SPRINGER. 2009: 64

  View details for Web of Science ID 000265382000171

• The Importance of Clinical Predictors of 30-Day Mortality Among Medicare Beneficiaries Hernandez, A. F., Liang, L., O'Brien, S. M., Heidenreich, P., Yancy, C., Curtis, L. H., Peterson, E. D., Fonarow, G. C. ELSEVIER SCIENCE INC. 2009: A387

  View details for Web of Science ID 000263864201606

• Clinical Characteristics and In-Hospital Outcome of Patients With End-Stage Renal Disease on Dialysis Referred for Implantable Cardioverter Defibrillator Implantation Aggarwal, A., Wang, Y., Rumsfeld, J. S., Curtis, J., Heidenreich, P. A., Natl Cardiovasc Data Registry ELSEVIER SCIENCE INC. 2009: A131

  View details for Web of Science ID 000263864200545

• Regional Variations of Primary Prevention Implantable Cardioverter-Defibrillators: Results From the National Cardiovascular Data Registry Matlock, D. D., Peterson, P. N., Heidenreich, P. A., Lucas, F., Malenka, D. J., Curtis, J. P., Wang, Y., Kutner, J. S., Fisher, E. S., Masoudi, F. A. ELSEVIER SCIENCE INC. 2009: A130

  View details for Web of Science ID 000263864200541

• Predictors of Guideline Adherence for Inpatient Heart Failure Care Heidenreich, P. A., Zhao, X., Hernandez, A. F., Yancy, C. W., Fonarow, G. C. ELSEVIER SCIENCE INC. 2009: A373-A374

  View details for Web of Science ID 000263864201551

• Variation in Early Death and All-Cause Readmission After a Hospitalization for Heart Failure Among Medicare Beneficiaries Curtis, L. H., Hernandez, A. F., Liang, L., Heidenreich, P., Yancy, C., O'Brien, S. M., Fonarow, G. C., Peterson, E. D. ELSEVIER SCIENCE INC. 2009: A379

  View details for Web of Science ID 000263864201574

• Higher Heart Rate at Discharge Is Associated With Increased Mortality in Hospital Survivors of an Acute Myocardial Infarction Charlap, E., Chan, P., Tang, F., Jones, P., Heidenreich, P., Spertus, J., Srinivas, V. S. ELSEVIER SCIENCE INC. 2009: A381-A382

  View details for Web of Science ID 000263864201584

• Gender Differences in Procedure-Related Adverse Events in Patients Receiving Implantable Cardioverter-Defibrillator Therapy CIRCULATION Peterson, P. N., Daugherty, S. L., Wang, Y., Vidaillet, H. J., Heidenreich, P. A., Curtis, J. P., Masoudi, F. A. 2009; 119 (8): 1078-U30

  Abstract

  Women are at higher risk than men for adverse events with certain invasive cardiac procedures. Our objective was to compare rates of in-hospital adverse events in men and women receiving implantable cardioverter- defibrillator (ICD) therapy in community practice.Using the National Cardiovascular Data Registry ICD Registry, we identified patients undergoing first-time ICD implantation between January 2006 and December 2007. Outcomes included in-hospital adverse events after ICD implantation. Multivariable analysis assessed the association between gender and in-hospital adverse events, with adjustment for demographic, clinical, procedural, physician, and hospital characteristics. Of 161,470 patients, 73% were male, and 27% were female. Women were more likely to have a history of heart failure (81% versus 77%, P<0.01), worse New York Heart Association functional status (57% versus 50% in class III and IV, P<0.01), and nonischemic cardiomyopathy (44% versus 27%, P<0.01) and were more likely to receive biventricular ICDs (39% versus 34%, P<0.01). In unadjusted analyses, women were more likely to experience any adverse event (4.4% versus 3.3%, P<0.001) and major adverse events (2.0% versus 1.1%, P<0.001). In multivariable models, women had a significantly higher risk of any adverse event (OR 1.32, 95% CI 1.24 to 1.39) and major adverse events (OR 1.71, 95% CI 1.57 to 1.86).Women are more likely than men to have in-hospital adverse events related to ICD implantation. Efforts are needed to understand the reasons for higher ICD implantation-related adverse event rates in women and to develop strategies to reduce the risk of these events.

  View details for DOI 10.1161/CIRCULATIONAHA.108.793463

  View details for Web of Science ID 000263772100004

  View details for PubMedID 19221223

• Ethnic and racial disparities in cardiac resynchronization therapy HEART RHYTHM Farmer, S. A., Kirkpatrick, J. N., Heidenreich, P. A., Curtis, J. P., Wang, Y., Groeneveld, P. W. 2009; 6 (3): 325-331

  Abstract

  Racial/ethnic differences in the use of cardiac resynchronization therapy with defibrillator (CRT-D) may result from underprovision or overprovision relative to published guidelines.The purpose of this study was to examine the National Cardiovascular Data Registry (NCDR) ICD Registry for ethnic/racial differences in use of CRT-D.We studied white, black, and Hispanic patients who received either an implantable cardioverter-defibrillator (ICD) or CRT-D between January 2005 and April 2007. Two multivariate logistic regression models were fit with the following outcome variables: (1) receipt of either ICD or CRT-D and (2) receipt of CRT-D outside of published guidelines.Of 108,341 registry participants, 22,205 met inclusion criteria for the first analysis and 27,165 met criteria for the second analysis. Multivariate analysis indicated CRT-eligible black (odds ratio [OR] 0.84; 95% confidence interval [CI], 0.75-0.95; P <.004) and Hispanic (OR 0.83; 95% CI, 0.71-0.99; P <.033) patients were less likely to receive CRT-D than were white patients. A substantial proportion of patients received CRT-D outside of published guidelines, although black (OR 1.18; 95% CI, 1.02-1.36; P = .001) and Hispanic (OR 1.17; 95% CI, 1.02-1.36; P = .03) patients were more likely to meet all three eligibility criteria.Black and Hispanic patients who were eligible for CRT-D were less likely to receive therapy compared with white patients. Conversely, in the context of widespread out-of-guideline use of CRT-D, black and Hispanic patients were more likely to meet established criteria. Our findings suggest systematic racial/ethnic differences in the treatment of patients with advanced heart failure.

  View details for DOI 10.1016/j.hrthm.2008.12.018

  View details for Web of Science ID 000264228100007

  View details for PubMedID 19251206

• SYSTEMIC DISORDERS IN HEART DISEASE Radiation induced heart disease HEART Heidenreich, P. A., Kapoor, J. R. 2009; 95 (3): 252-258

  View details for DOI 10.1136/hrt.2008.149088

  View details for Web of Science ID 000262463900020

• Is Anyone Too Old for an Implantable Cardioverter-Defibrillator? CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES Heidenreich, P. A., Tsai, V. 2009; 2 (1): 6-8

  View details for DOI 10.1161/CIRCOUTCOMES.108.842369

  View details for Web of Science ID 000276073800003

  View details for PubMedID 20031806

• ACC/AHA 2008 statement on performance measurement and reperfusion therapy: a report of the ACC/AHA Task Force on Performance Measures (Work Group to address the challenges of performance measurement and reperfusion therapy). Circulation Masoudi, F. A., Bonow, R. O., Brindis, R. G., Cannon, C. P., DeBuhr, J., Fitzgerald, S., Heidenreich, P. A., Ho, K. K., Krumholz, H. M., Leber, C., Magid, D. J., Nilasena, D. S., Rumsfeld, J. S., Smith, S. C., Wharton, T. P., DeLong, E., Estes, N. A., Goff, D. C., Grady, K., Green, L. A., Loth, A. R., Peterson, E. D., Radford, M. J., Rumsfeld, J. S., Shahian, D. M. 2008; 118 (24): 2649-2661

  View details for DOI 10.1161/CIRCULATIONAHA.108.191100

  View details for PubMedID 19001026

• ACC/AHA 2008 Statement on Performance Measurement and Reperfusion Therapy: A Report of the ACC/AHA Task Force on Performance Measures (Work Group to Address the Challenges of Performance Measurement and Reperfusion Therapy) CIRCULATION Masoudi, F. A., Bonow, R. O., Brindis, R. G., Cannon, C. P., DeBuhr, J., Fitzgerald, S., Heidenreich, P. A., Ho, K. K., Krumholz, H. M., Leber, C., Magid, D. J., Nilasena, D. S., Rumsfeld, J. S., Smith, S. C., Wharton, T. P. 2008; 118 (24): 2649-2661

  View details for DOI 10.1161/CIRCULATIONAHA.108.191100

  View details for Web of Science ID 000261512400021

• ACC/AHA 2008 Statement on Performance Measurement and Reperfusion Therapy A Report of the ACC/AHA Task Force on Performance Measures (Work Group to Address the Challenges of Performance Measurement and Reperfusion Therapy) JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Masoudi, F. A., Bonow, R. O., Brindis, R. G., Cannon, C. P., DeBuhr, J., Fitzgerald, S., Heidenreich, P. A., Ho, K. K., Krumholz, H. M., Leber, C., Magid, D. J., Nilasena, D. S., Rumsfeld, J. S., Smith, S. C., Wharton, T. P. 2008; 52 (24): 2100-2112

  View details for DOI 10.1016/j.jacc.2008.10.013

  View details for Web of Science ID 000261324000016

  View details for PubMedID 19056001

• The Heart Failure Clinic: A Consensus Statement of the Heart Failure Society of America JOURNAL OF CARDIAC FAILURE Hauptman, P. J., Rich, M. W., Heidenreich, P. A., Chin, J., Cummings, N., Dunlap, M. E., Edwards, M. L., Gregory, D., O'Connor, C. M., Pezzella, S. M., Philbin, E. 2008; 14 (10): 801-815

  Abstract

  Outpatient care accounts for a significant proportion of total heart failure (HF) expenditures. This observation, plus an expanding list of treatment options, has led to the development of the disease-specific HF clinic.The goals of the HF clinic are to reduce mortality and rehospitalization rates and improve quality of life for patients with HF through individualized patient care. A variety of staffing configurations can serve to meet these goals. Successful HF clinics require an ongoing commitment of resources, the application of established clinical practice guidelines, an appropriate infrastructure, and a culture of quality assessment.This consensus statement will identify the components of HF clinics, focusing on systems and procedures most likely to contribute to the consistent application of guidelines and, consequently, optimal patient care. The domains addressed are: disease management, functional assessment, quality of life assessment, medical therapy and drug evaluation, device evaluation, nutritional assessment, follow-up, advance planning, communication, provider education, and quality assessment.

  View details for DOI 10.1016/j.cardfail.2008.10.005

  View details for Web of Science ID 000262021100001

  View details for PubMedID 19041043

• Standards for Measures Used for Public Reporting of Efficiency in Health Care A Scientific Statement From the American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research and the American College of Cardiology Foundation CIRCULATION Krumholz, H. M., Keenan, P. S., Brush, J. E., Bufalino, V. J., Chernew, M. E., Epstein, A. J., Heidenreich, P. A., Ho, V., Masoudi, F. A., Matchar, D. B., Normand, S. T., Rumsfeld, J. S., Schuur, J. D., Smith, S. C., Spertus, J. A., Walsh, M. N. 2008; 118 (18): 1885-1893

  Abstract

  The assessment of medical practice is evolving rapidly in the United States. An initial focus on structure and process performance measures assessing the quality of medical care is now being supplemented with efficiency measures to quantify the "value" of healthcare delivery. This statement, building on prior work that articulated standards for publicly reported outcomes measures, identifies preferred attributes for measures used to assess efficiency in the allocation of healthcare resources. The attributes identified in this document combined with the previously published standards are intended to serve as criteria for assessing the suitability of efficiency measures for public reporting. This statement identifies the following attributes to be considered for publicly reported efficiency measures: integration of the quality and cost; valid cost measurement and analysis; minimal incentive to provide poor quality care; and proper attribution of the measure. The attributes described in this statement are relevant to a wide range of efforts to profile the efficiency of various healthcare providers, including hospitals, healthcare systems, managed-care organizations, physicians, group practices, and others that deliver coordinated care.

  View details for DOI 10.1161/CIRCULATIONAHA.108.190500

  View details for Web of Science ID 000260426200015

  View details for PubMedID 18838567

• Association of Implanting Physician Certification with Complications Following Implantable Cardioverter-Defibrillator Procedures: Insights from the ICD Registry Leubbert, J., Hammill, S., Wang, Y., Rathore, S. S., Lampert, R., Krumholz, H. M., Heidenreich, P., Curtis, J. P. LIPPINCOTT WILLIAMS & WILKINS. 2008: S926

  View details for Web of Science ID 000262104503420

• Association of Physician Certification with Rates of CRT-D Implantation in Eligible Patients: Insights from the ICD Registry Curtis, J. P., Leubbert, J., Wang, Y., Lampert, R., Rathore, S. S., Hammill, S., Heidenreich, P., Krumholz, H. M. LIPPINCOTT WILLIAMS & WILKINS. 2008: S950

  View details for Web of Science ID 000262104503518

• Obesity and Mortality in Patients with Heart Failure and Preserved Systolic Function Kapoor, J. R., Heidenreich, P. A. LIPPINCOTT WILLIAMS & WILKINS. 2008: S795

  View details for Web of Science ID 000262104502655

• Cost-Effectiveness Analysis Demonstrates Superiority of Screening Young Athletes with 12-Lead Electrocardiogram versus History and Physical in Preventing Sudden Cardiac Death Wheeler, M. T., Heidenreich, P. A., Froelicher, V. F., Hlatky, M. A., Ashley, E. A. LIPPINCOTT WILLIAMS & WILKINS. 2008: S1163

  View details for Web of Science ID 000262104504616

• Standards for Measures Used for Public Reporting of Efficiency in Health Care A Scientific Statement From the American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research and the American College of Cardiology Foundation JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Krumholz, H. M., Keenan, P. S., Brush, J. E., Bufalino, V. J., Chernew, M. E., Epstein, A. J., Heidenreich, P. A., Ho, V., Masoudi, F. A., Matchar, D. B., Normand, S. T., Rumsfeld, J. S., Schuur, J. D., Smith, S. C., Spertus, J. A., Walsh, M. N. 2008; 52 (18): 1518-1526

  Abstract

  The assessment of medical practice is evolving rapidly in the United States. An initial focus on structure and process performance measures assessing the quality of medical care is now being supplemented with efficiency measures to quantify the "value" of healthcare delivery. This statement, building on prior work that articulated standards for publicly reported outcomes measures, identifies preferred attributes for measures used to assess efficiency in the allocation of healthcare resources. The attributes identified in this document combined with the previously published standards are intended to serve as criteria for assessing the suitability of efficiency measures for public reporting. This statement identifies the following attributes to be considered for publicly reported efficiency measures: integration of the quality and cost; valid cost measurement and analysis; minimal incentive to provide poor quality care; and proper attribution of the measure. The attributes described in this statement are relevant to a wide range of efforts to profile the efficiency of various healthcare providers, including hospitals, healthcare systems, managed-care organizations, physicians, group practices, and others that deliver coordinated care.

  View details for DOI 10.1016/j.jacc.2008.09.004

  View details for Web of Science ID 000260258800014

  View details for PubMedID 19017522

• Predictors of smoking cessation after a myocardial infarction - The role of institutional smoking cessation programs in improving success ARCHIVES OF INTERNAL MEDICINE Dawood, N., Vaccarino, V., Reid, K. J., Spertus, J. A., Hamid, N., Parashar, S., PREMIER Registry Investigators 2008; 168 (18): 1961-1967

  Abstract

  Smoking cessation after myocardial infarction (MI) is an important goal for secondary prevention of mortality. Whether new initiatives to promote cessation improve patients' quit rates after MI is unknown.The Prospective Registry Evaluating Outcomes After Myocardial Infarction Events and Recovery (PREMIER) enrolled 2498 patients with MI from 19 US centers between January 2003 and June 2004. Smoking behavior was assessed by self-report during hospitalization and 6 months after an MI. Extensive sociodemographic, comorbidity, psychosocial, disease severity, and treatment data were collected by interview and medical record abstraction. Hierarchical multivariable logistic regression models with random site effects were constructed to predict smoking cessation 6 months after admission, with a focus on the presence of an inpatient smoking cessation program as a hospital-level covariate.Among 834 patients who smoked at the time of MI hospitalization, 639 were interviewed and reported their smoking habits 6 months post-MI (77%). Of these, 297 were not smoking at 6 months (46%). The odds of smoking cessation were greater among those receiving discharge recommendations for cardiac rehabilitation (odds ratio [OR], 1.80; 95% confidence interval [CI], 1.17-2.75) and being treated at a facility that offered an inpatient smoking cessation program (OR, 1.71; 95% CI, 1.03-2.83). However, medical chart-based individual smoking cessation counseling did not predict smoking cessation rates (OR, 0.80; 95% CI, 0.51-1.25). Patients with depressive symptoms during the MI hospitalization were less likely to quit smoking (OR, 0.57; 95% CI, 0.36-0.90).While individual smoking cessation counseling was not associated with smoking cessation post-MI, hospital-based smoking cessation programs, as well as referral to cardiac rehabilitation, were strongly associated with increased smoking cessation rates. Such programs appear to be underutilized in current clinical practice and may be a valuable structural measure of health care quality. Moreover, smoking cessation programs should likely incorporate screening for and treating depressive disorders.

  View details for DOI 10.1001/archinte.168.18.1961

  View details for Web of Science ID 000259984400004

  View details for PubMedID 18852396

• Improving heart failure care with a reminder attached to the echocardiography report AMERICAN JOURNAL OF MEDICINE Heidenreich, P. 2008; 121 (10): 853-854

  View details for DOI 10.1016/j.amjmed.2008.06.021

  View details for Web of Science ID 000259564200006

  View details for PubMedID 18823852

• Preventing tomorrow's sudden cardiac death today: Dissemination of effective therapies for sudden cardiac death prevention AMERICAN HEART JOURNAL Al-Khatib, S. M., Sanders, G. D., Carlson, M., Cicic, A., Curtis, A., Fonarow, G. C., Groeneveld, P. W., Hayes, D., Heidenreich, P., Mark, D., Peterson, E., Prystowsky, E. N., Sager, P., Salive, M. E., Thomas, K., Yancy, C. W., Zareba, W., Zipes, D. 2008; 156 (4): 613-622

  Abstract

  Because the burden of sudden cardiac death (SCD) is substantial, it is important to use all guideline-driven therapies to prevent SCD. Among those therapies is the implantable cardioverter defibrillator (ICD). When indicated, ICD use is beneficial and cost-effective. Unfortunately, studies suggest that most patients who have indications for this therapy for primary or secondary prevention of SCD are not receiving it. To explore potential reasons for this underuse and to propose potential facilitators for ICD dissemination, the Duke Center for the Prevention of SCD at the Duke Clinical Research Institute (Durham, NC) organized a think tank meeting of experts on this issue. The meeting took place on December 12 and 13, 2007, and it included representatives of clinical cardiology, cardiac electrophysiology, general internal medicine, economics, health policy, the US Food and Drug Administration, the Centers for Medicare and Medicaid Services, the Agency for Health care Research and Quality, and the device and pharmaceutical industry. Although the meeting was funded by industry participants, this article summarizing the presentations and discussions that occurred at the meeting presents the expert opinion of the authors.

  View details for DOI 10.1016/j.ahj.2008.05.027

  View details for Web of Science ID 000259963300001

  View details for PubMedID 18926144

• Low-dose growth hormone is cardioprotective in uremia JOURNAL OF THE AMERICAN SOCIETY OF NEPHROLOGY Rabkin, R., Awwad, I., Chen, Y., Ashley, E. A., Sun, D., Sood, S., Clusin, W., Heidenreich, P., Piecha, G., Gross, M. 2008; 19 (9): 1774-1783

  Abstract

  Growth hormone (GH) is required to maintain normal cardiac structure and function and has a positive effect on cardiac remodeling in experimental and possibly human disease. Cardiac resistance to GH develops in the uremic state, perhaps predisposing to the characteristic cardiomyopathy associated with uremia. It was hypothesized that administration of low-dosage GH may have a salutary effect on the cardiac remodeling process in uremia, but because high levels of GH have adverse cardiac effects, administration of high-dosage GH may worsen uremic cardiomyopathy. In rats with chronic renal failure, quantitative cardiac morphology revealed a decrease in total capillary length and capillary length density and an increase in mean intercapillary distance and fibroblast volume density evident. Low-dosage GH prevented these changes. Collagen and TGF-beta immunostaining, increased in chronic renal failure, were also reduced by GH, suggesting a mechanism for its salutary action. Low-dosage GH also prevented thickening of the carotid artery but did not affect aortic pathology. In contrast, high-dosage GH worsened several of these variables. These results suggest that low-dosage GH may benefit the heart and possibly the carotid arteries in chronic renal failure.

