Circulation-Cardiovascular Quality and Outcomes最新文献

Background: Previous observational studies showed left atrial appendage occlusions with the WATCHMAN device reduced 1-year mortality, which conflicted with evidence generated from randomized controlled trials. We proposed to use the high-dimensional propensity score (hdPS) to assist in nonactive comparator selection (prevalent user of medication) and compared 1-year mortality between patients with atrial fibrillation who received the WATCHMAN device (percutaneous left atrial appendage occlusion device [pLAAO]) and direct oral anticoagulants in 2 matched cohorts based on (1) traditional propensity score (PS) and (2) integrating traditional PS with information