  View details for DOI 10.1681/ASN.2007121386

  View details for Web of Science ID 000259167000021

  View details for PubMedID 18650479

  View details for PubMedCentralID PMC2518445

• National ICD Registry annual report 2007: Review of the Registry's second year, data collected, and plans to add lead and pediatric ICD procedures HEART RHYTHM Hammill, S. C., Kremers, M. S., Stevenson, L. W., Kadish, A. H., Heidenreich, P. A., Lindsay, B. D., Mirro, M. J., Radford, M. J., Wang, Y., Curtis, J. P., Lang, C. M., Harder, J. C., Brindis, R. G. 2008; 5 (9): 1359-1363

  View details for DOI 10.1016/j.hrthm.2008.07.015

  View details for Web of Science ID 000259281600036

• Review of the Registry's second year, data collected, and plans to add lead and pediatric ICD procedures. Heart rhythm Hammill, S. C., Kremers, M. S., Stevenson, L. W., Kadish, A. H., Heidenreich, P. A., Lindsay, B. D., Mirro, M. J., Radford, M. J., Wang, Y., Curtis, J. P., Lang, C. M., Harder, J. C., Brindis, R. G. 2008; 5 (9): 1359-1363

  View details for DOI 10.1016/j.hrthm.2008.07.015

  View details for PubMedID 18774117

• Evaluation of Polymorphisms in Candidate Genes in the Dramatic Response to Pharmacologic Therapy of Heart Failure Basic Cardiovascular Sciences Conference Wheeler, M. T., Pavlovic, A., Dewey, F., Perez, M., Absher, D., Ho, M. Y., Cretti, E., Southwick, A., Rosenthal, D. N., Bernstein, D., Myers, R. M., Heidenreich, P. A., Fowler, M. B., Robbins, R. C., Ashley, E. A. LIPPINCOTT WILLIAMS & WILKINS. 2008: E64–E65

  View details for Web of Science ID 000258845200165

• Overrepresentation of neuronal development pathways in heart failure patients who dramatically responded to pharmaceutical therapy 12th Annual Scientific Meeting of the Heart-Failure-Society-of-America Pavlovic, A., Perez, M., Absher, D., Wheeler, M., Ho, M., Dewey, R., Cretti, L., Southwick, A., Rosenthal, D., Bernstein, D., Myers, R. M., Heidenreich, P., Fowler, M. B., Robbins, R., Ashley, E. CHURCHILL LIVINGSTONE INC MEDICAL PUBLISHERS. 2008: S41–S41

  View details for Web of Science ID 000258565100129

• Heart failure clinics and quality of care for veterans with heart failure: Chronic heart failure (CHF) QUERI Sahay, A., Heidenreich, P. LIPPINCOTT WILLIAMS & WILKINS. 2008: E442

  View details for Web of Science ID 000256160700164

• Predictors of returning to work after myocardial infarction Longmore, L. S., Heidenreich, P. A., Decker, C., Buchanan, D. M., Reid, K. J., Spertus, J. A. LIPPINCOTT WILLIAMS & WILKINS. 2008: E427

  View details for Web of Science ID 000256160700100

• Cost-effectiveness of a nurse based clinic to initate beta-blocker therapy in patients with heart failure Heidenreich, P., Sahay, A., Shlipak, M., Van Osteyerean, D., Ansari, M., Massie, B. LIPPINCOTT WILLIAMS & WILKINS. 2008: E434

  View details for Web of Science ID 000256160700130

• Is Quantitation a Good Value? JACC-CARDIOVASCULAR IMAGING Heidenreich, P. 2008; 1 (3): 404-404

  View details for DOI 10.1016/j.jcmg.2008.02.007

  View details for Web of Science ID 000207649800020

  View details for PubMedID 19356456

• Heart transplant for status 2 patients may not be cost effective Vaidya, V., Yajnik, M., Heidenreich, P., Patel, J., Kittleson, M., Kawano, M., Vaidya, A., Ankrom, A., Ardehali, A., Kobashigawa, J. ELSEVIER SCIENCE INC. 2008: A258

  View details for Web of Science ID 000253997102015

• Computed tomographic angiography had high sensitivity for coronary artery disease in patients at intermediate risk. ACP journal club Heidenreich, P. 2008; 148 (2): 51-?

  View details for PubMedID 18311881

• Heart failure disease management programs: A cost-effectiveness analysis AMERICAN HEART JOURNAL Chan, D. C., Heidenreich, P. A., Weinstein, M. C., Fonarow, G. C. 2008; 155 (2): 332-338

  Abstract

  Heart failure (HF) disease management programs have shown impressive reductions in hospitalizations and mortality, but in studies limited to short time frames and high-risk patient populations. Current guidelines thus only recommend disease management targeted to high-risk patients with HF.This study applied a new technique to infer the degree to which clinical trials have targeted patients by risk based on observed rates of hospitalization and death. A Markov model was used to assess the incremental life expectancy and cost of providing disease management for high-risk to low-risk patients. Sensitivity analyses of various long-term scenarios and of reduced effectiveness in low-risk patients were also considered.The incremental cost-effectiveness ratio of extending coverage to all patients was $9700 per life-year gained in the base case. In aggregate, universal coverage almost quadrupled life-years saved as compared to coverage of only the highest quintile of risk. A worst case analysis with simultaneous conservative assumptions yielded an incremental cost-effectiveness ratio of $110,000 per life-year gained. In a probabilistic sensitivity analysis, 99.74% of possible incremental cost-effectiveness ratios were <$50,000 per life-year gained.Heart failure disease management programs are likely cost-effective in the long-term along the whole spectrum of patient risk. Health gains could be extended by enrolling a broader group of patients with HF in disease management.

  View details for DOI 10.1016/j.ahj.2007.10.001

  View details for Web of Science ID 000252812800024

  View details for PubMedID 18215605

• Racial and ethnic differences in cardiac resynchronization therapy outside of published guidelines Farmer, S. A., Kirkpatrick, J. N., Heidenreich, P. A., Curtis, J. P., Wang, Y., Groeneveld, P. W., Natl Cardiovasc Data Registry LIPPINCOTT WILLIAMS & WILKINS. 2007: 859

  View details for Web of Science ID 000250394303868

• Differences in implantation-related complications between men and women receiving ICD therapy for primary prevention Peterson, P. N., Luther, S. A., Wang, Y., Vidaillet, H. J., Krumholz, H. M., Heidenreich, P. A., Curtis, J. P., Masoudi, F. A., NCDR LIPPINCOTT WILLIAMS & WILKINS. 2007: 823

  View details for Web of Science ID 000250394303720

• Racial and ethnic differences in nationwide utilization of cardiac resynchronization therapy Farmer, S. A., Kirkpatrick, J. N., Heidenreich, P. A., Curtis, J. P., Wang, Y., Groeneveld, P. W., Natl Cardiovasc Data Registry LIPPINCOTT WILLIAMS & WILKINS. 2007: 823

  View details for Web of Science ID 000250394303719

• Sex differences in the characteristics of patients receiving ICD therapy for primary prevention Daugherty, S. L., Peterson, P. N., Wang, Y., Curtis, J. P., Heidenreich, P. A., Krumholz, H. M., Vidaillet, H. J., Masoudi, F. A., NCDR LIPPINCOTT WILLIAMS & WILKINS. 2007: 823

  View details for Web of Science ID 000250394303722

• Quality indicators for the care of heart failure in vulnerable elders JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Heidenreich, P. A., Fonarow, G. C. 2007; 55: S340-S346

  View details for DOI 10.1111/j.1532-5415.2007.01341.x

  View details for Web of Science ID 000250010400013

  View details for PubMedID 17910556

• Review of the registry's first year, data collected, and future plans HEART RHYTHM Hammill, S. C., Stevenson, L. W., Kadish, A. H., Kremers, M. S., Heidenreich, P., Lindsay, B. D., Mirro, M. J., Radford, M. J., Wang, Y., Lang, C. M., Harder, J. C., Brindis, R. G. 2007; 4 (9): 1260-1263

  View details for DOI 10.1016/j.hrthm.2007.07.021

  View details for Web of Science ID 000249448800037

  View details for PubMedID 17765637

• Stress echocardiography safely classified more patients as low risk of serious CAD than exercise electrocardiography. Evidence-based medicine Heidenreich, P. A. 2007; 12 (4): 119-?

  View details for PubMedID 17885167

• ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 appropriateness criteria for transthoracic and transesophageal echocardiography: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American Society of Echocardiography, American College of Emergency Physicians, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and the Society for Cardiovascular Magnetic Resonance endorsed by the American College of Chest Physicians and the Society of Critical Care Medicine. Journal of the American College of Cardiology Douglas, P. S., Khandheria, B., Stainback, R. F., Weissman, N. J., Brindis, R. G., Patel, M. R., Khandheria, B., Alpert, J. S., FitzGerald, D., Heidenreich, P., Martin, E. T., Messer, J. V., Miller, A. B., Picard, M. H., Raggi, P., Reed, K. D., Rumsfeld, J. S., Steimle, A. E., Tonkovic, R., Vijayaraghavan, K., Weissman, N. J., Yeon, S. B., Brindis, R. G., Douglas, P. S., Hendel, R. C., Patel, M. R., Peterson, E., Wolk, M. J., Allen, J. M. 2007; 50 (2): 187-204

  View details for PubMedID 17616306

• Stress echocardiography safely classified more patients as low risk for serious CAD than exercise electrocardiography. ACP journal club Heidenreich, P. A. 2007; 147 (1): 10-?

  View details for PubMedID 17608375

• ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 appropriateness criteria for transthoracic and transesophageal echocardiography JOURNAL OF THE AMERICAN SOCIETY OF ECHOCARDIOGRAPHY Douglas, P. S., Khandheria, B., Stainback, R. F., Weissman, N. J., Brindis, R. G., Patel, M. R., Khandheria, B., Alpert, J. S., FitzGerald, D., Heidenreich, P., Martin, E. T., Messer, J. V., Miller, A. B., Picard, M. H., Raggi, P., Reed, K. D., Rumsfeld, J. S., Steimle, A. E., Torkovic, R., Vijayaraghavan, K., Weissman, N. J., Yeon, S. B., Brindis, R. G., Douglas, P. S., Hendel, R. C., Patel, M. R., Peterson, E., Wolk, M. J., Allen, J. M. 2007; 20 (7): 787-805

  View details for DOI 10.1016/j.echo.2007.06.011

  View details for Web of Science ID 000248738600002

• ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 appropriateness criteria for transthoracic and transesophageal echocardiography: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American Society of Echocardiography, American College of Emergency Physicians, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and the Society for Cardiovascular Magnetic Resonance. Endorsed by the American College of Chest Physicians and the Society of Critical Care Medicine. Journal of the American Society of Echocardiography Douglas, P. S., Khandheria, B., Stainback, R. F., Weissman, N. J., Brindis, R. G., Patel, M. R., Alpert, J. S., FitzGerald, D., Heidenreich, P., Martin, E. T., Messer, J. V., Miller, A. B., Picard, M. H., Raggi, P., Reed, K. D., Rumsfeld, J. S., Steimle, A. E., Tonkovic, R., Vijayaraghavan, K., Yeon, S. B., Hendel, R. C., Peterson, E., Wolk, M. J., Allen, J. M. 2007; 20 (7): 787-805

  View details for PubMedID 17617305

• Cost effectiveness of whole breast IMRT for reduction of moist desquamation Strauss, J. B., Chen, S. S., Dickler, A. T., Griem, K. L. AMER SOC CLINICAL ONCOLOGY. 2007

  View details for Web of Science ID 000455043704281

• Temporal trends in clinical characteristics, treatments, and outcomes for heart failure hospitalizations, 2002 to 2004: findings from Acute Decompensated Heart Failure National Registry (ADHERE) AMERICAN HEART JOURNAL Fonarow, G. C., Heywood, J. T., Heidenreich, P. A., Lopatin, M., Yancy, C. W. 2007; 153 (6): 1021-1028

  Abstract

  The purpose of this study was to assess temporal trends in clinical characteristics, treatments, quality indicators, and outcomes for heart failure (HF) hospitalizations.Characteristics, treatments, quality measures, and inhospital outcomes were measured over 12 consecutive quarters (January 2002 to December 2004) using data from 159,168 enrollments from 285 ADHERE hospitals.Baseline characteristics were similar or showed only modest changes, and severity of illness by logistic regression was unchanged over all 12 quarters. Inhospital treatment changed significantly over time with inotrope use decreasing from 14.7% to 7.9% (P < .0001). Discharge instructions increased 133%; smoking counseling, 132%; left ventricular function measurement, 8%; and beta-blocker use, 29% (all P < .0001). Clinical outcomes improved over time, including need for mechanical ventilation, which decreased 5.3% to 3.4% (relative risk 0.64, P < .0001); length of stay (mean), 6.3 to 5.5 days; and mortality, 4.5% to 3.2% (relative risk 0.71, P < .0001).Over a 3-year period, demographics and clinical characteristics were relatively similar, but significant changes in intravenous therapy, enhancements in conformity to quality-of-care measures, increased administration of evidence-based HF medications, and substantial improvements in inhospital morbidity and mortality were observed during hospitalization for HF.

  View details for DOI 10.1016/j.ahj.2007.03.012

  View details for Web of Science ID 000247540600019

  View details for PubMedID 17540205

• Trends in beta-blocker use for VA patients with heart failure Heidenreich, P., Sahay, A., Costa, M., Massie, B. LIPPINCOTT WILLIAMS & WILKINS. 2007: E601

  View details for Web of Science ID 000246804600248

• Heart failure disease management programs: A cost-effectiveness analysis Chan, D. C., Heidenreich, P. A., Weinstein, M. C., Fonarow, G. C. SPRINGER. 2007: 39

  View details for Web of Science ID 000251610700133

• Quality of VA heart failure care, 2004-2005 Heidenreich, P. A., Sahay, A., Massie, B. ELSEVIER SCIENCE INC. 2007: 295A

  View details for Web of Science ID 000244651802088

• ACC/AHA 2007 Methodology for the Development of Clinical Data Standards - A report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Radford, M. J., Heidenreich, P. A., Bailey, S. R., Goff, D. C., Grover, F. L., Havranek, E. P., Kuntz, R. E., Malenka, D. J., Peterson, E. D., Redberg, R. F., Roger, V. L. 2007; 49 (7): 830-837

  View details for DOI 10.1016/j.jacc.2007.01.002

  View details for Web of Science ID 000244319900017

  View details for PubMedID 17306718

• ACC/AHA 2007 methodology for the development of clinical data standards - A report of the American College of Cardiology American Heart Association Task Force on Clinical Data Standards CIRCULATION Radford, M. J., Heidenreich, P. A., Bailey, S. R., Goff, D. C., Grover, F. L., Havranek, E. P., Kuntz, R. E., Malenka, D. J., Peterson, E. D., Redberg, R. F., Roger, V. L. 2007; 115 (7): 936-943

  View details for DOI 10.1161/CIRCULATIONAHA.107.182215

  View details for Web of Science ID 000244273700019

  View details for PubMedID 17296854

• The ACCF/ARA scientific statement on syncope needs rethinking - Reply JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Strickberger, S., Benson, D., Biaggioni, I., Callans, D. J., Cohen, M. I., Ellenbogen, K. A., Epstein, A. E., Friedman, P., Goldberger, J., Heidenreich, P. A., Klein, G. J., Knight, B. P., Morillo, C. A., Myerburg, R. J., Sila, C. A., Woo, M. A. 2006; 48 (12): 2599

  View details for DOI 10.1016/j.jacc.2006.09.026

  View details for Web of Science ID 000242916100029

• ACC/AHA/HRS 2006 Key Data Elements and Definitions for Electrophysiological Studies and Procedures A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (ACC/AHA/HRS Writing Committee to Develop Data Standards on Electrophysiology) CIRCULATION Buxton, A. E., Calkins, H., Callans, D. J., DiMarco, J. P., Fisher, J. D., Greene, H. L., Haines, D. E., Hayes, D. L., Heidenreich, P. A., Miller, J. M., Poppas, A., Prystowsky, E. N., Schoenfeld, M. H., Zimetbaum, P. J., Heidenreich, P. A., Goff, D. C., Grover, F. L., Malenka, D. J., Peterson, E. D., Radford, M. J., Redberg, R. F. 2006; 114 (23): 2534-2570

  View details for DOI 10.1161/CIRCULATIONAHA.106.180199

  View details for Web of Science ID 000243477500025

• ACC/AHA/HRS 2006 key data elements and definitions for electrophysiological studies and procedures - A report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (ACC/AHA/HRS Writing Committee to Develop Data Standards on Electrophysiology) JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Buxton, A. E., Calkins, H., Callans, D. J., DiMarco, J. P., Fisher, J. D., Greene, H. L., Haines, D. E., Hayes, D. L., Heidenreich, P. A., Miller, J. M., Poppas, A., Prystowsky, E. N., Schoenfeld, M. H., Zimetbaum, P. J., Goff, D. C., Grover, F. L., Malenka, D. J., Peterson, E. D., Radford, M. J., Redberg, R. F. 2006; 48 (11): 2360-2396

  View details for DOI 10.1016/j.jacc.2006.09.020

  View details for Web of Science ID 000242520900043

  View details for PubMedID 17161282

• The diffusion of medical technology, local conditions, and technology re-invention: A comparative case study on coronary stenting HEALTH POLICY Hashimoto, H., Noguchi, H., Heidenreich, P., Saynina, O., Moreland, A., Miyazaki, S., Ikeda, S., Kaneko, Y., Ikegami, N. 2006; 79 (2-3): 221-230

  Abstract

  Innovation of medical technology is a major driving force behind the increase in medical expenditures in developed countries. Previous studies identified that the diffusion of medical technology varied across countries according to the characteristics of regulatory policy and payment systems. Based on Roger's diffusion of innovation theory, this study purported to see how local practice norms, the evolving nature of diffusing technology, and local clinical needs in addition to differences in politico-economic systems would affect the process of innovation diffusion. Taking a case of coronary stenting, an innovative therapeutic technology in early 1990s, we provided a case study of hospital-based data between two teaching high-tech hospitals in Japan and the US for discussion. Stenting began to be widely used in both countries when complementary new technology modified its clinical efficacy, but the diffusion process still differed between the two hospitals due to (1) distinctive payment systems for hospitals and physicians, (2) practice norms in favor of percutaneous intervention rather than bypass surgery that was shaped by payment incentives and cultural attitudes, and (3) local patient's clinical characteristics that the technology had to be tailored for. The case study described the diffusion of stent technology as a dynamic process between patients, physicians, hospitals, health care systems, and technology under global and local conditions.

  View details for DOI 10.1016/j.healthpol.2006.01.005

  View details for Web of Science ID 000241834100010

  View details for PubMedID 16473435

• Costs and quality-of-life effects of implantable cardioverter-defibrillators AMERICAN JOURNAL OF CARDIOLOGY Groeneveld, P. W., Matta, M. A., Suh, J. J., Heidenreich, P. A., Shea, J. A. 2006; 98 (10): 1409-1415

  Abstract

  Although the clinical efficacy of implantable cardioverter-defibrillators (ICDs) has been convincingly demonstrated in clinical trials, the impact of ICDs on health care costs and recipients' quality of life (QOL) is less certain. The existing medical research on the health care costs and QOL effects of ICDs was reviewed and summarized. Medline and the Institute for Scientific Information's Web of Knowledge were searched for publications reporting costs of care and QOL assessments of ICD recipients. Unpublished and non-peer-reviewed "gray" publications were excluded. Reports were included if they reported primary, original patient data that were collected after 1993, when nonthoracotomy defibrillators entered clinical practice. Two reviewers independently evaluated publications for relevance and quality, abstracted study data, and summarized the findings. Excessive heterogeneity among studies prevented formal meta-analysis, so a narrative synthesis was performed, and key themes were identified from the published research. There were limited published data on the costs of ICD care, especially for the primary prevention of sudden cardiac death. The published research on ICD QOL lacked large, multicenter, longitudinal studies. Many ICD QOL studies were performed in small numbers of patients at single centers. Initial ICD implantation costs ranged (in 2006 United States dollars) from $28,500 to $55,200, with annual follow-up costs ranging from $4,800 to $17,000. QOL was higher for ICD recipients than for patients treated with antiarrhythmic drugs, but there was a substantial prevalence of anxiety, depression, and "loss of control" in ICD recipients, particularly in those who had received ICD shocks. In conclusion, ICD implantation remains costly but may be becoming less expensive over time, and ICD recipients' QOL is significantly affected by their devices.

  View details for DOI 10.1016/j.amjcard.2006.06.041

  View details for Web of Science ID 000244052400024

  View details for PubMedID 17134641

• Are registry hospitals different? A comparison of patients admitted to hospitals of a commercial heart failure registry with those from national and community cohorts AMERICAN HEART JOURNAL Heidenreich, P. A., Fonarow, G. C. 2006; 152 (5): 935-939

  Abstract

  Clinical registries have been created to address questions that are difficult to answer with clinical trials. However, the applicability of registry findings to the general population has been questioned because of concerns over potential bias in the selection of participating hospitals. The purpose of this study was to determine if patients admitted to hospitals participating in a heart failure registry (ADHERE) are comparable with patients admitted to other hospitals, including those admitted to Framingham area hospitals.We used a 20% random sample of all Medicare patients discharged during 1984 to 2001 to determine rates of hospitalization, procedure use, and survival after a first admission for heart failure (none in the prior 3 years). Hospitals were classified as participating in the ADHERE registry (n = 189), located within or near Framingham, MA (n = 9), or other (n = 5541).A total of 725,702 first admissions were identified, including 80,338 to ADHERE hospitals and 1716 to Framingham area hospitals. Minimal differences in patient characteristics were noted between patients admitted to ADHERE and non-ADHERE hospitals, although patients admitted to Framingham area hospitals were more likely to be white (95%) than were patients admitted to ADHERE (84%) or other hospitals (87%, P < .0001). Mortality at 1 year was 35.8% for ADHERE, 36.2% for other hospitalized patients, and 32.9% for Framingham patients (P < .0001). Rehospitalization for heart failure at 90 days was 13.0% for following admission to ADHERE, 13.0% to other hospitals, and 16.4% to Framingham hospitals (P = .0004). After adjustment for patient characteristics, differences in outcome between ADHERE and non-ADHERE hospitals remained minimal.Patients admitted with heart failure to ADHERE registry hospitals had similar baseline characteristics and outcomes to other patients.

  View details for DOI 10.1016/j.ahj.2006.06.037

  View details for Web of Science ID 000241745800028

  View details for PubMedID 17070163

• Clinical significance of HDL-c levels among patients with LDL-c less than 60 mg/dl deGoma, E., Leeper, N. J., Heidenreich, P. A. LIPPINCOTT WILLIAMS & WILKINS. 2006: 899

  View details for Web of Science ID 000241792805638

• The effect of angiotensin-converting enzyme inhibition on progression of aortic sclerosis and mortality Ardehali, R., Leeper, N. J., Heidenreich, P. A. LIPPINCOTT WILLIAMS & WILKINS. 2006: 657

  View details for Web of Science ID 000241792804292

• Statin use in patients with extremely low LDL levels is associated with improved survival Leeper, N. J., Ardehali, R., DeGoma, E. M., Heidenreich, P. A. LIPPINCOTT WILLIAMS & WILKINS. 2006: 827–28

  View details for Web of Science ID 000241792805338

• Association of functional and health status measures in heart failure JOURNAL OF CARDIAC FAILURE Myers, J., Zaheer, N., Quaglietti, S., Madhavan, R., Froelicher, V., Heidenreich, P. 2006; 12 (6): 439-445

  Abstract

  A wide variety of instruments have been used to assess the functional capabilities and health status of patients with chronic heart failure (HF), but it is not known how well these tests are correlated with one another, nor which one has the best association with measured exercise capacity.Forty-one patients with HF were assessed with commonly used functional, health status, and quality of life measures, including maximal cardiopulmonary exercise testing, the Duke Activity Status Index (DASI), the Veterans Specific Activity Questionnaire (VSAQ), the Kansas City Cardiomyopathy Questionnaire (KCCQ), and 6-minute walk distance. Pretest clinical variables, including age, resting pulmonary function tests (forced expiratory volume in 1 s and forced vital capacity), and ejection fraction (EF) were also considered. The association between performance on these functional tools, clinical variables, and exercise test responses including peak VO2 and the VO2 at the ventilatory threshold, was determined. Peak oxygen uptake (VO2) was significantly related to VO2 at the ventilatory threshold (r = 0.76, P < .001) and estimated METs from treadmill speed and grade (r = 0.72, P < .001), but had only a modest association with 6-minute walk performance (r = 0.49, P < .01). The functional questionnaires had modest associations with peak VO2 (r = 0.37, P < .05 and r = 0.26, NS for the VSAQ and DASI, respectively). Of the components of the KCCQ, peak VO2 was significantly related only to quality of life score (r = 0.46, P < .05). Six-minute walk performance was significantly related to KCCQ physical limitation (r = 0.53, P < .01) and clinical summary (r = 0.44, P < .05) scores. Among pretest variables, only age and EF were significantly related to peak VO2 (r = -0.58, and 0.46, respectively, P < .01). Multivariately, age and KCCQ quality of life score were the only significant predictors of peak VO2, accounting for 72% of the variance in peak VO2.Commonly used functional measures, symptom tools, and quality of life assessments for patients with HF are poorly correlated with one another and are only modestly associated with exercise test responses. These findings suggest that exercise test responses, non-exercise test estimates of physical function, and quality of life indices reflect different facets of health status in HF and one should not be considered a surrogate for another.

  View details for DOI 10.1016/j.cardfail.2006.04.004

  View details for PubMedID 16911910

• National trends in outcomes among elderly patients with heart failure AMERICAN JOURNAL OF MEDICINE Kosiborod, M., Lichtman, J. H., Heidenreich, P. A., Normand, S. T., Wang, Y., Brass, L. M., Krumholz, H. M. 2006; 119 (7)

  Abstract

  Despite dramatic changes in heart failure management during the 1990s, little is known about the national heart failure mortality trends during this time period, particularly among the elderly. The purpose of this study was to determine temporal trends in outcomes of elderly patients with heart failure between 1992 and 1999.We analyzed a national sample of 3,957,520 Medicare beneficiaries aged 65 years or more who were hospitalized with heart failure between 1992 and 1999, assessing temporal trends in 30-day and 1-year all-cause mortality and 30-day and 6-month all-cause hospital readmission. In risk-adjusted analyses, mortality and readmission for each year between 1994 and 1999 were compared with the referent year of 1993.Crude 30-day and 1-year mortality decreased slightly (range for 1992-1999: 11.0%-10.3% and 32.5%-31.7%, respectively), whereas 30-day and 6-month readmission increased (10.2%-13.8% and 35.4%-40.3%, respectively). After risk adjustment, there was no change in 30-day mortality between 1993 and 1999 (eg, for 1999 vs 1993, odds ratio [OR] 1.01, 95% confidence interval [CI], 1.00-1.02). One-year mortality was lower in 1994 compared with 1993 (OR 0.91, 95% CI, 0.90-0.92), but data from subsequent years suggested no continuous improvement after 1994 (1999 vs 1993: OR 0.93, 95% CI, 0.92-0.94). Thirty-day readmission increased (1999 vs 1993: OR 1.09, 95% CI, 1.07-1.10), but there was no change in 6-month readmission (1999 vs 1993: OR 1.00, 95% CI, 0.99-1.01).We found no substantial improvement in mortality and hospital readmission during the 1990s among elderly patients hospitalized with heart failure. These findings suggest that recent innovations in heart failure management have not yet translated into better outcomes in this population.

  View details for DOI 10.1016/j.amjmed.2005.11.019

  View details for Web of Science ID 000238835500014

  View details for PubMedID 16828634

• Patient-reported economic burden and the health status of heart failure patients JOURNAL OF CARDIAC FAILURE Conard, M. W., Heidenreich, P., Rumsfeld, J. S., Weintraub, W. S., Spertus, J. 2006; 12 (5): 369-374

  Abstract

  Heart failure (HF) guidelines recommend treatment with multiple medications to improve survival, functioning, and quality of life. Yet, HF treatments can be costly, resulting in significant economic burden for some patients. To date, there are few data on the impact of patients' perceived difficulties in affording medical care on their health outcomes.Comprehensive clinical data, health status, and the perceived economic burden of 539 HF outpatients from 13 centers were assessed at baseline and 1 year later. Health status was quantified with the Kansas City Cardiomyopathy Questionnaire overall summary score. Cross-sectional and longitudinal (1-year) analyses were conducted comparing the health status of patients with and without self-reported economic burden. Patients with economic burden had significantly lower health status scores at both baseline and 1 year later. Although baseline perceptions of economic burden were associated with poorer health status, patients' perceived difficulty affording medical care at 1 year was a more important determinant of lower 1-year health status.HF patients reporting difficulty affording their medical care had lower perceived health status than those reporting little to no economic burden. More research is needed to further evaluate this association and to determine whether addressing perceived economic difficulties affording health care can improve HF patients' health status.

  View details for DOI 10.1016/j.cardfail.2006.03.004

  View details for Web of Science ID 000238518600009

  View details for PubMedID 16762800

• The value of BNP testing ARCHIVES OF INTERNAL MEDICINE Hlatky, M., Heidenreich, P. 2006; 166 (10): 1063-1064

  View details for Web of Science ID 000237720500001

  View details for PubMedID 16717166

• A dilated inferior vena cava is a marker of poor survival AMERICAN HEART JOURNAL Nath, J., Vacek, J. L., Heidenreich, P. A. 2006; 151 (3): 730-735

  Abstract

  The inferior vena cava (IVC) morphology is often used to estimate right atrial pressure; however, the association of IVC morphology and outcome is poorly described.We evaluated 4383 consecutive outpatients (98% men) undergoing echocardiography at 1 of 3 Veterans Affairs laboratories.Of the 3729 with adequate images, 3295 (88%) had a normal IVC (< 2 cm), 358 (10%) had a dilated IVC that collapsed at least 50% with inspiration, and 76 (2%) had dilated IVC that did not collapse. Compared with patients with a normal IVC, those with a dilated IVC were older (66 +/- 13 vs 69 +/- 12 years if dilated with collapse and 70 +/- 12 years if dilated without collapse, P = .0005) and were more likely to have a history of heart failure (11% vs 18% if dilated with collapse and 38% if dilated without collapse, P < .0001). The 90-day and 1-year survival rates were 99% and 95% for those with a normal IVC, 98% and 91% for those with a dilated IVC with collapse, and 89% and 67% for those with a dilated IVC without collapse (P < .0001). After adjustment for clinical and echocardiographic characteristics including left and right ventricular function and pulmonary artery pressure, a dilated IVC without collapse remained associated with increased mortality: hazard ratio 1.43 (1.29-1.57 compared with a normal IVC, P < .0001).A dilated IVC without collapse with inspiration is associated with worse survival in men independent of a history of heart failure, other comorbidities, ventricular function, and pulmonary artery pressure.

  View details for DOI 10.1016/j.ahj.2005.04.023

  View details for Web of Science ID 000236353900029

  View details for PubMedID 16504642

• A small pericardial effusion is a marker of shortened survival Mitiku, T. Y., Heidenreich, P. A. ELSEVIER SCIENCE INC. 2006: 96A-97A

  View details for Web of Science ID 000235530400415

• Cost-effectiveness of chlorthalidone, amlodipine, and lisinopril as first-line treatment for patients with hypertension: An ALLHAT analysis Heidenreich, P. A., Davis, B. R., Furberg, C. D., Lairson, D. R., Pressel, S., Goldman, L. ELSEVIER SCIENCE INC. 2006: 372A

  View details for Web of Science ID 000235530402417

• Trends in survival following a diagnosis of heart failure Heidenreich, P. A. ELSEVIER SCIENCE INC. 2006: 82A

  View details for Web of Science ID 000235530400358

• AHA/ACCF scientific statement on the evaluation of syncope: from the American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascular Disease in the Young, and Stroke, and the Quality of Care and Outcomes Research Interdisciplinary Working Group; and the American College of Cardiology Foundation In Collaboration With the Heart Rhythm Society. Journal of the American College of Cardiology Strickberger, S. A., Benson, D. W., Biaggioni, I., Callans, D. J., Cohen, M. I., Ellenbogen, K. A., Epstein, A. E., Friedman, P., Goldberger, J., Heidenreich, P. A., Klein, G. J., Knight, B. P., Morillo, C. A., Myerburg, R. J., Sila, C. A. 2006; 47 (2): 473-484

  View details for PubMedID 16412888

• AHA/ACCF scientific statement on the evaluation of syncope - From the American Heart Association Councils on Clinical Cardiology, Cardiovascular Nursing, Cardiovascular Disease in the Young, and Stroke, and the Quality of Care and Outcomes Research Interdisciplinary Working Group; and the American College of Cardiology Foundation in collaboration with the Heart Rhythm Society - Endorsed by the American Autonomic Society JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Strickberger, S. A., Benson, W., Biaggioni, I., Callans, D. J., Cohen, M. I., Ellenbogen, K. A., Epstein, A. E., Friedman, P., Goldberger, J., Heidenreich, P. A., Klein, G. J., Knight, B. P., Morillo, C. A., Myerburg, R. J., Sila, C. A. 2006; 47 (2): 473-484

  View details for DOI 10.1016/j.jacc.2005.12.019

  View details for Web of Science ID 000234667100043

• AHA/ACCF scientific statement on the evaluation of syncope - From the American Heart Association Councils on clinical cardiology, cardiovascular nursing, cardiovascular disease in the young, and stroke, and the quality of care and outcomes research interdisciplinary working group; and the American College of Cardiology Foundation in collaboration with the Heart Rhythm Society - Endorsed by the American Autonomic Society CIRCULATION Strickberger, S. A., Benson, W., Biaggioni, I., Callans, D. J., Cohen, M. I., Ellenbogen, K. A., Epstein, A. E., Friedman, P., Goldberger, J., Heidenreich, P. A., Klein, G. J., Knight, B. P., Morillo, C. A., Myerburg, R. J., Sila, C. A. 2006; 113 (2): 316-327

  View details for DOI 10.1161/CIRCULATIONAHA.105.170274

  View details for Web of Science ID 000234677900024

  View details for PubMedID 16418451

• Peripheral edema due to heart disease: Diagnosis and outcome CLINICAL CARDIOLOGY Shah, M. G., Cho, S., Atwood, J. E., Heidenreich, P. A. 2006; 29 (1): 31-35

  Abstract

  The purpose of this study was to determine whether baseline physical examination and history are useful in identifying patients with cardiac edema as defined by echocardiography, and to compare survival for patients with cardiac and noncardiac causes of edema.Physical examination and history data can help to identify patients with edema who have significant cardiac disease.We reviewed the medical records of 278 consecutive patients undergoing echocardiography for evaluation of peripheral edema. We classified cardiac edema as the presence of any of the following: left ventricular ejection fraction < 45%, systolic pulmonary artery pressure > 45 mmHg, reduced right ventricular function, enlarged right ventricle, and a dilated inferior vena cava.The mean age of the 243 included patients was 67 +/- 12 years and 92% were male. A cardiac cause of edema was found in 56 (23%). Independent predictors of a cardiac cause of edema included chronic obstructive pulmonary disease (COPD, odds ratio [OR] 1.74, 95% confidence interval [CI] 1.14-2.60) and crackles (OR 1.98, 95% CI 1.26-3.10). The specificity for a cardiac cause of edema was high (91% for COPD, 93% for crackles); however, the sensitivity was quite low (27% for COPD, for 24% crackles). Compared with patients without a cardiac cause of edema, those with a cardiac cause had increased mortality (25 vs. 8% at 2 years, p < 0.01), even after adjustment for other characteristics (hazard ratio 1.55, 95% CI 1.08-2.24).A cardiac cause of edema is difficult to predict based on history and examination and is associated with high mortality.

  View details for Web of Science ID 000234454100008

  View details for PubMedID 16477775

• Will beta-blockers save money? JOURNAL OF CARDIAC FAILURE Heidenreich, P. A. 2005; 11 (9): 657-658

  View details for DOI 10.1016/j.cardfail.2005.09.004

  View details for Web of Science ID 000234655900002

  View details for PubMedID 16360959

• Diastolic dysfunction after mediastinal irradiation AMERICAN HEART JOURNAL Heidenreich, P. A., Hancock, S. L., Vagelos, R. H., Lee, B. K., Schnittger, I. 2005; 150 (5): 977-982

  Abstract

  Mediastinal irradiation is known to cause cardiac disease, but its effect on left ventricular diastolic function is unknown. The purpose of this study was to determine the prevalence of diastolic dysfunction and its association with prognosis in asymptomatic patients after mediastinal irradiation.We recruited 294 patients who had received at least 35 Gy to the mediastinum for treatment of Hodgkin disease. Each patient underwent resting echocardiography, stress echocardiography, and nuclear scintigraphy. Survival free from cardiac events was determined during 3.2 years of follow-up.The mean age of the included patients was 42 years, and 49% were male. Adequate measurements of diastolic function were obtained in 282 (97%) patients. Diastolic dysfunction was considered mild in 26 (9%) and moderate in 14 (5%). Exercise-induced ischemia was more common in patients with diastolic dysfunction (23%) than those with normal diastolic function (11%, P = .008). After adjustment for patient demographics, clinical characteristics, and radiation history, patients with diastolic dysfunction had worse event-free survival than patients with normal function (hazard ratio 1.66, 95% CI 1.06-2.4).There is a high prevalence of diastolic dysfunction in asymptomatic patients after mediastinal irradiation, and the presence of diastolic dysfunction is associated with stress-induced ischemia and a worse prognosis. Screening with Doppler echocardiography may be helpful in identifying patients at risk for subsequent cardiac events.

  View details for DOI 10.1016/j.ahj.2004.12.026

  View details for Web of Science ID 000233478800024

  View details for PubMedID 16290974

• Monitoring clinical changes in patients with heart failure: A comparison of methods AMERICAN HEART JOURNAL Spertus, J., Peterson, E., Conard, M. W., Heidenreich, P. A., Krumholz, H. M., Jones, P., McCullough, P. A., Pina, I., Tooley, J., Weintraub, W. S., Rumsfeld, J. S. 2005; 150 (4): 707-715

  Abstract

  Although monitoring the clinical status of patients with heart failure rests at the core of clinical medicine, the ability of different techniques to reflect clinical change has not been evaluated. This study sought to describe changes in various measures of disease status associated with gradations of clinical change.A prospective, 14-center cohort of 476 outpatients was assessed at baseline and 6 +/- 2 weeks to compare changes in 7 heart failure measures with clinically observed change. Measures included health status instruments (the Kansas City Cardiomyopathy Questionnaire [KCCQ], Short Form-12, and EQ-5D), physician-assessed functional class (New York Heart Association [NYHA]), an exercise test (6-minute walk), patient weight, and a biomarker (B-type natriuretic peptide). Cardiologists, blinded to all measures except weight and NYHA, categorized clinical change ranging from large deterioration to large improvement.The KCCQ, NYHA, and 6-minute walk test were most sensitive to clinical change. For patients with large, moderate, and small deteriorations, the KCCQ decreased by 25 +/- 16, 17 +/- 14, and 5.3 +/- 11 points, respectively. For patients with small, moderate, and large improvements, the KCCQ increased by 5.7 +/- 16, 10.5 +/- 16, and 22.3 +/- 16 points, respectively (P < .01 for all compared with the no change group). New York Heart Association and 6-minute walk distance were significantly different for those with moderate and large changes (P < .05) but neither revealed a difference between those with small versus no clinical deterioration. The KCCQ had the highest c statistic for monitoring individual patients, followed by NYHA and 6-minute walk.The KCCQ, followed by the NYHA and the 6-minute walk test, most accurately reflected clinical change in patients with heart failure.

  View details for DOI 10.1016/j.ahj.2004.12.010

  View details for Web of Science ID 000232953300016

  View details for PubMedID 16209970

• ACC/AHA key data elements and definitions for measuring the clinical management and outcomes of patients with chronic heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (Writing Committee to Develop Heart Failure Clinical Data Standards): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Failure Society of America. Circulation Radford, M. J., Arnold, J. M., Bennett, S. J., Cinquegrani, M. P., Cleland, J. G., Havranek, E. P., Heidenreich, P. A., Rutherford, J. D., Spertus, J. A., Stevenson, L. W., Goff, D. C., Grover, F. L., Malenka, D. J., Peterson, E. D., Redberg, R. F. 2005; 112 (12): 1888-1916

  View details for PubMedID 16162914

• Cost-effectiveness of clopidogrel plus aspirin versus aspirin alone - Response ANNALS OF INTERNAL MEDICINE Schleinitz, M. D., Heidenreich, P. A. 2005; 143 (6): 464-465

  View details for DOI 10.7326/0003-4819-143-6-200509200-00015

  View details for Web of Science ID 000232099900011

• ACC/AHA key data elements and definitions for measuring the clinical management and outcomes of patients with chronic heart failure - A report of the American College of Cardiology/American Heart Association Task Force on Clinical Data Standards (Writing committee to develop heart failure clinical data standards) JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Radford, M. J. 2005; 46 (6): 1179-1207

  View details for DOI 10.1016/j.jacc.2005.07.013

  View details for Web of Science ID 000231991600034

• ACC/AHA key data elements and definitions for measuring the clinical management and outcomes of patients with chronic heart failure CIRCULATION Radford, M. J., Arnold, J. M., Bennett, S. J., Cinquegrani, M. P., Cleland, J. G., Havranek, E. P., Heidenreich, P. A., Rutherford, J. D., Spertus, J. A., Stevenson, L. W. 2005; 112 (12): 1888-1916

  View details for DOI 10.1161/CIRCULATIONAHA.105.170073

  View details for Web of Science ID 000231978800023

• The relationship between B-type natriuretic peptide and health status in patients with heart failure JOURNAL OF CARDIAC FAILURE Luther, S. A., McCullough, P. A., Havranek, E. P., Rumsfeld, J. S., Jones, P. G., Heidenreich, P. A., Peterson, E. D., Rathore, S. S., Krumholz, H. M., Weintraub, W. S., Spertus, J. A., Masoudi, F. A. 2005; 11 (6): 414-421

  Abstract

  Although B-type natriuretic peptide (BNP) levels have been proposed as a means of assessing disease severity in patients with heart failure, it is not known if BNP levels are correlated with health status (symptom burden, functional limitation, and quality of life).We studied 342 outpatients with systolic heart failure from 14 centers at baseline and 6 +/- 2 weeks with BNP levels and the Kansas City Cardiomyopathy Questionnaire (KCCQ), a heart-failure-specific health status instrument. We assessed the correlation between KCCQ scores and BNP at baseline and changes in KCCQ according to changes in BNP levels between baseline and follow-up. Mean baseline BNP levels were 379 +/- 387 pg/mL and mean KCCQ summary scores were 62 +/- 23 points. Although baseline BNP and KCCQ were both associated with New York Heart Association classification (P < .001 for both), BNP and KCCQ were not correlated (r(2) = 0.008, P = .15). There was no significant relationship between changes in BNP and KCCQ regardless of the threshold used to define a clinically meaningful BNP change. For example, using >50% BNP change threshold, KCCQ improved by 3.7 +/- 14.2 in patients with decreasing BNP, improved by 1.7 +/- 13.6 in patients with no BNP change, and improved by 1.0 +/- 13.4 in patients with increasing BNP (P = .6).BNP and health status are not correlated in outpatients with heart failure in the short term. This suggests that these measures may assess different aspects of heart failure severity, and that physiologic measures do not reflect patients' perceptions of the impact of heart failure on their health status.

  View details for DOI 10.1016/j.cardfail.2005.02.004

  View details for Web of Science ID 000231643400002

  View details for PubMedID 16105631

• Correlation between right ventricular indices and clinical improvement in epoprostenol treated pulmonary hypertension patients ECHOCARDIOGRAPHY-A JOURNAL OF CARDIOVASCULAR ULTRASOUND AND ALLIED TECHNIQUES Nath, J., DeMarco, T., Hourigan, L., Heidenreich, P. A., Foster, E. 2005; 22 (5): 374-379

  Abstract

  The aim of this study was to evaluate which parameter of right ventricular (RV) echocardiographic best mirrors the clinical status of patients with pulmonary arterial hypertension. Patients with pulmonary arterial hypertension on epoprostenol therapy were identified via hospital registry. Twenty patients, (16 females, 4 males) were included in the study, 9 with primary pulmonary hypertension and 11 with other diseases. Echocardiograms before therapy and at 22.7 (+/-9.3) months into therapy were compared. The right ventricular myocardial performance index (RVMPI) was measured as the sum of the isometric contraction time and the isometric relaxation time divided by right ventricular ejection time. Other measures included peak tricuspid regurgitation jet velocity (TRV), pulmonary artery systolic pressure (PASP), pulmonary valve velocity time integral (PVVTI), PASP/PVVTI (as an index of total pulmonary resistance) and symptoms by New York Heart Association (NYHA) functional class. Echo parameters of right ventricular function were analyzed in patients, before and during therapy. There was significant improvement of NYHA class in patients following epoprostenol therapy (P < 0.0001). Peak tricuspid regurgitant jet velocity (pre 4.2 +/- 0.6 m/sec, post 3.8 +/- 0.7 m/sec, P = 0.02) and PASP/PVVTI (pre 6.7 +/- 3.3 mmHg/m per second, post 4.8 +/- 2.2 mmHg/m per second, P < 0.0001) were significantly improved during treatment. RVMPI did not improve (pre 0.6 +/- 0.3, post 0.6 +/- 0.3, P = 0.54). Changes in NYHA class did not correlate with changes in RVMPI (P = 0.33) or changes in PASP/PVVTI (P = 0.58). Despite significant improvements in TRV, PASP/PVVTI, and NYHA class, there was no significant change in RVMPI on epoprostenol therapy. Changes in right ventricular indices were not correlated with changes in NYHA class.

  View details for Web of Science ID 000229202200002

  View details for PubMedID 15901287

• A systolic murmur is a common presentation of aortic regurgitation detected by echocardiography - P. A. Heidenreich, I. Schnittger, S. L. Hancock, J. E. Atwood: Clin cardiol 2004;27 : 502-506 - Reply CLINICAL CARDIOLOGY Heidenreich, P. A., Schnittger, I., Hancock, S. L., Atwood, J. E. 2005; 28 (3): A30-A30

  View details for Web of Science ID 000227460800002

• A randomized trial of reminders attached to echocardiography reports to increase use of beta-blockers for patients with systolic dysfunction Heidenreich, P. A., Goldstein, M., Pham, M., Gholami, P., Nath, J., Gimmler, C., Atwood, J. E. ELSEVIER SCIENCE INC. 2005: 345A

  View details for Web of Science ID 000226808201489

• Cost of care for patients with chronic stable angina in the United States Heidenreich, P. A., Krumholz, H., Spertus, J., Lee, D. W., Goldberg, G. A., Watson, J. B., Haberman, M., Cohen, D. J. ELSEVIER SCIENCE INC. 2005: 203A

  View details for Web of Science ID 000226808200889

• Trends in implantable cardioverter-defibrillator racial disparity - The importance of geography JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Groeneveld, P. W., Heidenreich, P. A., Garber, A. M. 2005; 45 (1): 72-78

  Abstract

  The study was designed to determine whether racial disparity in utilization of the implantable cardioverter-defibrillator (ICD) has improved over time, and whether small-area geographic variation in ICD utilization contributed to national levels of racial disparity.Although racial disparities in cardiac procedures have been well-documented, it is unknown whether there has been improvement over time. Low ICD utilization rates in predominantly black geographic areas may have exacerbated national levels of disparity.Discharge abstracts from elderly black and white Medicare beneficiaries hospitalized with ventricular arrhythmias from 1990 to 2000 were analyzed to determine if ICD implantation occurred within 90 days of initial hospitalization. Multivariate logistic regression models were constructed to assess the relationship between ICD implantation, year of admission, and the percentage of black inhabitants in each patient's county of hospitalization while controlling for clinical, hospital, and demographic characteristics.There was improvement in ICD implantation racial disparity: In the period 1990 to 1992, black patients had an odds ratio of 0.52 (95% confidence interval [CI] 0.42 to 0.64) for receiving an ICD compared with whites. However, by 1999 to 2000, the odds ratio for blacks had risen to 0.69 (95% CI 0.61 to 0.78) (test-for-trend p=0.01). Approximately 20% of this trend could be explained by reduction in geographic variation in ICD use between areas with larger black and predominantly white populations.Rates of ICD implants became more equal among whites and blacks during the 1990s, although persistent disparity remained at the decade's end. Geographic equalization in cardiovascular procedure rates may be an essential mechanism in rectifying disparities in health care.

  View details for DOI 10.1016/j.jacc.2004.07.061

  View details for Web of Science ID 000226012600014

  View details for PubMedID 15629377

• Measuring the quality of the VA Health Care System. Health services research Heidenreich, P. A. 2004; 39 (6): 1793-1798

  View details for PubMedID 15533187

  View details for PubMedCentralID PMC1361098

• Cilostazol, clopidogrel or ticlopidine to prevent sub-acute stent thrombosis: A meta-analysis of randomized trials AMERICAN HEART JOURNAL Schleinitz, M. D., Olkin, I., Heidenreich, P. A. 2004; 148 (6): 990-997

  Abstract

  Sub-acute thrombosis is a serious complication of coronary artery stenting. Clopidogrel plus aspirin is the accepted prophylactic regimen, but has yet to be proven superior to ticlopidine plus aspirin, and a new regimen combining cilostazol and aspirin has been introduced.We conducted a meta-analysis of all trials that compared >or=2 oral anti-thrombotic strategies in patients undergoing coronary stent placement to determine which treatment optimally prevents adverse cardiac events in the 30 days following stent insertion. We used meta-regression to compare all strategies to a shared control strategy: ticlopidine plus aspirin. We also compared randomized trials to historically controlled and other non-randomized trials. We conducted sensitivity analysis and subgroup analysis to assess for possible heterogeneity.In comparison to ticlopidine plus aspirin the odds-ratios for cardiac events, with 95% confidence intervals were: aspirin alone, 4.29 (3.09-5.97), coumadin plus aspirin, 2.65 (2.18-3.21), clopidogrel plus aspirin, 1.06 (0.86-1.31), cilostazol plus aspirin, 0.73 (0.47-1.14). Among trials that compared clopidogrel plus aspirin to ticlopidine plus aspirin, historically controlled trials were statistically distinct from randomized trials. The analysis of cilostazol was sensitive to the small size of the included studies.Neither clopidogrel plus aspirin nor cilostazol plus aspirin can be statistically distinguished from ticlopidine plus aspirin for the prevention of adverse cardiac events in the 30 days after stenting. A randomized trial including cilostazol is warranted.

  View details for DOI 10.1016/j.ahj.2004.03.066

  View details for Web of Science ID 000225970400012

  View details for PubMedID 15632883

• Trends in heart failure outcomes for black and white medicare patients Heidenreich, P. LIPPINCOTT WILLIAMS & WILKINS. 2004: 800

  View details for Web of Science ID 000224783504263

• Patients with minor elevations in pulmonary artery pressure have increased mortality Heidenreich, P., Pham, M., Nath, J. LIPPINCOTT WILLIAMS & WILKINS. 2004: 592

  View details for Web of Science ID 000224783503207

• Age, functional capacity, and health-related quality of life in patients with heart failure JOURNAL OF CARDIAC FAILURE Masoudi, F. A., Rumsfeld, J. S., Havranek, E. P., House, J. A., Peterson, E. D., Krumholz, H. M., Spertus, J. A., Spertus, J., Tsuyuki, R. T., Clark, C. B., Hott, B., Havranek, E. P., Masoudi, F. A., Rumsfeld, J. S., Kale, P., Williams, R. E., Heidenreich, P. A., Peterson, E. D., McCullough, P., Krumholz, H., Dunlap, M., Goff, D. 2004; 10 (5): 368-373

  Abstract

  Although heart failure disproportionately affects older persons and is associated with significant physical disability, existing data on physical limitations and health-related quality of life (HRQL) derive largely from studies of younger subjects. We compared the relationship between functional limitation and HRQL between older and younger patients with heart failure.We evaluated 546 outpatients with heart failure enrolled in a multicenter prospective cohort study. At baseline and 6 +/- 2 weeks later, functional status was assessed by New York Heart Association (NYHA) classification and 6-minute walk testing. HRQL was measured with the Kansas City Cardiomyopathy Questionnaire (KCCQ). Comparing older (age >65 years, n = 218) and younger patients (n = 328), we assessed baseline HRQL across strata of functional status. In the 484 patients who completed follow-up (194 older and 290 younger patients), we also assessed the changes in HRQL associated with changes in functional status over time. At baseline, older patients had better HRQL than younger patients (mean KCCQ score 60 +/- 25 versus 54 +/- 28, P = .005) in spite of worse NYHA class (mean 2.54 versus 2.35, P < .001) and lower 6-minute walk distances (824 +/- 378 versus 1064 +/- 371 feet, P < .001). After multivariable adjustment including baseline NYHA class, older age was independently correlated with better HRQL (beta = +7.9 points, P < .001). At follow-up, older patients with a deterioration in NYHA class experienced marked declines in HRQL compared with younger patients (mean HRQL change of -14.4 points versus +0.3 points, respectively, P < .001). Analyses using 6-minute walk distance as the functional measure yielded similar results.Although older patients with heart failure have relatively good HRQL in spite of significant functional limitations, they are at risk for worsening HRQL with further decline in functional status. These results underscore the importance of treatments aimed at maintaining functional status in older persons with heart failure, including those with significant baseline functional limitations.

  View details for DOI 10.1016/j.cardfail.2004.01.009

  View details for Web of Science ID 000224591200003

  View details for PubMedID 15470645

• A systolic murmur is a common presentation of aortic regurgitation detected by echocardiography CLINICAL CARDIOLOGY Heidenreich, P. A., Schnittger, I., Hancock, S. L., Atwood, J. E. 2004; 27 (9): 502-506

  Abstract

  The finding of aortic regurgitation at a classical examination is a diastolic murmur.Aortic regurgitation is more likely to be associated with a systolic than with a diastolic murmur during routine screening by a noncardiologist physician.In all, 243 asymptomatic patients (mean age 42 +/- 10 years) with no known cardiac disease but at risk for aortic valve disease due to prior mediastinal irradiation (> or = 35 Gy) underwent auscultation by a noncardiologist followed by echocardiography. A systolic murmur was considered benign if it was grade < or = II/VI, not holosystolic, was not heard at the apex, did not radiate to the carotids, and was not associated with a diastolic murmur.Of the patients included, 122 (49%) were male, and 86 (35%) had aortic regurgitation, which was trace in 20 (8%), mild in 52 (21%), and moderate in 14 (6%). A systolic murmur was common in patients with aortic regurgitation, occurring in 12 (86%) with moderate, 26 (50%) with mild, 6 (30%) with trace, and 27 (17%) with no aortic regurgitation (p < 0.0001). The systolic murmurs were classified as benign in 21 (78%) patients with mild and 8 (67%) with moderate aortic regurgitation. Diastolic murmurs were rare, occurring in two (14%) with moderate, two (4%) with mild, and three (2%) with no aortic regurgitation (p=0.15).An isolated systolic murmur is a common auscultatory finding by a noncardiologist in patients with moderate or milder aortic regurgitation. A systolic murmur in patients at risk for aortic valve disease should prompt a more thorough physical examination for aortic regurgitation.

  View details for Web of Science ID 000223604300004

  View details for PubMedID 15471160

• Health-care costs and exercise capacity CHEST Weiss, J. P., Froelicher, V. F., Myers, J. N., Heidenreich, P. A. 2004; 126 (2): 608-613

  Abstract

  While the beneficial effect of exercise capacity on mortality is well-accepted, its effect on health-care costs remains uncertain. This study investigates the relationship between exercise capacity and health-care costs.The Veterans Affairs Health Care System recently implemented a Decision Support System that provides data on patterns of care, patient outcomes, workload, and costs. Total inpatient and outpatient costs were derived from existing administrative and clinical data systems, were adjusted for relative value units, and were expressed in relative cost units. We used univariable and multivariable analyses to evaluate the 1-year total costs in the year following a standard exercise test. Costs were compared with exercise capacity estimated in metabolic equivalents (METs), other test results, and clinical variables for 881 consecutive patients who were referred for clinical reasons for treadmill testing at the Palo Alto Veterans Affairs Health Care System facility between October 1, 1998, and September 30, 2000.The patients had a mean age of 59 years, 95% were men, and 74% were white. Eight patients (< 1%) died during the year of follow-up. Exercise testing showed an average maximum heart rate of 138 beats/min, 8.2 METs, and a peak Borg scale of 17. In unadjusted analysis, costs were incrementally lower by an average of 5.4% per MET increase (p < 0.001). In a multivariable analysis adjusting for demographic variables, treadmill test performance and results, and clinical history, METs were found to be the most significant predictor of cost (F-statistic, 21.8; p < 0.001).These findings are consistent with the hypothesis that exercise capacity is inversely associated with health-care costs.

  View details for PubMedID 15302750

• Patient adherence: The next frontier in quality improvement AMERICAN JOURNAL OF MEDICINE Heidenreich, P. A. 2004; 117 (2): 130-132

  View details for DOI 10.1016/j.amjmed.2004.03.007

  View details for Web of Science ID 000222615700011

  View details for PubMedID 15234651

• Time trends in racial disparity in the use of the implantable cardioverter-defibrillator: The crucial role of geographic diffusion Groeneveld, P. W., Heidenreich, P. A., Garber, A. M. LIPPINCOTT WILLIAMS & WILKINS. 2004: E231

  View details for Web of Science ID 000221604400035

• Managed care, information, and diffusion: The case of treatment for heart-attack patients Joint Meeting of the Society-of-Government-Economists/116th Annual Meeting of the American-Economic-Association Baker, L. C., Afendulis, C. C., Heidenreich, P. A. AMER ECONOMIC ASSOC. 2004: 347–51

  View details for Web of Science ID 000222423100063

• Increasing rates of cardiac device infections among Medicare beneficiaries: 1990-1999 AMERICAN HEART JOURNAL Cabell, C. H., Heidenreich, P. A., Chu, V. H., Moore, C. M., Stryjewski, M. E., Corey, G. R., Fowler, V. G. 2004; 147 (4): 582-586

  Abstract

  Although cardiac devices have been found to reduce symptoms and mortality rates in appropriate patient populations, the implications of certain important risks, such as infection, are incompletely understood. The purpose of this study was to use a large population-based database to define the population that is at risk for cardiac device infections, determine the prevalence of device infections, and study changes in the rates of cardiac device implantation and infection in the past decade.Patients with cardiac device implantations and infections were identified with claims files from the Health Care Finance Administration for Medicare beneficiaries from January 1, 1990, through December 31, 1999. Rates of implantation of cardiac devices were determined. Time trend analyses were performed to determine the significance of the observed change in rates.Cardiac device implantation rates increased from 3.26 implantations per 1000 beneficiaries in 1990 to 4.64 implantations per 1000 beneficiaries in 1999, which represents an increase of 42% in 10 years (P for trend <.001). Cardiac device infections showed a larger increase, from 0.94 device infections per 1000 beneficiaries in 1990 to 2.11 device infections per 1000 beneficiaries in 1999, which represents an increase of 124% during the study period (P for trend <.001).During the previous decade, there was a significant increase in both cardiac device implantations and infections in elderly patients, although the increase in the rates of device infections was substantially higher. Additional studies are needed to better understand the relationship and timing between cardiac device implantation and infection.

  View details for DOI 10.1016/j.ahj.2003.06.005

  View details for Web of Science ID 000226896900005

  View details for PubMedID 15077071

• Cost-effectiveness of carvedilol versus metoprolol tartrate for patients with heart failure Heidenreich, P. A. ELSEVIER SCIENCE INC. 2004: 425A

  View details for DOI 10.1016/S0735-1097(04)91793-7

  View details for Web of Science ID 000189388501796

• Dilated inferior vena cava: A marker of poor survival Nath, J., Heidenreich, P. A. ELSEVIER SCIENCE INC. 2004: 347A

  View details for DOI 10.1016/S0735-1097(04)91469-6

  View details for Web of Science ID 000189388501471

• Cost-effectiveness of screening coronary artery disease patients with B-type natriuretic peptide Heidenreich, P. A., Bibbins-Domingo, K., Pham, M. X., Whooley, M. A. ELSEVIER SCIENCE INC. 2004: 422A

  View details for DOI 10.1016/S0735-1097(04)91780-9

  View details for Web of Science ID 000189388501783

• Impact of tricuspid regurgitation on long-term survival JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Nath, J., Foster, E., Heidenreich, P. A. 2004; 43 (3): 405-409

  Abstract

  The goal of this study was to examine mortality associated with tricuspid regurgitation (TR) after controlling for left ventricular ejection fraction (LVEF), right ventricular (RV) dilation and dysfunction, and pulmonary artery systolic pressure (PASP).Tricuspid regurgitation is a frequent echocardiographic finding; however, the association with prognosis is unclear.We retrospectively identified 5,223 patients (age 66.5 +/- 12.8 years; predominantly male) undergoing echocardiography at one of three Veterans Affairs Medical Center laboratories over a period of four years. Follow-up data were available for four years (mean 498 +/- 402 days). Kaplan-Meier and proportional hazards methods were used to compare differences in survival among TR grades.Mortality increased with increasing severity of TR. The one-year survival was 91.7% with no TR, 90.3% with mild TR, 78.9% with moderate TR, and 63.9% with severe TR. Moderate or greater TR was associated with increased mortality regardless of PASP (hazard ratio [HR] 1.31, 95% confidence interval [CI] 1.16 to 1.49 for PASP >40 mm Hg; HR 1.32, 95% CI 1.05 to 1.62 for PASP < or =40 mm Hg) and LVEF (HR 1.49, 95% CI 1.34 to 1.66 for EF <50%; HR 1.54, 95% CI 1.37 to 1.71 for EF > or =50%). When adjusted for age, LVEF, inferior vena cava size, and RV size and function, survival was worse for patients with moderate (HR 1.17, 95% CI 0.96 to 1.42) and severe TR (HR 1.31, 95% CI 1.05 to 1.66) than for those with no TR.We conclude that increasing TR severity is associated with worse survival in men regardless of LVEF or pulmonary artery pressure. Severe TR is associated with a poor prognosis, independent of age, biventricular systolic function, RV size, and dilation of the inferior vena cava.

  View details for DOI 10.1016/j.jacc.2003.09.036

  View details for Web of Science ID 000188588100014

  View details for PubMedID 15013122

• Managed Care, Information, and Diffusion: The Case of Treatment for Heart-Attack Patients. The American economic review Baker, L. C., Afendulis, C. C., Heidenreich, P. A. 2004; 94 (2): 347-51

  View details for PubMedID 29068187

• The prognostic value of the Kansas city cardiomyopathy questionnaire Heidenreich, P. A., Jones, P., Rumsfeld, J. G., Masoudi, F. A., Havranek, E. P., Conard, M., Weintraub, W. S., Williams, R. E. LIPPINCOTT WILLIAMS & WILKINS. 2003: 715-716

  View details for Web of Science ID 000186360603292

• The natural history of asymptomatic mitral regurgitation Yue, P., Heidenreich, P. A. LIPPINCOTT WILLIAMS & WILKINS. 2003: 551

  View details for Web of Science ID 000186360602571

• Trends in heart failure survival for the US elderly Heidenreich, P. A. LIPPINCOTT WILLIAMS & WILKINS. 2003: 714

  View details for Web of Science ID 000186360603287

• The effect of ethnicity on survival in male veterans referred for electrocardiography and treadmill testing ARCHIVES OF INTERNAL MEDICINE PRAKASH, M., Partington, S., Froelicher, V. F., Heidenreich, P. A., Myers, J. 2003; 163 (18): 2204-2210

  Abstract

  Ethnic differences in the relationship between access to health care and survival are difficult to define because of many confounding factors, such as socioeconomic status and baseline differences in health. Because the Veterans Affairs health care system offers health care largely without financial considerations, it provides an ideal setting in which to identify and understand ethnic differences in health outcomes. Previous studies in this area have lacked clinical and cardiovascular data with which to adjust for baseline differences in patients' health.Data were collected from consecutive men referred for resting electrocardiography (ECG) (n = 41 087) or exercise testing (n = 6213) during 12 years. We compared ethnic differences in survival between whites, blacks, and Hispanics after considering baseline differences in age and hospitalization status. We also adjusted for electrocardiogram abnormalities and cardiac risk factors, exercise test results, and cardiovascular comorbidities.White patients tended to be older and had more baseline comorbidities and cardiovascular interventions when they presented for testing. White patients had increased mortality rates compared with blacks and Hispanics. In the ECG population, after adjusting for demographics and baseline electrocardiogram abnormalities, Hispanics had improved survival compared with whites and blacks. In the exercise test population, after adjusting for the same factors, as well as adjusting for the presence of cardiovascular comorbidities, cardiac risk factors, and exercise test findings, Hispanics also exhibited improved survival compared with the other 2 ethnicities. There were no differences in mortality rates between whites and blacks.Our findings demonstrate that the health care provided to veterans referred for routine ECG or exercise testing is not associated with poorer survival in ethnic minorities.

  View details for PubMedID 14557218

• Asymptomatic cardiac disease following mediastinal irradiation JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Heidenreich, P. A., Hancock, S. L., Lee, B. K., Mariscal, C. S., Schnittger, I. 2003; 42 (4): 743-749

  Abstract

  This study was designed to evaluate the potential benefit of screening previously irradiated patients with echocardiography.Mediastinal irradiation is known to cause cardiac disease. However, the prevalence of asymptomatic cardiac disease and the potential for intervention before symptom development are unknown.We recruited 294 asymptomatic patients (mean age 42 +/- 9 years, 49% men, mean mantle irradiation dose 43 +/- 0.3 Gy) treated with at least 35 Gy to the mediastinum for Hodgkin's disease. After providing written consent, each patient underwent electrocardiography and transthoracic echocardiography. Valvular disease was common and increased with time following irradiation. Patients who had received irradiation more than 20 years before evaluation had significantly more mild or greater aortic regurgitation (60% vs. 4%, p < 0.0001), moderate or greater tricuspid regurgitation (4% vs. 0%, p = 0.06), and aortic stenosis (16% vs. 0%, p = 0.0008) than those who had received irradiation within 10 years. The number needed to screen to detect one candidate for endocarditis prophylaxis was 13 (95% confidence interval [CI] 7 to 44) for patients treated within 10 years and 1.6 (95% CI 1.3 to 1.9) for those treated at least 20 years ago. Compared with the Framingham Heart Study population, mildly reduced left ventricular fractional shortening (<30%) was more common (36% vs. 3%), and age- and gender-adjusted left ventricular mass was lower (90 +/- 27 g/m vs. 117 g/m) in irradiated patients.There is a high prevalence of asymptomatic heart disease in general, and aortic valvular disease in particular, following mediastinal irradiation. Screening echocardiography should be considered for patients with a history of mediastinal irradiation.

  View details for DOI 10.1016/S0735-1097(03)00759-9

  View details for Web of Science ID 000184780600027

  View details for PubMedID 12932613

• Racial disparity in cardiac procedures and mortality among long-term survivors of cardiac arrest CIRCULATION Groeneveld, P. W., Heidenreich, P. A., Garber, A. M. 2003; 108 (3): 286-291

  Abstract

  It is unknown whether white and black Medicare beneficiaries have different rates of cardiac procedure utilization or long-term survival after cardiac arrest.A total of 5948 elderly Medicare beneficiaries (5429 white and 519 black) were identified who survived to hospital discharge between 1990 and 1999 after admission for cardiac arrest. Demographic, socioeconomic, and clinical information about these patients was obtained from Medicare administrative files, the US census, and the American Hospital Association's annual institutional survey. A Cox proportional hazard model that included demographic and clinical predictors indicated a hazard ratio for mortality of 1.30 (95% CI 1.09 to 1.55) for blacks aged 66 to 74 years compared with whites of the same age. The addition of cardiac procedures to this model lowered the hazard ratio for blacks to 1.23 (95% CI 1.03 to 1.46). In analyses stratified by race, implantable cardioverter-defibrillators (ICDs) had a mortality hazard ratio of 0.53 (95% CI 0.45 to 0.62) for white patients and 0.50 (95% CI 0.27 to 0.91) for black patients. Logistic regression models that compared procedure rates between races indicated odds ratios for blacks aged 66 to 74 years of 0.58 (95% CI 0.36 to 0.94) to receive an ICD and 0.50 (95% CI 0.34 to 0.75) to receive either revascularization or an ICD.There is racial disparity in long-term mortality among elderly cardiac arrest survivors. Both black and white patients benefited from ICD implantation, but blacks were less likely to undergo this potentially life-saving procedure. Lower rates of cardiac procedures may explain in part the lower survival rates among black patients.

  View details for DOI 10.1161/01.CIR.0000079164.95019.5A

  View details for Web of Science ID 000184282200012

  View details for PubMedID 12835222

• Pharmacologic management of heart failure and left ventricular systolic dysfunction: effect in female, black, and diabetic patients, and cost-effectiveness. Evidence report/technology assessment (Summary) Shekelle, P., Morton, S., Atkinson, S., Suttorp, M., Tu, W., Heidenreich, P., Gubens, M., Maglione, M., Jungvig, L., Roth, E., Newberry, S. 2003: 1-6

  View details for PubMedID 14571595

• 34th Bethesda Conference: Task force #5--Is atherosclerosis imaging cost effective? Journal of the American College of Cardiology Mark, D. B., Shaw, L. J., Lauer, M. S., O'Malley, P. G., Heidenreich, P. 2003; 41 (11): 1906-1917

  View details for PubMedID 12798557

• Severity of tricuspid regurgitation and survival Nath, J., Foster, E., Heidenreich, P. LIPPINCOTT WILLIAMS & WILKINS. 2003: E141

  View details for Web of Science ID 000183014500074

• Efficacy of angiotensin-converting enzyme inhibitors and beta-blockers in the management of left ventricular systolic dysfunction according to race, gender, and diabetic status - A meta-analysis of major clinical trials JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Shekelle, P. G., Rich, M. W., Morton, S. C., Atkinson, S. W., Tu, W. L., Maglione, M., Rhodes, S., Barrett, M., Fonarow, G. C., Greenberg, B., Heidenreich, P. A., Knabel, T., Konstam, M. A., Steimle, A., Stevenson, L. W. 2003; 41 (9): 1529-1538

  Abstract

  This study sought to assess the effect of angiotensin-converting enzyme (ACE) inhibitors and beta-blockers on all-cause mortality in patients with left ventricular (LV) systolic dysfunction according to gender, race, and the presence of diabetes.Major randomized clinical trials have established that ACE inhibitors and beta-blockers have life-saving benefits in patients with LV systolic dysfunction. Most patients enrolled in these trials were Caucasian men. Whether an equal effect is achieved in women, non-Caucasians, and patients with major comorbidities has not been established.The authors performed a meta-analysis of published and individual patient data from the 12 largest randomized clinical trials of ACE inhibitors and beta-blockers to produce random effects estimates of mortality for subgroups.Data support beneficial reductions in all-cause mortality for the use of beta-blockers in men and women, the use of ACE inhibitors and some beta-blockers in black and white patients, and the use of ACE inhibitors and beta-blockers in patients with or without diabetes. Women with symptomatic LV systolic dysfunction probably benefit from ACE inhibitors, but women with asymptomatic LV systolic dysfunction may not have reduced mortality when treated with ACE inhibitors (pooled relative risk = 0.96; 95% confidence interval: 0.75 to 1.22). The pooled estimate of three beta-blocker studies supports a beneficial effect in black patients with heart failure, but one study assessing bucindolol reported a nonsignificant increase in mortality.Angiotensin-converting enzyme inhibitors and beta-blockers provide life-saving benefits in most of the subpopulations assessed. Women with asymptomatic LV systolic dysfunction may not achieve a mortality benefit when treated with ACE inhibitors.

  View details for DOI 10.1016/S0735-1097(03)00262-6

  View details for Web of Science ID 000182631800018

  View details for PubMedID 12742294

• Cost-effectiveness of measuring fractional flow reserve to guide coronary interventions AMERICAN HEART JOURNAL Fearon, W. F., Yeung, A. C., Lee, D. P., Yock, P. G., Heidenreich, P. A. 2003; 145 (5): 882-887

  Abstract

  Most patients come to the catheterization laboratory without prior functional tests, which makes the cost-effective treatment of patients with intermediate coronary lesions a practical challenge.We developed a decision model to compare the long-term costs and benefits of 3 strategies for treating patients with an intermediate coronary lesion and no prior functional study: 1) deferring the decision for percutaneous coronary intervention (PCI) to obtain a nuclear stress imaging study (NUC strategy); 2) measuring fractional flow reserve (FFR) at the time of angiography to help guide the decision for PCI (FFR strategy); and 3) stenting all intermediate lesions (STENT strategy). On the basis of the literature, we estimated that 40% of intermediate lesions would produce ischemia, 70% of patients treated with PCI and 30% of patients treated medically would be free of angina after 4 years, and the quality-of-life adjustment for living with angina was 0.9 (1.0 = perfect health). We estimated the cost of FFR to be 761 dollars, the cost of nuclear stress imaging to be 1093 dollars, and the cost of medical treatment for angina to be 1775 dollars per year. The extra cost of splitting the angiogram and PCI as dictated by the NUC strategy was 3886 dollars by use of hospital cost-accounting data. Sensitivity and threshold analyses were performed to determine which variables affected our results.The FFR strategy saved 1795 dollars per patient compared with the NUC strategy and 3830 dollars compared with the STENT strategy. Quality-adjusted life expectancy was similar among the 3 strategies (NUC-FFR = 0.8 quality-adjusted days, FFR-STENT = 6 quality-adjusted life days). Compared with the FFR strategy, the NUC strategy was expensive (>800,000 dollars per quality-adjusted life year gained). Both screening strategies were superior to (less cost, better outcomes) the STENT strategy. Sensitivity analysis indicated that the NUC strategy would only become attractive (<50,000 dollars/quality-adjusted life years compared with FFR) if the specificity of nuclear stress imaging was >25% better than FFR. Our results were not altered significantly by changing the other assumptions.In patients with an intermediate coronary lesion and no prior functional study, measuring FFR to guide the decision to perform PCI may lead to significant cost savings compared with performing nuclear stress imaging or with simply stenting lesions in all patients.

  View details for DOI 10.1016/S0002-8703(03)00072-3

  View details for PubMedID 12766748

• Health care costs and exercise capacity Weiss, J. P., Froelicher, V. F., Myers, J. N., Heidenreich, P. A. ELSEVIER SCIENCE INC. 2003: 198A–199A

  View details for Web of Science ID 000181669500855

• Regional variation in quality of heart failure care: VA versus medicare Heidenreich, P., Deswal, A., Wray, N. ELSEVIER SCIENCE INC. 2003: 535A

  View details for Web of Science ID 000181669502315

• Ephedra and ephedrine for weight loss and athletic performance enhancement: clinical efficacy and side effects. Evidence report/technology assessment (Summary) Shekelle, P., Hardy, M. L., Morton, S. C., Maglione, M., Suttorp, M., Roth, E., Jungvig, L., Mojica, W. A., Gagne, J., Rhodes, S., McKinnon, E. 2003: 1-4

  View details for PubMedID 12647510

• Cost-effectiveness of screening with BNP to identify patients with reduced left ventricular ejection fraction Heidenreich, P., Gubens, M. LIPPINCOTT WILLIAMS & WILKINS. 2002: 725

  View details for Web of Science ID 000179142703608

• Endocarditis in the elderly: Incidence, surgery, and survival in 16,921 patients over 12 years Cabell, C. H., Fowler, V. G., Engemann, J. J., McClellan, M., Heidenreich, P. A. LIPPINCOTT WILLIAMS & WILKINS. 2002: 547

  View details for Web of Science ID 000179142702739

• The search for myocardial viability: Do Q waves help? AMERICAN HEART JOURNAL Heidenreich, P. A. 2002; 144 (5): 745-746

  View details for DOI 10.1067/mhj.2002.125626

  View details for Web of Science ID 000179252400001

  View details for PubMedID 12422139

• Regional variation in cardiac care is similar for the VA and Medicare Heidenreich, P., Deswal, A., Wray, N. LIPPINCOTT WILLIAMS & WILKINS. 2002: E110–E111

  View details for Web of Science ID 000178683600192

• Predictors of quality of VA heart failure care Heidenreich, P., Deswal, A., Kessler, D., Wray, N. LIPPINCOTT WILLIAMS & WILKINS. 2002: E110

  View details for Web of Science ID 000178683600191

• Association of renal insufficiency with treatment and outcomes after myocardial infarction in elderly patients ANNALS OF INTERNAL MEDICINE Shlipak, M. G., Heidenreich, P. A., Noguchi, H., Chertow, G. M., Browner, W. S., McClellan, M. B. 2002; 137 (7): 555-562

  Abstract

  Patients with end-stage renal disease are known to have decreased survival after myocardial infarction, but the association of less severe renal dysfunction with survival after myocardial infarction is unknown.To determine how patients with renal insufficiency are treated during hospitalization for myocardial infarction and to determine the association of renal insufficiency with survival after myocardial infarction.Cohort study.All nongovernment hospitals in the United States.130 099 elderly patients with myocardial infarction hospitalized between April 1994 and July 1995.Patients were categorized according to initial serum creatinine level: no renal insufficiency (creatinine level < 1.5 mg/dL [<132 micromol/L]; n = 82 455), mild renal insufficiency (creatinine level, 1.5 to 2.4 mg/dL [132 to 212 micromol/L]; n = 36 756), or moderate renal insufficiency (creatinine level, 2.5 to 3.9 mg/dL [221 to 345 micromol/L]; n = 10 888). Vital status up to 1 year after discharge was obtained from Social Security records.Compared with patients with no renal insufficiency, patients with moderate renal insufficiency were less likely to receive aspirin, beta-blockers, thrombolytic therapy, angiography, and angioplasty during hospitalization. One-year mortality was 24% in patients with no renal insufficiency, 46% in patients with mild renal insufficiency, and 66% in patients with moderate renal insufficiency (P < 0.001). After adjustment for patient and treatment characteristics, mild (hazard ratio, 1.68 [95% CI, 1.63 to 1.73]) and moderate (hazard ratio, 2.35 [CI, 2.26 to 2.45]) renal insufficiency were associated with substantially elevated risk for death during the first month of follow-up. This increased mortality risk continued until 6 months after myocardial infarction.Renal insufficiency was an independent risk factor for death in elderly patients after myocardial infarction. Targeted interventions may be needed to improve treatment for this high-risk population.

  View details for Web of Science ID 000178355100001

  View details for PubMedID 12353942

• Overview of randomized trials of antiarrhythmic drugs and devices for the prevention of sudden cardiac death AMERICAN HEART JOURNAL Heidenreich, P. A., Keeffe, B., McDonald, K. M., Hlatky, M. A. 2002; 144 (3): 422-430

  Abstract

  Sudden cardiac death is a prominent feature of the natural history of heart disease. The efficacy of antiarrhythmic drugs and devices in preventing sudden death and reducing total mortality is uncertain.We reviewed randomized trials and quantitative overviews of type I and type III antiarrhythmic drugs. We also reviewed the randomized trials of implantable cardioverter defibrillators and combined these outcomes in a quantitative overview.Randomized trials of type I antiarrhythmic agents used as secondary prevention after myocardial infarction show an overall 21% increase in mortality rate. Randomized trials of amiodarone suggest a 13% to 19% decrease in mortality rate, and sotalol has been effective in several small trials. Trials of pure type III agents, however, have shown no mortality benefit. An overview of implantable defibrillator trials shows a 24% reduction in mortality rate (CI 15%-33%) compared with alternative therapy, most often amiodarone.Amiodarone is effective in reducing the total mortality rate by 13% to 19%, and the implantable defibrillator reduces the mortality rate by a further 24%.

  View details for DOI 10.1067/mhj.2002.125499

  View details for Web of Science ID 000178086800009

  View details for PubMedID 12228778

• Effect of risk stratification on cost-effectiveness of the implantable cardioverter defibrillator AMERICAN HEART JOURNAL Owens, D. K., Sanders, G. D., Heidenreich, P. A., McDonald, K. M., Hlatky, M. A. 2002; 144 (3): 440-448

  Abstract

  Implantable cardioverter defibrillators (ICDs) effectively prevent sudden cardiac death, but selection of appropriate patients for implantation is complex. We evaluated whether risk stratification based on risk of sudden cardiac death alone was sufficient to predict the effectiveness and cost-effectiveness of the ICD.We developed a Markov model to evaluate the cost-effectiveness of ICD implantation compared with empiric amiodarone treatment. The model incorporated mortality rates from sudden and nonsudden cardiac death, noncardiac death and costs for each treatment strategy. We based our model inputs on data from randomized clinical trials, registries, and meta-analyses. We assumed that the ICD reduced total mortality rates by 25%, relative to use of amiodarone.The relationship between cost-effectiveness of the ICD and the total annual cardiac mortality rate is U-shaped; cost-effectiveness becomes unfavorable at both low and high total cardiac mortality rates. If the annual total cardiac mortality rate is 12%, the cost-effectiveness of the ICD varies from $36,000 per quality-adjusted life-year (QALY) gained when the ratio of sudden cardiac death to nonsudden cardiac death is 4 to $116,000 per QALY gained when the ratio is 0.25.The cost-effectiveness of ICD use relative to amiodarone depends on total cardiac mortality rates as well as the ratio of sudden to nonsudden cardiac death. Studies of candidate diagnostic tests for risk stratification should distinguish patients who die suddenly from those who die nonsuddenly, not just patients who die suddenly from those who live.

  View details for DOI 10.1067/mhj.2002.125501

  View details for Web of Science ID 000178086800011

  View details for PubMedID 12228780

• Task force #2--the cost of prevention: can we afford it? Can we afford not to do it? 33rd Bethesda Conference. Journal of the American College of Cardiology Krumholz, H. M., Weintraub, W. S., Bradford, W. D., Heidenreich, P. A., Mark, D. B., Paltiel, A. D. 2002; 40 (4): 603-615

  View details for PubMedID 12204490

• Task force #2 - The cost of prevention: Can we afford it? Can we afford not to do it? 33rd Bethesda Conference on Preventive Cardiology Krumholz, H. M., Weintraub, W. S., Bradford, W. D., Heidenreich, P. A., Mark, D. B., Paltiel, A. D. ELSEVIER SCIENCE INC. 2002: 603–15

  View details for Web of Science ID 000177474000004

• Racial and sex differences in refusal of coronary angiography AMERICAN JOURNAL OF MEDICINE Heidenreich, P. A., Shlipak, M. G., Geppert, J., McClellan, M. 2002; 113 (3): 200-207

  Abstract

  To determine the effect of patient refusal on racial and sex differences in the use of coronary angiography and in outcomes among elderly patients with acute myocardial infarction.We included Medicare beneficiary patients admitted to hospitals performing coronary angiography from February 1994 through July 1995. In-hospital use and refusal of coronary angiography were determined, and adjusted for patient, hospital, and physician characteristics.Of 124,691 patients, 53,671 (43%) underwent angiography during hospitalization and 2881 (2.3%) refused. Patients refusing angiography were more likely to be female (odds ratio [OR] = 1.37; 95% confidence interval [CI]: 1.23 to 1.53), black (OR = 1.26 vs. whites; 95% CI: 1.02 to 1.56), and older (OR = 2.25 per 10-year increase; 95% CI: 2.05 to 2.43) than patients who underwent angiography. Angiography use was lower in blacks (OR = 0.78; 95% CI: 0.72 to 0.83) than in whites, and lower in women (OR = 0.83; 95% CI: 0.80 to 0.86) than in men. Increased refusal explained 6% (95% CI: -3% to 15%) of the difference in angiography use between whites and blacks, and 16% (95% CI: 10% to 22%) of the difference between men and women. After adjustment for patient characteristics, refusal of angiography was not associated with worse survival at 1 year (OR = 0.99; 95% CI: 0.82 to 1.20).Among Medicare beneficiaries, elderly female and black patients are more likely to refuse angiography than are male and white patients. However, patient refusal is uncommon and accounts for only a small fraction of the racial and sex differences in use of angiography after myocardial infarction.

  View details for Web of Science ID 000177717900004

  View details for PubMedID 12208378

• Increased risk of colorectal neoplasia in patients with primary sclerosing cholangitis and ulcerative colitis: a meta-analysis GASTROINTESTINAL ENDOSCOPY Soetikno, R. M., Lin, O. S., Heidenreich, P. A., Young, H. S., Blackstone, M. O. 2002; 56 (1): 48-54

  Abstract

  Published data on the risk of colorectal neoplasia in patients with ulcerative colitis with and without primary sclerosing cholangitis are conflicting. A meta-analysis was performed to synthesize available publications and to compare the risk of colorectal neoplasia in patients with ulcerative colitis with and without primary sclerosing cholangitis.By using MEDLINE and manual search methods, studies were identified that compared the risk of colorectal neoplasia (dysplasia and carcinoma) in patients with ulcerative colitis with and without primary sclerosing cholangitis. In addition, citations were reviewed in relevant articles and proceedings from gastroenterology meetings, and investigators were contacted when data were incomplete. The summary odds ratio (OR) was then calculated for the risk for patients with ulcerative colitis and primary sclerosing cholangitis of having colorectal neoplasia develop compared with that of patients with ulcerative colitis without primary sclerosing cholangitis.Eleven studies met all eligibility criteria for the meta-analysis. Patients with ulcerative colitis and primary sclerosing cholangitis are at increased risk of colorectal dysplasia and carcinoma compared with patients with ulcerative colitis alone; OR 4.79: 95% CI [3.58, 6.41] with the Mantel-Haenszel method, and OR 5.11: 95% CI [3.15, 8.29] with the Der Simonian and Laird method. This increased risk is present even when the risk of colorectal carcinoma alone is considered; OR 4.09: 95% CI [2.89, 5.76] and OR 4.26: 95% CI [2.80, 6.48] by using, respectively, the Mantel-Haenszel and the Der Simonian and Laird methods.Patients with ulcerative colitis and primary sclerosing cholangitis have a significantly higher risk for the development of colorectal neoplasia than patients with ulcerative colitis but not primary sclerosing cholangitis. More intensive colonoscopic surveillance should be considered for patients with ulcerative colitis and primary sclerosing cholangitis.

  View details for DOI 10.1067/mge.2002.125367

  View details for Web of Science ID 000176579800007

  View details for PubMedID 12085034

• Association of medical school training and quality of myocardial infarction care Heidenreich, P., McClellan, M., Kessler, D. F. ELSEVIER SCIENCE INC. 2002: 436A

  View details for Web of Science ID 000174106701961

• Racial differences in endocarditis treatment and outcome Heidenreich, P. A., Cabell, C. H., Engemann, J. J., Fowler, V. G., McClellan, M. ELSEVIER SCIENCE INC. 2002: 425A-426A

  View details for Web of Science ID 000174106701912

• Strategies to improve guideline adherence: A randomized clinical trial Ansari, M. N., Shlipak, M. G., Heidenreich, P. A., Massie, B. M. ELSEVIER SCIENCE INC. 2002: 453A

  View details for Web of Science ID 000174106702037

• Racial and gender differences in refusal of coronary angiography Heidenreich, P., Shlipak, M., Geppert, J., McClellan, M. ELSEVIER SCIENCE INC. 2002: 453A

  View details for Web of Science ID 000174106702039

• Examining the concordance between patient and physician assessments of health status in heart failure patients Conard, M. W., Spertus, J. A., Heidenreich, P., Peterson, E., Poston, W. S., Weintraub, W. ELSEVIER SCIENCE INC. 2002: 461A

  View details for Web of Science ID 000174106702073

• American College of Cardiology key data elements and definitions for measuring the clinical management and outcomes of patients with acute coronary syndromes - A report of the American College of Cardiology Task Force on Clinical Data Standards (Acute Coronary Syndromes Writing Committee) JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Cannon, C. P., Battler, A., Brindis, R. G., Cox, J. L., Ellis, S. G., Every, N. R., Flaherty, J. T., Harrington, R. A., Krumholz, H. M., Simoons, M. L., Van de Werf, F. J., Weintraub, W. S., Mitchell, K. R., Morrisson, S. L., Brandis, R. G., Anderson, H. V., Cannom, D. S., Chitwood, W. R., Cigarroa, J. E., Collins-Nakai, R. L., Ellis, S. G., Gibbons, R. J., Grover, F. L., Heidenreich, P. A., Khandheria, B. K., Knoebel, S. B., Krumholz, H. L., Malenka, D. J., Mark, D. B., McKay, C. R., Passamani, E. R., Radford, M. J., Riner, R. N., Schwartz, J. B., Shaw, R. E., Shemin, R. J., Van Fossen, D. B., Verrier, E. D., Watkins, M. W., Phoubandith, D. R., Furnelli, T. 2001; 38 (7): 2114-2130

  View details for Web of Science ID 000172458000051

  View details for PubMedID 11738323

• Potential cost-effectiveness of prophylactic use of the implantable cardioverter defibrillator or amiodarone after myocardial infarction ANNALS OF INTERNAL MEDICINE Sanders, G. D., Hlatky, M. A., Every, N. R., McDonald, K. M., Heidenreich, P. A., Parsons, L. S., Owens, D. K. 2001; 135 (10): 870-883

  Abstract

  Clinical trials have shown that implantable cardioverter defibrillators (ICDs) improve survival in patients with sustained ventricular arrhythmias.To determine the efficacy necessary to make prophylactic ICD or amiodarone therapy cost-effective in patients with myocardial infarction.Markov model-based cost utility analysis.Survival, cardiac death, and inpatient costs were estimated on the basis of the Myocardial Infarction Triage and Intervention registry. Other data were derived from the literature.Patients with past myocardial infarction who did not have sustained ventricular arrhythmia.Lifetime.Societal.ICD or amiodarone compared with no treatment.Life-years, quality-adjusted life-years (QALYs), costs, number needed to treat, and incremental cost-effectiveness.Compared with no treatment, ICD use led to the greatest QALYs and the highest expenditures. Amiodarone use resulted in intermediate QALYs and costs. To obtain acceptable cost-effectiveness thresholds (

  View details for PubMedID 11712877

• Cost-effectiveness of radiofrequency ablation for supraventricular tachycardia. (vol 133, pg 864, 2000) ANNALS OF INTERNAL MEDICINE Cheng, C. H., Sanders, G. D., Hlatky, H. A., Heidenreich, P., McDonald, K. M., Lee, B. K. 2001; 135 (10): 933

  View details for DOI 10.7326/0003-4819-135-10-200111200-00029

  View details for Web of Science ID 000172267500024

• A randomized trial of attaching clinical reminders to echocardiography reports to improve ACE inhibitor use. Heidenreich, P. A., Alloggiamento, T., Fadel, B., Atwood, J. E. LIPPINCOTT WILLIAMS & WILKINS. 2001: 839

  View details for Web of Science ID 000171895003890

• The prognostic value of troponin in patients with non-ST elevation acute coronary syndromes: A meta-analysis JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Heidenreich, P. A., Alloggiamento, T., Melsop, K., McDonald, K. M., Go, A. S., Hlatky, M. A. 2001; 38 (2): 478-485

  Abstract

  This study was designed to compare the prognostic value of an abnormal troponin level derived from studies of patients with non-ST elevation acute coronary syndromes (ACS).Risk stratification for patients with suspected ACS is important for determining need for hospitalization and intensity of treatment.We identified clinical trials and cohort studies of consecutive patients with suspected ACS without ST-elevation from 1966 through 1999. We excluded studies limited to patients with acute myocardial infarction and studies not reporting mortality or troponin results.Seven clinical trials and 19 cohort studies reported data for 5,360 patients with a troponin T test and 6,603 with a troponin I test. Patients with positive troponin (I or T) had significantly higher mortality than those with a negative test (5.2% vs. 1.6%, odds ratio [OR] 3.1). Cohort studies demonstrated a greater difference in mortality between patients with a positive versus negative troponin I (8.4% vs. 0.7%, OR 8.5) than clinical trials (4.8% if positive, 2.1% if negative, OR 2.6, p = 0.01). Prognostic value of a positive troponin T was also slightly greater for cohort studies (11.6% mortality if positive, 1.7% if negative, OR 5.1) than for clinical trials (3.8% if positive, 1.3% if negative, OR 3.0, p = 0.2)In patients with non-ST elevation ACS, the short-term odds of death are increased three- to eightfold for patients with an abnormal troponin test. Data from clinical trials suggest a lower prognostic value for troponin than do data from cohort studies.

  View details for Web of Science ID 000170205800026

  View details for PubMedID 11499741

• Medical therapy or coronary artery bypass graft surgery for chronic stable angina: An update using decision analysis AMERICAN JOURNAL OF MEDICINE Kwok, Y. S., Kim, C., Heidenreich, P. A. 2001; 111 (2): 89-95

  Abstract

  Randomized trials comparing medical and surgical therapies for the treatment of chronic stable angina were completed in the early 1980s. Therapies developed since then have decreased mortality and myocardial infarction rates from coronary artery disease. Using decision analysis and incorporating current recommendations for treatment, we simulated a trial comparing coronary artery bypass graft surgery and medical therapy.A Markov decision analysis model was constructed to compare the 5-year and 10-year outcomes of a simulated trial of medical therapy versus bypass surgery for stable chronic angina. Baseline data were obtained from a meta-analysis of trials comparing the two treatments. Data on risk reduction from contemporary therapies were obtained from randomized trials and meta-analyses.All subgroups experienced modest gains in survival with current therapies. At 5 years, the survival rate was 90% in the medical group (an absolute gain of 6%) and 94% in the surgical group (an absolute gain of 4%). Similar results were obtained for patients with triple-vessel disease. Among patients with a low ejection fraction, the 5-year survival rate was 85% for medical patients and 92% for surgical patients. Sensitivity analyses did not substantially affect the conclusions.Advances in the treatment of chronic stable angina have improved the outcome both for patients treated initially with surgery and for those treated initially with medical therapy. The improvements were of similar magnitude in both groups, so the fundamental conclusions of the bypass trials are unchanged.

  View details for Web of Science ID 000170624600001

  View details for PubMedID 11498060

• Underuse of beta-blockers following myocardial infarction - Reply JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Phillips, K. A., Shlipak, M. G., Coxson, P., Goldman, L., Heidenreich, P. A., Weinstein, M. C., Goldman, P. A. 2001; 285 (8): 1013-1013

  View details for Web of Science ID 000167046400013

• Trends in survival following a new admission for heart failure Heidenreich, P. A., Kagay, C., McClellan, M. ELSEVIER SCIENCE INC. 2001: 502A–503A

  View details for Web of Science ID 000166914402282

• Higher doses of intracoronary adenosine are necessary for FFR-based stent optimization Fearon, W. F., Samady, H., Powers, E. R., Feldman, T., Dib, N., Tuzcu, E. M., Cleman, M. W., Chou, T. M., Cohen, D. J., Takagi, A., Luna, J., Jeremias, A., Yeung, A. C., Kern, M. J., Yock, P. G. ELSEVIER SCIENCE INC. 2001: 12A

  View details for Web of Science ID 000166914400054

• Health and economic benefits of increased beta-blocker use following myocardial infarction JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Phillips, K. A., Shlipak, M. G., Coxson, P., Heidenreich, P. A., Hunink, M. G., Goldman, P. A., Williams, L. W., Weinstein, M. C., Goldman, L. 2000; 284 (21): 2748-2754

  Abstract

  beta-blockers are underused in patients who have myocardial infarction (MI), despite the proven efficacy of these agents. New evidence indicates that beta-blockers can have benefit in patients with conditions that have been considered relative contraindications. Understanding the consequences of underuse of beta-blockers is important because of the implications for current policy debates over quality-of-care measures and Medicare prescription drug coverage.To examine the potential health and economic impact of increased use of beta-blockers in patients who have had MI.We used the Coronary Heart Disease (CHD) Policy Model, a computer-simulation Markov model of CHD in the US population, to estimate the epidemiological impact and cost-effectiveness of increased beta-blocker use from current to target levels among survivors of MI aged 35 to 84 years. Simulations included 1 cohort of MI survivors in 2000 followed up for 20 years and 20 successive annual cohorts of all first-MI survivors in 2000-2020. Mortality and morbidity from CHD were derived from published meta-analyses and recent studies. This analysis used a societal perspective.Prevented MIs, CHD mortality, life-years gained, and cost per quality-adjusted life-year (QALY) gained in 2000-2020.Initiating beta-blocker use for all MI survivors except those with absolute contraindications in 2000 and continuing treatment for 20 years would result in 4300 fewer CHD deaths, 3500 MIs prevented, and 45,000 life-years gained compared with current use. The incremental cost per QALY gained would be $4500. If this increase in beta-blocker use were implemented in all first-MI survivors annually over 20 years, beta-blockers would save $18 million and result in 72,000 fewer CHD deaths, 62,000 MIs prevented, and 447,000 life-years gained. Sensitivity analyses demonstrated that the cost-effectiveness of beta-blocker therapy would always be less than $11,000 per QALY gained, even under unfavorable assumptions, and may even be cost saving. Restricting beta-blockers only to ideal patients (those without absolute or relative contraindications) would reduce the epidemiological impact of beta-blocker therapy by about 60%.Our simulation indicates that increased use of beta-blockers after MI would lead to impressive gains in health and would be potentially cost saving. JAMA. 2000;284:2748-2754.

  View details for Web of Science ID 000165509500029

  View details for PubMedID 11105180

• Cost-effectiveness of radiofrequency ablation for supraventricular tachycardia ANNALS OF INTERNAL MEDICINE Cheng, C. H., Sanders, G. D., Hlatky, M. A., Heidenreich, P., McDonald, K. M., Lee, B. K., Larson, M. S., Owens, D. K. 2000; 133 (11): 864-876

  Abstract

  Radiofrequency ablation is an established but expensive treatment option for many forms of supraventricular tachycardia. Most cases of supraventricular tachycardia are not life-threatening; the goal of therapy is therefore to improve the patient's quality of life.To compare the cost-effectiveness of radiofrequency ablation with that of medical management of supraventricular tachycardia.Markov model.Costs were estimated from a major academic hospital and the literature, and treatment efficacy was estimated from reports from clinical studies at major medical centers. Probabilities of clinical outcomes were estimated from the literature. To account for the effect of radiofrequency ablation on quality of life, assessments by patients who had undergone the procedure were used.Cohort of symptomatic patients who experienced 4.6 unscheduled visits per year to an emergency department or a physician's office while receiving long-term drug therapy for supraventricular tachycardia.Patient lifetime.Societal.Initial radiofrequency ablation, long-term antiarrhythmic drug therapy, and treatment of acute episodes of arrhythmia with antiarrhythmic drugs.Costs, quality-adjusted life-years, life-years, and marginal cost-effectiveness ratios.Among patients who have monthly episodes of supraventricular tachycardia, radiofrequency ablation was the most effective and least expensive therapy and therefore dominated the drug therapy options. Radiofrequency ablation improved quality-adjusted life expectancy by 3.10 quality-adjusted life-years and reduced lifetime medical expenditures by $27 900 compared with long-term drug therapy. Long-term drug therapy was more effective and had lower costs than episodic drug therapy.The findings were highly robust over substantial variations in assumptions about the efficacy and complication rate of radiofrequency ablation, including analyses in which the complication rate was tripled and efficacy was decreased substantially.Radiofrequency ablation substantially improves quality of life and reduces costs when it is used to treat highly symptomatic patients. Although the benefit of radiofrequency ablation has not been studied in less symptomatic patients, a small improvement in quality of life is sufficient to give preference to radiofrequency ablation over drug therapy.

  View details for PubMedID 11103056

• Does physician specialty affect the survival of elderly patients with myocardial infarction? HEALTH SERVICES RESEARCH Frances, C. D., Shlipak, M. G., Noguchi, H., Heidenreich, P. A., McClellan, M. 2000; 35 (5): 1093-1116

  Abstract

  To determine the effect of treatment by a cardiologist on mortality of elderly patients with acute myocardial infarction (AMI, heart attack), accounting for both measured confounding using risk-adjustment techniques and residual unmeasured confounding with instrumental variables (IV) methods.Medical chart data and longitudinal administrative hospital records and death records were obtained for 161,558 patients aged > or =65 admitted to a nonfederal acute care hospital with AMI from April 1994 to July 1995. Our principal measure of significant cardiologist treatment was whether a patient was admitted by a cardiologist. We use supplemental data to explore whether our analysis would differ substantially using alternative definitions of significant cardiologist treatment.This retrospective cohort study compared results using least squares (LS) multivariate regression with results from IV methods that accounted for additional unmeasured patient characteristics. Primary outcomes were 30-day and one-year mortality, and secondary outcomes included treatment with medications and revascularization procedures.Medical charts for the initial hospital stay of each AMI patient underwent a comprehensive abstraction, including dates of hospitalization, admitting physician, demographic characteristics, comorbid conditions, severity of clinical presentation, electrocardiographic and other diagnostic test results, contraindications to therapy, and treatments before and after AMI.Patients admitted by cardiologists had fewer comorbid conditions and less severe AMIs. These patients had a 10 percent (95 percent CI: 9.5-10.8 percent) lower absolute mortality rate at one year. After multivariate adjustment with LS regression, the adjusted mortality difference was 2 percent (95 percent CI: 1.4-2.6 percent). Using IV methods to provide additional adjustment for unmeasured differences in risk, we found an even smaller, statistically insignificant association between physician specialty and one-year mortality, relative risk (RR) 0.96 (0.88-1.04). Patients admitted by a cardiologist were also significantly more likely to have a cardiologist consultation within the first day of admission and during the initial hospital stay, and also had a significantly larger share of their physician bills for inpatient treatment from cardiologists. IV analysis of treatments showed that patients treated by cardiologists were more likely to undergo revascularization procedures and to receive thrombolytic therapy, aspirin, and calcium channel-blockers, but less likely to receive beta-blockers.In a large population of elderly patients with AMI, we found significant treatment differences but no significant incremental mortality benefit associated with treatment by cardiologists.

  View details for Web of Science ID 000165914100004

  View details for PubMedID 11130812

  View details for PubMedCentralID PMC1089165

• Transesophageal echocardiography (TEE) in the critical care patient. Cardiology clinics Heidenreich, P. A. 2000; 18 (4): 789-?

  Abstract

  Critically ill patients often pose special diagnostic problems to the clinician, intensified by limited physical examination findings and difficulty in transportation to imaging suites. Mechanical ventilation and the limited ability to position the patient make transthoracic echocardiography difficult. Transesophageal echocardiographic (TEE) imaging, however, is well suited to the critical care patient and is frequently used to evaluate hemodynamic status, the presence of vegetations, a cardioembolic source, and an intracardiac cause of hypoxemia. Using proper precautions, TEE can be performed safely in unstable patients and frequently leads to important changes in management.

  View details for PubMedID 11236166

• Hospital characteristics and outcome for elderly patients with heart failure. Heidenreich, P. A., Kagay, C. R., McClellan, M. LIPPINCOTT WILLIAMS & WILKINS. 2000: 878

  View details for Web of Science ID 000090072304200

• Statin therapy attenuates the effect of LDL cholesterol on progression of aortic stenosis Putz, E. J., Atwood, J. E., Heidenreich, P. A. LIPPINCOTT WILLIAMS & WILKINS. 2000: 445

  View details for Web of Science ID 000090072302161

• Lack of prognostic value for cardiac troponin T and I and CKMB in patients with chronic renal failure on hemodialysis Schreiber, D. H., Petersen, J., Lafayette, R., Heidenreich, P. A. LIPPINCOTT WILLIAMS & WILKINS. 2000: 520

  View details for Web of Science ID 000090072302523

• Effects of renal insufficiency on treatment and survival after myocardial infarction in the elderly Shlipak, M. G., Heidenreich, P. A., Noguchi, H., Browner, W. S., McClellan, M. LIPPINCOTT WILLIAMS & WILKINS. 2000: 795

  View details for Web of Science ID 000090072303834

• Garlic: effects on cardiovascular risks and disease, protective effects against cancer, and clinical adverse effects. Evidence report/technology assessment (Summary) Mulrow, C., Lawrence, V., Ackermann, R., Gilbert Ramirez, G., Morbidoni, L., Aguilar, C., Arterburn, J., Block, E., Chiquette, E., Gardener, C., Harris, M., Heidenreich, P., Mullins, D., Richardson, M., Russell, N., Vickers, A., Young, V. 2000: 1-4

  View details for PubMedID 11089496

• Prediction of risk for patients with unstable angina. Evidence report/technology assessment (Summary) Heidenreich, P. A., Go, A., Melsop, K. A., Alloggiamento, T., McDonald, K. M., Hagan, V., Hastie, T., Hlatky, M. A. 2000: 1-3

  View details for PubMedID 11013605

• Costs and effectivity of treatment with tirofiban in patients with acute coronary syndromes: results from the PRISM trial Heeschen, C., Hamm, C. W., Heidenreich, P., Hlatky, M., White, H. D. W B SAUNDERS CO LTD. 2000: 218

  View details for Web of Science ID 000089136600857

• Power Doppler imaging: Initial evaluation as a screening examination for carotid artery stenosis RADIOLOGY Bluth, E. I., Sunshine, J. H., Lyons, J. B., Beam, C. A., Troxclair, L. A., Althans-Kopecky, L., Crewson, P. E., Sullivan, M. A., Smetherman, D. H., Heidenreich, P. A., Neiman, H. L., Burkhardt, J. H. 2000; 215 (3): 791-800

  Abstract

  To evaluate power Doppler imaging as a possible screening examination for carotid artery stenosis.In the principal pilot study, a prospective, blinded comparison of power Doppler imaging with duplex Doppler imaging, the reference-standard method, was conducted in 100 consecutive patients routinely referred for carotid artery imaging at a large, private multispecialty clinic. In the validation pilot study, a prospective, blinded comparison of power Doppler imaging with digital subtraction angiography, the reference-standard method, was conducted in 20 consecutive patients routinely referred at a teaching hospital. Using conservative assumptions, the authors performed cost-effectiveness analysis.Power Doppler imaging produced diagnostic-quality images in 89% of patients. When the images of the patients with nondiagnostic examinations were regarded as positive, power Doppler imaging had an area under the receiver operating characteristic curve, A(z), of 0.87, sensitivity of 70%, and specificity of 91%. The validation study results were very similar. The cost-effectiveness of screening and, as indicated, duplex Doppler imaging as the definitive diagnostic examination and endarterectomy was $47,000 per quality-adjusted life-year.The A(z) value for power Doppler imaging compares well with that for mammography, a generally accepted screening examination, and with most other imaging examinations. Power Doppler imaging is likely to be a reasonably accurate and cost-effective screening examination for carotid artery stenosis in asymptomatic populations.

  View details for Web of Science ID 000087247000026

  View details for PubMedID 10831701

• What a physician needs to know about cost-effectiveness. Cardiology in review Heidenreich, P. A., Lee, T. T. 2000; 8 (2): 96-102

  Abstract

  The cost of medical care in the United States continues to spiral upward, partly as a result of new technological breakthroughs that promise improved length of life and quality of life for patients. But how good are these treatments in everyday practice? How do we make policies for adopting innovations that improve outcome but also increase costs? Cost-effectiveness studies are designed to answer these questions. They reveal important aspects of a particular medical decision and inform treatment choices by systematically analyzing the relationships between the costs and outcomes of alternative health care interventions. This article provides an introduction to the field of cost-effectiveness analysis and describes an approach to interpreting the rapidly proliferating cost-effectiveness literature.

  View details for PubMedID 11174880

• The prognostic value of troponin in patients with non-ST-elevation acute coronary syndromes: A meta-analysis Heidenreich, P. A., Alloggiamento, T., Hagan, Melsop, K., McDonald, K. M., Go, A. S., Hlatky, M. A. ELSEVIER SCIENCE INC. 2000: 267A

  View details for Web of Science ID 000085209701028

• Effect of managed care market share on treatment of fee-for service patients with myocardial infarction Heidenreich, P. A., McClellan, M., Frances, C. D., Baker, L. C. ELSEVIER SCIENCE INC. 2000: 268A

  View details for Web of Science ID 000085209701030

• Cost-effective use of the Duke Treadmill Score Heidenreich, P. A., Froelicher, V. F., Garber, A. M. ELSEVIER SCIENCE INC. 2000: 210A

  View details for Web of Science ID 000085209700809

• Long-term outcomes and resource utilization after admission for unstable angina Heidenreich, P. A., Parsons, L., Every, N. R. LIPPINCOTT WILLIAMS & WILKINS. 1999: 318

  View details for Web of Science ID 000083417101665

• Lessons learned from studies of the standard exercise ECG test CHEST Froelicher, V. F., Fearon, W. F., Ferguson, C. M., Morise, A. P., Heidenreich, P., West, J., Atwood, J. E. 1999; 116 (5): 1442-1451

  View details for PubMedID 10559110

• An evaluation of beta-blockers, calcium antagonists, nitrates, and alternative therapies for stable angina. Evidence report/technology assessment (Summary) Heidenreich, P. A., McDonald, K. M., Hastie, T., Fadel, B., Hagan, V., Lee, B. K., Hlatky, M. A. 1999: 1-2

  View details for PubMedID 11925969

• Effect of a home monitoring system on hospitalization and resource use for patients with heart failure AMERICAN HEART JOURNAL Heidenreich, P. A., Ruggerio, C. M., Massie, B. M. 1999; 138 (4): 633-640

  Abstract

  Heart failure has a large medical and economic impact on the elderly. Past studies have shown that high-intensity multidisciplinary interventions at academic medical centers can reduce future hospitalizations. Our pilot study examined the effects of a low-intensity monitoring program on hospitalizations and cost of care for patients with heart failure treated by community physicians.We enrolled 68 patients with heart failure (mean age 73 +/- 13 years, 53% male) monitored by 31 physicians in a multidisciplinary program of patient education, daily self-monitoring, and physician notification of abnormal weight gain, vital signs, and symptoms. Comparisons of medical claims were made between the patients who received the intervention and a control group of 86 patients matched to the intervention group on medical claims during the preceding year.Compared with the prior year, medical claims per year decreased in the intervention group ($8500 +/- $13,000 to $7400 +/- $11,400), whereas they increased in the control group ($9200 +/- $15,000 to $18,800 +/- $34,000, P <.05). Similar differences were observed for hospitalizations and total hospital days. The program's effectiveness was unrelated to age, sex, or type of left ventricular dysfunction.These findings suggest that a multidisciplinary program of patient education, monitoring, and physician notification can reduce resource use in patients with heart failure managed in a community setting.

  View details for Web of Science ID 000082958200011

  View details for PubMedID 10502207

• Echocardiography in patients with suspected endocarditis: A cost-effectiveness analysis AMERICAN JOURNAL OF MEDICINE Heidenreich, P. A., Masoudi, F. A., Maini, B., Chou, T. M., Foster, E., Schiller, N. B., Owens, D. K. 1999; 107 (3): 198-208

  Abstract

  We sought to determine the appropriate use of echocardiography for patients with suspected endocarditis.We constructed a decision tree and Markov model using published data to simulate the outcomes and costs of care for patients with suspected endocarditis.Transesophageal imaging was optimal for patients who had a prior probability of endocarditis that is observed commonly in clinical practice (4% to 60%). In our base-case analysis (a 45-year-old man with a prior probability of endocarditis of 20%), use of transesophageal imaging improved quality-adjusted life expectancy (QALYs) by 9 days and reduced costs by $18 per person compared with the use of transthoracic echocardiography. Sequential test strategies that reserved the use of transesophageal echocardiography for patients who had an inadequate transthoracic study provided similar QALYs compared with the use of transesophageal echocardiography alone, but cost $230 to $250 more. For patients with prior probabilities of endocarditis greater than 60%, the optimal strategy is to treat for endocarditis without reliance on echocardiography for diagnosis. Patients with a prior probability of less than 2% should receive treatment for bacteremia without imaging. Transthoracic imaging was optimal for only a narrow range of prior probabilities (2% or 3%) of endocarditis.The appropriate use of echocardiography depends on the prior probability of endocarditis. For patients whose prior probability of endocarditis is 4% to 60%, initial use of transesophageal echocardiography provides the greatest quality-adjusted survival at a cost that is within the range for commonly accepted health interventions.

  View details for Web of Science ID 000082557100003

  View details for PubMedID 10492311

• Intraoperative gamma-probes: Performance of commercially available systems - A comparison Kopp, J., Wengenmair, H., Vogt, H., Heidenreich, P. SPRINGER VERLAG. 1999: S59

  View details for Web of Science ID 000079696000028

• Evaluation of risk in patients with chest pain presenting to the emergency department AMERICAN JOURNAL OF MEDICINE Heidenreich, P. A., Hlatky, M. A. 1999; 106 (3): 378-379

  View details for Web of Science ID 000079310300018

  View details for PubMedID 10190390

• Trends in technology use for acute myocardial infarction Heidenreich, P. A., McClellan, M. LIPPINCOTT WILLIAMS & WILKINS. 1998: 134

  View details for Web of Science ID 000076594400735

• Impact of echocardiography on antibiotic prophylaxis with suspected mitral valve prolapse - Reply AMERICAN JOURNAL OF MEDICINE Heidenreich, P. A., Foster, E. 1998; 104 (5): 509-510

  View details for Web of Science ID 000073882100025

• Prevention of hospitalizations for heart failure with an interactive home monitoring program 69th Annual Scientific Session of the American-Heart-Association Shah, N. B., Der, E., Ruggerio, C., Heidenreich, P. A., Massie, B. M. MOSBY-ELSEVIER. 1998: 373–78

  Abstract

  Congestive heart failure is the most common cause of hospitalization for the older population. A previous study demonstrated that rehospitalizations, undertaken by 30% to 50% of elderly patients, can be prevented with intensive multidisciplinary intervention. A pilot study was designed to determine whether a less intensive program with patient education materials, automated reminders for medication compliance, self-monitoring of daily weights and vital signs, and facilitated telephone communication with a nurse-monitor could reduce hospitalizations and whether this benefit could be extended to younger outpatients. Twenty-seven male patients (mean age 62 years) with New York Heart Association class II to IV congestive heart failure caused by dilated cardiomyopathy underwent follow-up with an independent service, which provided the primary cardiologist with information concerning changes in vital signs or symptoms. The number of hospitalizations and hospital days during the mean value of 8.5 months in the program was compared patient by patient with the number during the equivalent period before entrance in the program. The number of hospitalizations for cardiovascular diagnoses and hospital days was reduced from 0.6 to 0.2 (p = 0.09) per patient year of follow-up and 7.8 to 0.7 days per patient per year (p < 0.05). Hospitalizations for all causes fell from 0.8 to 0.4 per patient per year (p = not significant) and 9.5 to 0.8 days per patient per year (p < 0.05). The greatest absolute and relative benefit was observed among patients with more severe congestive heart failure. The most frequent indication for intervention was an increase in weight, which was managed with adjustment of diuretic dosages. This preliminary experience suggests that close telephone monitoring by personnel from an independent service can prevent hospitalizations for heart failure among both recently discharged patients and ambulatory outpatients and among both elderly and middle-aged persons.

  View details for Web of Science ID 000072371100002

  View details for PubMedID 9506321

• Reduced hospitalizations and health care costs by an interactive home monitoring program for heart failure patients Heidenreich, P. A., Ruggerio, C., Massie, B. M. ELSEVIER SCIENCE INC. 1998: 115A

  View details for DOI 10.1016/S0735-1097(97)84205-2

  View details for Web of Science ID 000071920600474

• Design of a modular, extensible decision support system for arrhythmia therapy JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION Cheng, C. H., Sanders, G. D., McDonald, K. M., Heidenreich, P. A., Hlatky, M. A., Owens, D. K. 1998: 693-697

  Abstract

  We developed a decision-support system for evaluation of treatment alternatives for supraventricular and ventricular arrhythmias. The system uses independent decision models that evaluate the costs and benefits of treatment for recurrent atrioventricular-node reentrant tachycardia (AVNRT), and of therapies to prevent sudden cardiac death (SCD) in patients at risk for life-threatening ventricular arrhythmias. Each of the decision models is accessible through a web-based interface that enables remote users to browse the model's underlying evidence and to perform analyses of effectiveness, cost effectiveness, and sensitivity to input variables. Because the web-based interface is independent of the models, we can extend the functionality of the system by adding decision models. This system illustrates that the use of a library of web-accessible decision models provides decision support economically to widely dispersed users.

  View details for PubMedID 9929308

• Effect of HMO penetration on resource utilization following myocardial infarction Heidenreich, P. A., Baker, L. C., McClellan, M. B. AMER HEART ASSOC. 1997: 3148

  View details for Web of Science ID A1997YC88003129

• The role of carotid bruit in screening for carotid stenosis - Reply ANNALS OF INTERNAL MEDICINE Lee, T. T., Heidenreich, P. A., Solomon, N. A. 1997; 127 (8): 657-658

  View details for DOI 10.7326/0003-4819-127-8_Part_1-199710150-00033

  View details for Web of Science ID A1997YB41900029

• Effect of beta-blockade on mortality in patients with heart failure: A meta-analysis of randomized clinical trials Seminar Series on Meta-Analysis Heidenreich, P. A., Lee, T. T., Massie, B. M. ELSEVIER SCIENCE INC. 1997: 27–34

  Abstract

  We sought to evaluate the current evidence for an effect of beta-blockade treatment on mortality in patients with congestive heart failure (CHF).Although numerous small studies have suggested a benefit with beta-blocker therapy in patients with heart failure, a clear survival benefit has not been demonstrated. A recent combined analysis of several studies with the alpha- and beta-adrenergic blocking agent carvedilol demonstrated a significant survival advantage; however, the total number of events was small. Furthermore, it is unclear if previous studies with other beta-blockers are consistent with this finding.Randomized clinical trials of beta-blockade treatment in patients with CHF from January 1975 through February 1997 were identified using a MEDLINE search and a review of reports from scientific meetings. Studies were included if mortality was reported during 3 or more months of follow-up.We identified 35 reports, 17 of which met the inclusion criteria. These studies included 3,039 patients with follow-up ranging from 3 months to 2 years. Beta-blockade was associated with a trend toward mortality reduction in 13 studies. When all 17 reports were combined, beta-blockade significantly reduced all-cause mortality (random effect odds ratio [OR] 0.69, 95% confidence interval [CI] 0.54 to 0.88). A trend toward greater treatment effect was noted for nonsudden cardiac death (OR 0.58, 95% CI 0.40 to 0.83) compared with sudden cardiac death (OR 0.84, 95% CI 0.59 to 1.2). Similar reductions in mortality were observed for patients with ischemic (OR 0.69, 95% CI 0.49 to 0.98) and nonischemic cardiomyopathy (OR 0.69, 95% CI 0.47 to 0.99). The survival benefit was greater for trials of the drug carvedilol (OR 0.54, 95% CI 0.36 to 0.81) than for noncarvedilol drugs (OR 0.82, 95% CI 0.60 to 1.12); however, the difference did not reach statistical significance (p = 0.10).Pooled evidence suggests that beta-blockade reduces all-cause mortality in patients with CHF. Additional trials are required to determine whether carvedilol differs in its effect from other agents.

  View details for Web of Science ID A1997XG02100004

  View details for PubMedID 9207617

• The clinical impact of echocardiography on antibiotic prophylaxis use in patients with suspected mitral valve prolapse AMERICAN JOURNAL OF MEDICINE Heidenreich, P. A., Bear, J., Browner, W., Foster, E. 1997; 102 (4): 337-343

  Abstract

  To determine the impact of echocardiography on the use of antibiotic prophylaxis in patients with suspected mitral valve prolapse (MVP).We evaluated 147 consecutive patients who were referred for "rule out mitral valve prolapse" to a university hospital echocardiography laboratory. Chart review and phone contact were used to determine the demographic characteristics of the patients; past diagnosis of MVP, symptoms, and exam at referral; practice specialty of referring MD; echocardiographic findings; and change in prophylaxis usage as a result of the echocardiogram (ECHO). Prophylaxis was considered to be indicated if the echocardiogram demonstrated MVP with at least mild regurgitation or abnormal thickening of at least one mitral leaflet.Based on the ECHO a change in antibiotic prophylaxis was indicated in 20 of 147 (14%) patients including initiation of prophylaxis in 6, and discontinuation of prophylaxis in 14. However, only 4 of 20 patients (20%) actually changed their prophylaxis habits leading to an actual yield of 4 management changes per 131 ECHOs ordered (3%). This corresponded to 1 change in management per $36,250 in hospital and physician costs. Younger age, female gender, and presence of symptoms were associated with a benign ECHO. Indications for a change in management were not significantly different between physician specialities: 18% for generalists (internal medicine and family practice), 12% for cardiologists, and 7% for other specialists, P = 0.3.In patients referred for evaluation of MVP, echocardiography infrequently resulted in changes in antibiotic prophylaxis management and was associated with significant expense.

  View details for Web of Science ID A1997XA46300004

  View details for PubMedID 9217614

• Increased risk of colorectal neoplasia in patients with primary sclerosing cholangitis and ulcerative colitis Soetikno, R. M., Heidenreich, P. A., Young, H. S., Blackstone, M. O. W B SAUNDERS CO-ELSEVIER INC. 1997: A43

  View details for Web of Science ID A1997WV41900167

• Cost-effectiveness of screening for carotid stenosis in asymptomatic persons Society-of-General-Internal-Medicine Meeting Lee, T. T., Solomon, N. A., Heidenreich, P. A., Oehlert, J., Garber, A. M. AMER COLL PHYSICIANS. 1997: 337-?

  Abstract

  The Asymptomatic Carotid Atherosclerosis Study (ACAS) showed that carotid endarterectomy was beneficial for symptom-free patients with carotid stenosis of 60% or more. This finding raises the question of whether widespread screening to identify cases of asymptomatic carotid stenosis should be implemented.To determine whether a screening program to identify cases of asymptomatic carotid stenosis would be a cost-effective strategy for stroke prevention.Cost-effectiveness analysis using published data from clinical trials.General population of asymptomatic 65-year-old men.Patients who were screened for carotid disease with duplex Doppler ultrasonography were compared with patients who were not screened. If ultrasonography found significant carotid stenosis (> or = 60%), disease was confirmed by angiography before carotid endarterectomy was done.Quality-adjusted life-years, costs, and marginal cost-effectiveness ratios.When the conditions and results of ACAS were modeled and it was assumed that the survival advantage produced by endarterectomy would last for 30 years, the lifetime marginal cost-effectiveness of screening relative to no screening was $120,000 per quality-adjusted life-year. Sensitivity analysis showed that marginal cost-effectiveness decreased to $50,000 or less per quality-adjusted life-year only under implausible conditions (for example, if a free screening instrument with perfect test characteristics was used or an asymptomatic population with a 40% prevalence of carotid stenosis was found).Surgery offers a real but modest absolute reduction in the rate of stroke at a substantial cost. A program to identify candidates for endarterectomy by screening asymptomatic populations for carotid stenosis costs more per quality-adjusted life-year than is usually considered acceptable.

  View details for Web of Science ID A1997WL10400001

  View details for PubMedID 9054277

• Cost-effectiveness of implantable cardioverter defibrillators relative to amiodarone for prevention of sudden cardiac death ANNALS OF INTERNAL MEDICINE Owens, D. K., Sanders, G. D., Harris, R. A., McDonald, K. M., Heidenreich, P. A., Dembitzer, A. D., Hlatky, M. A. 1997; 126 (1): 1-12

  Abstract

  Implantable cardioverter defibrillators (ICDs) are remarkably effective in terminating ventricular arrhythmias, but they are expensive and the extent to which they extend life is unknown. The marginal cost-effectiveness of ICDs relative to amiodarone has not been clearly established.To compare the cost-effectiveness of a third-generation implantable ICD with that of empirical amiodarone treatment for preventing sudden cardiac death in patients at high or intermediate risk.A Markov model was used to evaluate health and economic outcomes of patients who received an ICD, amiodarone, or a sequential regimen that reserved ICD for patients who had an arrhythmia during amiodarone treatment.Life-years gained, quality-adjusted life-years gained, costs, and marginal cost-effectiveness.For the base-case analysis, it was assumed that treatment with an ICD would reduce the total mortality rate by 20% to 40% at 1 year compared with amiodarone and that the ICD generator would be replaced every 4 years. In high-risk patients, if an ICD reduces total mortality by 20%, patients who receive an ICD live for 4.18 quality-adjusted life-years and have a lifetime expenditure of $88,400. Patients receiving amiodarone live for 3.68 quality-adjusted life-years and have a lifetime expenditure of $51,000. Marginal cost-effectiveness of an ICD relative to amiodarone is $74,400 per quality-adjusted life-year saved. If an ICD reduces mortality by 40%, the cost-effectiveness of ICD use is $37,300 per quality-adjusted life-year saved. Both choice of therapy (an ICD or amiodarone) and the cost-effectiveness ratio are sensitive to assumptions about quality of life.Use of an ICD will cost more than $50,000 per quality-adjusted life-year gained unless it reduces all-cause mortality by 30% or more relative to amiodarone. Current evidence does not definitively support or exclude a benefit of this magnitude, but ongoing randomized trials have sufficient statistical power to do so.

  View details for Web of Science ID A1997WA16500001

  View details for PubMedID 8992917

• Prediction of outcome for critically ill patients with unexplained hypotension CRITICAL CARE MEDICINE Heidenreich, P. A., Foster, E., Cohen, N. H. 1996; 24 (11): 1835-1840

  Abstract

  To determine the clinical variables that affect the prognosis of critically ill patients with sustained unexplained hypotension. A further goal was to develop a prognostic scoring system based on clinical data available at the onset of hypotension.Prospective cohort study.The intensive care units (ICUs) of an academic medical center.One hundred one adult ICU patients with sustained (> 60 mins) unexplained hypotension. Using the initial 50 patients (derivation set), a prognostic score was developed that was then tested in the next 51 patients (validation set).NoneThe main outcome variable was death or hospital discharge. The overall hospital mortality in the combined sets was 58%. Using a multivariable model we identified three independent (p < .05) predictors of hospital mortality, including the Acute Physiology and Chronic Health Evaluation (APACHE) II score at the time of hypotension, the time from hospital admission to hypotensive episode, and hospital admission for surgery or treatment of malignancy. These variables were weighted and combined to create a Hypotension Score which separated patients in the combined sets into three prognostic groups: a) Hypotension Score of < 40, mortality 7%, (n = 27); b) Hypotension Score of 40 to 64, mortality 70%, (n = 50); and c) Hypotension Score of > or = 65, mortality 92%, (n = 24). The area under the receiver operating characteristic curve was .85 for the derivation set and .83 for the validation set vs. .76 for the APACHE II score alone.The prognosis of hypotension in the critical care setting is highly variable, but can be predicted from patient characteristics.

  View details for Web of Science ID A1996VT11600013

  View details for PubMedID 8917034

• Increased survival of AIDS patients with heart disease within 10 years? Response CIRCULATION Heidenreich, P. A., Eisenberg, M. J., Schiller, N. B., Cheitlin, M. D. 1996; 94 (9): 2313

  View details for Web of Science ID A1996VN75400059

• The effect of beta-blockade on survival in congestive heart failure: A meta-analysis. Heidenreich, P. A., Lee, T. T., Massie, B. M. AMER HEART ASSOC. 1996: 3884

  View details for Web of Science ID A1996VN11903875

• Echocardiograghic score as a predictor of in-hospital cost in patients undergoing percutaneous balloon mitral valvuloplasty AMERICAN JOURNAL OF CARDIOLOGY Eisenberg, M. J., Ballal, R., Heidenreich, P. A., Brown, K. J., Griffin, B. P., Casale, P. N., Tuzcu, E. M. 1996; 78 (7): 790-794

  Abstract

  Percutaneous balloon mitral valvuloplasty (PBMV) is an effective means of palliating mitral stenosis, but it sometimes leads to adverse clinical outcomes and exorbitant in-hospital costs. Because echocardiographic score is known to be predictive of clinical outcome in patients undergoing PBMV, we examined whether it could also be used to predict in-hospital cost. Preprocedure echocardiographic scores, baseline clinical characteristics, and total in-hospital costs were examined among 45 patients who underwent PBMV between January 1, 1992, and January 1, 1994. Patients ranged in age from 18 to 71 years and had preprocedure echocardiographic scores that ranged from 4 to 12. Following PBMV, mean mitral valve area increased from 1.1 +/- 0.3 to 2.4 +/- 0.6 cm2 (p = 0.0001), and mean pressure gradient decreased from 18.3 +/- 5.9 to 6.7 +/- 2.7 mm Hg (p = 0.0001). In-hospital cost for the 45 patients ranged from $3,591 to $70,975 (mean $9,417; median $5,311). Univariate and multiple linear regression analyses demonstrated that among the variables examined, echocardiographic score (p = 0.0007), age (p = 0.01), and preprocedure mitral valve gradient (p = 0.03) were associated with in-hospital cost. Regression modeling suggested that every increase in preprocedure echocardiographic score of one grade was associated with an increase in in-hospital cost of $2,663. Because echocardiographic score is predictive of both clinical outcome and in-hospital cost, we conclude that patients with elevated scores should be considered for alternative therapy.

  View details for Web of Science ID A1996VN50700012

  View details for PubMedID 8857484

• The diagnosis of pericardial effusion and cardiac tamponade by 12-lead ECG - A technology assessment CHEST Eisenberg, M. J., deRomeral, L. M., Heidenreich, P. A., Schiller, N. B., Evans, C. T. 1996; 110 (2): 318-324

  Abstract

  This study was designed to determine the diagnostic value of 12-lead ECG for pericardial effusion and cardiac tamponade.Cross-sectional study.University hospital.Hospitalized patients with and without pericardial effusion and cardiac tamponade.In a blinded manner, we reviewed 12-lead ECGs from 136 patients with echocardiographically diagnosed pericardial effusions (12 of whom had cardiac tamponade) and from 19 control subjects without effusions. We examined the diagnostic value of three ECG signs: low voltage, PR segment depression, and electrical alternans. We found that all three ECG signs were specific but not sensitive for pericardial effusion (specificity, 89 to 100%; sensitivity, 1 to 17%) and cardiac tamponade (specificity, 86 to 99%; sensitivity, 0 to 42%). None of the ECG signs were associated with pericardial effusions of all sizes, but low voltage was associated with large and moderate pericardial effusions (odds ratio = 2.5; 95% confidence interval [CI] = 0.9 to 6.5; p = 0.06) and with cardiac tamponade (odds ratio = 4.7; 95% CI = 1.1 to 21.0; p = 0.004). In contrast, PR segment depression was associated only with cardiac tamponade (odds ratio = 2.0; 95% CI = 1.0 to 4.0; p = 0.05), while electrical alternans was not associated with either pericardial effusion or cardiac tamponade.Low voltage and PR segment depression are ECG signs that are suggestive, but not diagnostic, of pericardial effusion and cardiac tamponade. Because these ECG findings cannot reliably identify these conditions, we conclude that 12-lead ECG is poorly diagnostic of pericardial effusion and cardiac tamponade.

  View details for Web of Science ID A1996VB92300009

  View details for PubMedID 8697827

• Impact of the operating physician on costs of percutaneous transluminal coronary angioplasty AMERICAN JOURNAL OF CARDIOLOGY Heidenreich, P. A., Chou, T. M., Amidon, T. M., Ports, T. A., Browner, W. S. 1996; 77 (14): 1169-1173

  Abstract

  The hospital charts and billing records of 250 consecutive admissions for percutaneous transluminal coronary angioplasty (PTCA) at a university hospital were reviewed. Clinical characteristics, performing physician, angiographic features of the dilated lesion, procedural outcome, length of stay, and total and departmental hospital costs were recorded for each patient. We identified several independent predictors of hospital cost, including the physician ($4,400 increase from highest- to lowest-cost physician, p=0.004), age ($790 increase per 10-year increase in age, p=0.002), urgency of the procedure ($4,100 increase for urgent vs elective, p < 0.001), and combined angiography and PTCA ($850 increase vs separate angiography, p=0.04). Independent predictors of catheterization laboratory cost included the physician ($1,280 increase from highest- to lowest-cost physician, p=0.03), American College of Cardiology/American Heart Association lesion type B2 or C ($320 increase, p=0.03), and combined angiography and PTCA ($430 increase, p=0.003). Expensive operators used more catheterization laboratory resources than inexpensive operators; however, there are no significant differences in success rate or need for emergent bypass surgery between physicians. PTCA cost is determined by both patient characteristics and the performing physician. The increase in cost due to the physician was not explained by patient variables, lesions characteristics, success rate, or complications.

  View details for Web of Science ID A1996UQ84700006

  View details for PubMedID 8651090

• Transesophageal echocardiography: Additional diagnostic and therapeutic role in critically Ill patients? Reply JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Heidenreich, P., Foster, E., Cohen, N. 1996; 27 (7): 1818

  View details for DOI 10.1016/S0735-1097(96)90235-1

  View details for Web of Science ID A1996UM59800042

• Recurrent non-Q-wave myocardial infarction associated with toluene abuse AMERICAN HEART JOURNAL Hussain, T. F., Heidenreich, P. A., Benowitz, N. 1996; 131 (3): 615-616

  View details for Web of Science ID A1996TZ29500031

  View details for PubMedID 8604650

• Presentation and explanation of medical decision models using the World Wide Web. Proceedings : a conference of the American Medical Informatics Association / ... AMIA Annual Fall Symposium. AMIA Fall Symposium Sanders, G. D., Dembitzer, A. D., Heidenreich, P. A., McDonald, K. M., Owens, D. K. 1996: 60-64

  Abstract

  We demonstrated the use of the World Wide Web for the presentation and explanation of a medical decision model. We put on the web a treatment model developed as part of the Cardiac Arrhythmia and Risk of Death Patient Outcomes Research Team (CARD PORT). To demonstrate the advantages of our web-based presentation, we critiqued both the conventional paper-based and the web-based formats of this decision-model presentation with reference to an accepted published guide to understanding clinical decision models. A web-based presentation provides a useful supplement to paper-based publications by allowing authors to present their model in greater detail, to link model inputs to the primary evidence, and to disseminate the model to peer investigators for critique and collaborative modeling.

  View details for PubMedID 8947628

• CATHETER FRAGMENTATION OF MASSIVE PULMONARY EMBOLUS - GUIDANCE WITH TRANSESOPHAGEAL ECHOCARDIOGRAPHY AMERICAN HEART JOURNAL Heidenreich, P. A., Chou, T. M., Smedira, N. G., Sweeney, J. P., Schiller, N. B., Schwartz, D. E., Merrick, S. H., Ports, T. A. 1995; 130 (6): 1306-1308

  View details for Web of Science ID A1995TH12600030

  View details for PubMedID 7484792

• PERICARDIAL-EFFUSION IN AIDS - INCIDENCE AND SURVIVAL CIRCULATION Heidenreich, P. A., Eisenberg, M. J., KEE, L. L., Somelofski, C. A., Hollander, H., Schiller, N. B., Cheitlin, M. D. 1995; 92 (11): 3229-3234

  Abstract

  Although pericardial effusion is known to be common among patients infected with HIV, the incidence of pericardial effusion and its relation to survival have never been described.To evaluate the incidence of pericardial effusion and its relation to mortality in HIV-positive subjects, 601 echocardiograms were performed on 231 subjects recruited over a 5-year period (inception cohort: 59 subjects with asymptomatic HIV, 62 subjects with AIDS-related complex, and 74 subjects with AIDS; 21 HIV-negative healthy gay men; and 15 subjects with non-HIV end-stage medical illness). Echocardiograms were performed every 3 to 6 months (82% had follow-up studies). Sixteen subjects were diagnosed with effusions (prevalence of effusion for AIDS subjects entering the study was 5%). Thirteen subjects developed effusions during follow-up; 12 of these were subjects with AIDS (incidence, 11%/y). The majority of effusions (80%) were small and asymptomatic. The survival of AIDS subjects with effusions was significantly shorter (36% at 6 months) than survival for AIDS subjects without effusions (93% at 6 months). This shortened survival remained significant (relative risk, 2.2, P = .01) after adjustment for lead time bias and was independent of CD4 count and albumin level.There is a high incidence of pericardial effusion in patients with AIDS, and the presence of an effusion is associated with shortened survival. The development of an effusion in the setting of HIV infection suggests end-stage HIV disease (AIDS).

  View details for Web of Science ID A1995TG29200014

  View details for PubMedID 7586308

• SHOULD TRANSESOPHAGEAL ECHOCARDIOGRAPHY BE USED IN EVERY PATIENT WITH SUSPECTED ENDOCARDITIS - A DECISION-ANALYSIS HEIDENREICH, P. A., MASOUDI, F. A., MAINI, B. S., FOSTER, E., BROWNER, W. S., CHOU, T. M. AMER HEART ASSOC. 1995: 2440

  View details for Web of Science ID A1995TB48002422

• Three-dimensional transabdominal ultrasound identification of aortic plaque. American journal of cardiac imaging Webber, J. D., Foster, E., Heidenreich, P., Laberge, J., Ring, E. J., Schiller, N. B. 1995; 9 (4): 245-249

  Abstract

  Tree-dimensional (3-D) reconstruction of acquired tomographic images in adults has recently been described. With an adaptation of this technique, we performed 3-D reconstruction of transabdominal images of the abdominal aorta to test the hypotheses that 3-D reconstruction of the abdominal aorta is feasible and that 3-D images have incremental value over 2-D in the detection of atheromatous plaque. Twenty-one patients undergoing contrast aortography (Aogram) for clinical indications (1 abdominal aorta (AA) aneurysm, 5 peripheral vascular disease, 1 renal artery stenosis, 14 renal donors) were studied using a 5-MHz annular array probe fitted to a mechanical registration device. In 13 of 21 patients, adequate 2-D ultrasound slices were acquired around a 180 degrees rotation and stored as a volumetric data set using a dedicated computer and 3-D images were reconstructed off-line. Three-dimensional and planar images were blindly compared with Aograms using the following scale: grade 1, normal; grade 2, increased echodensity of the intimal surface; grade 3, local intimal thickening and/or luminal irregularity; and grade 4, protruding mass. Analogous 3-D images were produced in all 13 patients with branching vessels visible in 3 of 13. In 10 patients, the Aogram was interpreted as normal. Compared with Aogram, blindly interpreted 3-D images were compared and correctly identified normal AA in 8 of 10 and atherosclerotic plaque (grade 3 or 4) in 2 of 3. Discordant results were present in 2 of 10 normal aortas and 1 of 3 disease aortas. When 2-D (planar) images were compared with Aograms, 8 of 10 identified normal AA and 3 of 3 aortas with grade 3 or 4 plaque. Thus, in 2 patients, 3-D and planar images suggested atherosclerotic changes not seen by Aogram. Transabdominal 3-D imaging of the abdominal aorta is a feasible technique. Early data suggest that 3-D imaging may distinguish normal from moderate to severe disease, but currently has no demonstrable incremental value over conventional 2-D images. These early results in a small number of patients suggest that this promising technique warrants further evaluation.

  View details for PubMedID 8680140

• TRANSESOPHAGEAL ECHOCARDIOGRAPHY PREDICTS MORTALITY IN CRITICALLY ILL PATIENTS WITH UNEXPLAINED HYPOTENSION JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Heidenreich, P. A., Stainback, R. F., Redberg, R. F., Schiller, N. B., Cohen, N. H., Foster, E. 1995; 26 (1): 152-158

  Abstract

  This study sought to determine the prognostic yield and utility of transesophageal echocardiography in critically ill patients with unexplained hypotension.Transesophageal echocardiography is increasingly utilized in the intensive care setting and is particularly suited for the evaluation of hypotension; however, the prognostic yield of transesophageal echocardiography in these patients is unknown.We prospectively studied 61 adult patients in the intensive care unit with sustained (> 60 min) unexplained hypotension. Both transthoracic and transesophageal echocardiography were performed, and results were immediately disclosed to the primary physician, who reported any resulting changes in management. Patients were classified on the basis of transesophageal echocardiographic findings into one of three prognostic groups: 1) nonventricular (valvular, pericardial) cardiac limitation to cardiac output; 2) ventricular failure; and 3) noncardiac systemic disease (hypovolemia or low systemic vascular resistance, or both). Primary end points were death or discharge from the intensive care unit.A transesophageal echocardiographic diagnosis of nonventricular limitation to cardiac output was associated with improved survival to discharge from the intensive care unit (81%) versus a diagnosis of ventricular disease (41%) or hypovolemia/low systemic vascular resistance (44%, p = 0.03). Twenty-nine (64%) of 45 transthoracic echocardiographic studies were inadequate compared with 2 (3%) of 61 transesophageal echocardiographic studies (p < 0.001). Transesophageal echocardiography contributed new clinically significant diagnoses (not seen with transthoracic echocardiography) in 17 patients (28%), leading to operation in 12 (20%).Transesophageal echocardiography makes a clinically important contribution to the diagnosis and management of unexplained hypotension and predicts prognosis in the critical care setting.

  View details for Web of Science ID A1995RG11000020

  View details for PubMedID 7797744

• EVALUATION OF MITRAL-STENOSIS WITH VELOCITY-ENCODED CINE-MAGNETIC RESONANCE IMAGING AMERICAN JOURNAL OF CARDIOLOGY Heidenreich, P. A., Steffens, J., Fujita, N., OSULLIVAN, M., Caputo, G. R., Foster, E., Higgins, C. B. 1995; 75 (5): 365-369

  Abstract

  Velocity-encoded cine-magnetic resonance imaging (VEC-MRI) is a new method for quantitation of blood flow with the potential to measure high-velocity jets across stenotic valves. The objective of this study was to evaluate the ability of VEC-MRI to measure transmitral velocity in patients with mitral stenosis. Sixteen patients with known mitral stenosis were studied. A 1.5 Tesla superconducting magnet was used to obtain velocity-encoded images in the left ventricular short-axis plane. Images were obtained throughout the cardiac cycle at 3 consecutive slices beginning proximal to the mitral coaptation point. To determine the optimal slice thickness for MRI imaging, both 10 mm and 5 mm thicknesses were used. Echocardiography including continuous-wave Doppler was performed on every patient within 2 hours of MRI imaging. Peak velocity was determined for both VEC-MRI and Doppler-echo images. Two observers independently measured the VEC-MRI mitral inflow velocities. Of the 16 patients, imaged data were incomplete in only 1 study, and all images were adequate for analysis. Strong correlations were found for measurements of mitral valve gradient for both 10 mm (peak r = 0.89, mean r = 0.84) and 5 mm (peak r = 0.82, mean r = 0.95) slice thicknesses. Measurements of peak velocity with VEC-MRI (10 mm) agreed well with Doppler: mean 1.46 m/s, mean of differences (Doppler MRI) 0.38 m/s, standard deviation of differences 0.2 m/s. These findings suggest that VEC-MRI can noninvasively determine the severity of mitral stenosis.

  View details for Web of Science ID A1995QG27900010

  View details for PubMedID 7856529

• MYOCARDIAL BLOOD TRANSIT-TIME MEASURED BY INTRAVASCULAR CONTRAST ULTRASOUND HEIDENREICH, P. A., CHAZOUILLERES, A. F., REDBERG, R. F., SUDHIR, K., SCHILLER, N. B. AMER HEART ASSOC. 1994: 556

  View details for Web of Science ID A1994PN41703025

• COST-EFFECTIVENESS OF EVALUATING SUSPECTED MITRAL-VALVE PROLAPSE WITH ECHOCARDIOGRAPHY HEIDENREICH, P. A., BEAR, J., FOSTER, E. AMER HEART ASSOC. 1994: 43

  View details for Web of Science ID A1994PN41700261

• PREDICTORS OF PTCA COST - THE IMPORTANCE OF THE OPERATING PHYSICIAN HEIDENREICH, P. A., AMIDON, T. M., PORTS, T. A., CHOU, T. M. AMER HEART ASSOC. 1994: 92

  View details for Web of Science ID A1994PN41700526

• THE PROGNOSTIC VALUE OF TRANSESOPHAGEAL ECHOCARDIOGRAPHY IN UNEXPLAINED HYPOTENSION HEIDENREICH, P. A., STAINBACK, R. F., REDBERG, R. F., SCHILLER, N. B., COHEN, N. H. AMER HEART ASSOC. 1994: 549

  View details for Web of Science ID A1994PN41702992

• QUANTIFICATION OF MITRAL REGURGITATION BY VELOCITY-ENCODED CINE NUCLEAR-MAGNETIC-RESONANCE IMAGING JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Fujita, N., CHAZOUILLERES, A. F., Hartiala, J. J., OSULLIVAN, M., Heidenreich, P., Kaplan, J. D., Sakuma, H., Foster, E., Caputo, G. R., Higgins, C. B. 1994; 23 (4): 951-958

  Abstract

  The feasibility of velocity-encoded cine nuclear magnetic resonance (NMR) imaging to measure regurgitant volume and regurgitant fraction in patients with mitral regurgitation was evaluated.Velocity-encoded cine NMR imaging has been reported to provide accurate measurement of the volume of blood flow in the ascending aorta and through the mitral annulus. Therefore, we hypothesized that the difference between mitral inflow and aortic systolic flow provides the regurgitant volume in the setting of mitral regurgitation.Using velocity-encoded cine NMR imaging at a magnet field strength of 1.5 T and color Doppler echocardiography, 19 patients with isolated mitral regurgitation and 10 normal subjects were studied. Velocity-encoded cine NMR images were acquired in the short-axis plane of the ascending aorta and from the short-axis plane of the left ventricle at the level of the mitral annulus. Two independent observers measured the ascending aortic flow volume and left ventricular inflow volume to calculate the regurgitant volume as the difference between left ventricular inflow volume and aortic flow volume, and the regurgitant fraction was calculated. Using accepted criteria of color flow Doppler imaging and spectral analysis, the severity of mitral regurgitation was qualitatively graded as mild, moderate or severe and compared with regurgitant volume and regurgitant fraction, as determined by velocity-encoded cine NMR imaging.In normal subjects the regurgitant volume was -6 +/- 345 ml/min (mean +/- SD). In patients with mild, moderate and severe mitral regurgitation, the regurgitant volume was 156 +/- 203, 1,384 +/- 437 and 4,763 +/- 2,449 ml/min, respectively. In normal subjects the regurgitant fraction was 0.7 +/- 6.1%. In patients with mild, moderate and severe mitral regurgitation, the regurgitant fraction was 3.1 +/- 3.4%, 24.5 +/- 8.9% and 48.6 +/- 7.6%, respectively. The regurgitant fraction correlated well with the echocardiographic severity of mitral regurgitation (r = 0.87). Interobserver reproducibilities for regurgitant volume and regurgitant fraction were excellent (r = 0.99, SEE = 238 ml; r = 0.98, SEE = 4.1%, respectively).These findings suggest that velocity-encoded NMR imaging can be used to estimate regurgitant volume and regurgitant fraction in patients with mitral regurgitation and can discriminate patients with moderate or severe mitral regurgitation from normal subjects and patients with mild regurgitation. It may be useful for monitoring the effect of therapy intended to reduce the severity of mitral regurgitation.

  View details for Web of Science ID A1994PH37000016

  View details for PubMedID 8106701

• ENDOCARDIAL PHASE MAPPING IMPROVES DETECTION OF REGIONAL WALL-MOTION ABNORMALITIES HEIDENREICH, P. A., BEAR, J., FOSTER, E., SEEBERGER, M., CHU, E., CAHALAN, M., BOTVINICK, E., OCONNELL, W., SCHILLER, N. B. ELSEVIER SCIENCE INC. 1994: A310

  View details for Web of Science ID A1994PP51801227

• THE EVALUATION OF MITRAL-STENOSIS WITH VELOCITY-ENCODED CINE MAGNETIC-RESONANCE HEIDENREICH, P. A., STEFFENS, J., FUJITA, N., OSULLIVAN, M., CAPUTO, G. R., FOSTER, E., HIGGINS, C. B. ELSEVIER SCIENCE INC. 1994: A298

  View details for Web of Science ID A1994PP51801178

• ASSESSMENT OF RENAL BLOOD-FLOW WITH CONTRAST ULTRASONOGRAPHY ANESTHESIA AND ANALGESIA ARONSON, S., WIENCEK, J. G., Feinstein, S. B., Heidenreich, P. A., Zaroff, J. G., Walker, R., Roizen, M. F. 1993; 76 (5): 964-970

  Abstract

  Sonicated albumin microspheres, a digitalizing ultrasound system, and a mathematical model for flow were used to determine whether blood flow in the canine kidney could be assessed with contrast ultrasound. Albunex ultrasound contrast microspheres were injected into the aorta while ultrasound images of the kidney and aorta were recorded simultaneously. Ultrasound data were obtained during contrast injections at 93 different renal blood flow rates in nine dogs. Contrast dose was calibrated to ultrasound system response for both aortic and renal images. A linear relationship between microbubble concentration used and pixel intensity was established (r = 0.89 for aortic images and r = 0.91 for renal images). Renal blood flow was manipulated from baseline by means of a hydraulic renal artery occluder and by intravenous dopamine or fenoldopam infusion. Blood flow calculated with contrast ultrasonography was compared with direct measurement obtained with an electromagnetic flow probe at each flow rate. Direct measurement correlated with rates calculated with contrast ultrasonography (r = 0.84, 95% confidence limits from 0.75 to 0.90). Overall, calculations tended to overestimate absolute flow measurements, and overestimation of flow tended to be greater during pharmacologically manipulated flow rates. We conclude the changes and trends in renal blood flow can be serially assessed in vivo with contrast ultrasonography, but technical limitations of present commercial ultrasounds systems preclude absolute quantification at this time.

  View details for Web of Science ID A1993LA49000008

  View details for PubMedID 8484552

• In vitro calculation of flow by use of contrast ultrasonography. Journal of the American Society of Echocardiography Heidenreich, P. A., WIENCEK, J. G., Zaroff, J. G., ARONSON, S., Segil, L. J., Harper, P. V., Feinstein, S. B. 1993; 6 (1): 51-61

  Abstract

  Contrast echocardiography has been used for qualitative assessment of cardiac function, and its potential for quantitative assessment of blood flow is being explored. With the development of an ultrasound contrast agent capable of passage through the microcirculation, a mathematical model based on classic dye dilution theory, and a digital ultrasound acquisition system, absolute quantitation of myocardial perfusion may be feasible. This study validates the mathematical model in a simple in vitro tube system. Flow was delivered at variable rates through an in vitro tube system while a longitudinal section was imaged with a modified commercial ultrasound scanner. Albunex contrast agent was injected, and videointensity data were captured and analyzed off line. Time-intensity curves were generated, and flow was calculated by use of a mathematical model derived from classic dye dilution mathematics. For 39 different flow rates, ranging for 9.2 to 110 ml/seconds, a correlation coefficient of r = 0.928 (p < 0.001) with a slope of 0.97 was calculated. We conclude that (1) contrast ultrasonography is capable of quantitative determination of flow in an in vitro system, and (2) a mathematical model based on dye dilution theory can be used to calculate flow with accuracy and precision.

  View details for PubMedID 8439423

• CONTRAST ECHOCARDIOGRAPHY - A COMPARISON OF VIDEODENSITOMETRIC TECHNIQUES WIENCEK, J. G., ZAROFF, J. G., HEIDENREICH, P. A., HARPER, P. V., POWSNER, S. M., ARONSON, S., FEINSTEIN, S. B. AMER HEART ASSOC. 1990: 27

  View details for Web of Science ID A1990EC76400129

• SAFETY AND EFFICACY OF A NEW TRANSPULMONARY ULTRASOUND CONTRAST AGENT - INITIAL MULTICENTER CLINICAL-RESULTS JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY Feinstein, S. B., Cheirif, J., TENCATE, F. J., Silverman, P. R., Heidenreich, P. A., Dick, C., DESIR, R. M., Armstrong, W. F., Quinones, M. A., Shah, P. M. 1990; 16 (2): 316-324

  Abstract

  Myocardial contrast echocardiography has been found to be a safe and useful technique for evaluating relative changes in myocardial perfusion and delineating areas at risk. Although earlier contrast agents required direct delivery into the coronary arteries or aortic root, a new echocardiographic contrast agent, sonicated albumin microspheres (Albunex), has been found to cross the pulmonary circulation in experimental models. To determine the safety and preliminary efficacy of intravenous injections of Albunex in humans, 71 patients at three independent medical institutions underwent two-dimensional echocardiographic examination before, during and after the administration of three intravenous doses of Albunex, ranging from 0.01 to 0.12 ml/kg body weight. All patients provided a complete history and underwent physical and neurologic examination and laboratory and electrocardiographic evaluation before the injections; all evaluations (except for the history) were repeated at 2 h and 3 days after the injections of Albunex. The efficacy of the injections was qualitatively assessed by two independent blinded observers using a grading system of 0 to +3, with 0 indicating an absence of contrast effect and +3 indicating full opacification of the cavities examined. All injections were well tolerated and no serious side effects were noted in any of the patients. Irrespective of dose group, a cavity opacification greater than or equal to +2 was seen in the right ventricle in 212 (88%) of 240 injections and in the left ventricle in 151 (63%) of 240 injections as judged by the independent observers. The degree of ventricular cavity opacification appeared to be dose and concentration related.(ABSTRACT TRUNCATED AT 250 WORDS)

  View details for Web of Science ID A1990DR59300006

  View details for PubMedID 2197312

• CONTRAST ECHOCARDIOGRAPHY - A METHOD TO VISUALIZE CHANGES IN REGIONAL MYOCARDIAL PERFUSION IN THE DOG-MODEL FOR CABG SURGERY ANESTHESIOLOGY ARONSON, S., Bender, E., Feinstein, S. B., HEIDENREICH, P. H., Ellis, J., Dick, C., Roizen, M. F., Karp, R. B. 1990; 72 (2): 295-301

  Abstract

  The ability of contrast echocardiography to assess regional myocardial perfusion during cardiopulmonary bypass in a dog model for coronary artery bypass surgery was evaluated. Sonicated Renograffin-76 microbubbles (meglumin diatrigoate and sodium diatrigoate) were injected into an aortic root proximal to an aortic occlusion clamp root while dogs were on cardiopulmonary bypass, with the heart arrested in diastole. Echocardiographic contrast-enhanced regions of myocardial perfusion were easily visualized. Differences in contrast-enhanced myocardial regions depended on coronary artery occlusion or patency. The contrast-enhanced images of myocardial perfusion showed that, for a given myocardial segment of the supplying vessel, the presence or absence of contrast effect reliably predicted vessel occlusion or patency (P less than .01). In the future contrast echocardiography may allow the direct assessment of regional myocardial perfusion in the operating room.

  View details for Web of Science ID A1990CL65000015

  View details for PubMedID 2301760

• Quantitation of renal blood flow by contrast ultrasonography: preliminary results. Cardiologia (Rome, Italy) Voci, P., Heidenreich, P., ARONSON, S., WIENCEK, J. G., Zaroff, J. G., Feinstein, S. B., Reale, A. 1989; 34 (12): 1001-1006

  Abstract

  Contrast ultrasonography, employing tracers behaving like red blood cells, is a promising technique to study regional blood flow distribution. Aim of this note is to quantitate renal blood flow in the dog using contrast ultrasonography. Mathematical formulae derived from the classical dye-dilution theory are applied. Ten different renal blood flow levels (ranging from 16 to 125 ml/min) were obtained by means of mechanical (stenosis and reperfusion) and pharmacological interventions (iv infusion of adrenaline, noradrenaline and fenoldopam). Renal blood flow was measured by electromagnetic flow-meter and contemporary calculated by contrast ultrasonography. The correlation coefficient between measured and calculated flow was 0.92 (p less than 0.01). Contrast ultrasonography is a technique capable of measuring renal blood flow at a wide range of different flow levels.

  View details for PubMedID 2699440

• EFFECT OF FOLATE SUPPLEMENTATION ON THE INCIDENCE OF DYSPLASIA AND CANCER IN CHRONIC ULCERATIVE-COLITIS - A CASE-CONTROL STUDY GASTROENTEROLOGY Lashner, B. A., Heidenreich, P. A., Su, G. L., Kane, S. V., Hanauer, S. B. 1989; 97 (2): 255-259

  Abstract

  Folate deficiency has been associated with dysplasia in human cancer models. Patients with ulcerative colitis commonly have decreased folate levels, which are partially due to sulfasalazine, a competitive inhibitor of folate absorption. To study the effect of folate supplementation on the risk of dysplasia or cancer (neoplasia) in ulcerative colitis, records from 99 patients with pancolitis for greater than 7 yr and enrolled in a surveillance program were reviewed. Thirty-five patients with neoplasia were compared with 64 patients in whom dysplasia was never found to determine the effect of folate supplementation on the rate of development of neoplasia using case-control methodology. At the time of the index colonoscopy, patients with neoplasia were older (43 +/- 11 vs. 39 +/- 12 yr) and had disease of longer duration (20 +/- 8 vs. 15 +/- 7 yr, p less than 0.05). Folate supplementation was associated with a 62% lower incidence of neoplasia compared with individuals not receiving supplementation (odds ratio, 0.38; 95% confidence interval, 0.12-1.20). There was no appreciable change in this effect when models were fit to adjust for sulfasalazine dose, duration of disease, age at symptom onset, prednisone dose, sulfa allergy, sex, race, or family history of colon cancer. The statistical power of the association between folate supplementation and neoplasia was 72%. Correction of risk factors before the development of neoplasia may prevent this serious complication. Pending a larger case-control study, folate supplementation during sulfasalazine administration is recommended to possibly prevent the complication of dysplasia or cancer in ulcerative colitis.

  View details for Web of Science ID A1989AG00700001

  View details for PubMedID 2568304

• DOES FOLATE SUPPLEMENTATION HAVE A PROTECTIVE EFFECT FOR DYSPLASIA AND CANCER IN CHRONIC ULCERATIVE-COLITIS (UC) - A CASE-CONTROL STUDY LASHNER, B. A., HEIDENREICH, P. A., SU, G., KANE, S. V., HANAUER, S. B. W B SAUNDERS CO-ELSEVIER INC. 1988: A252

  View details for Web of Science ID A1988M939401002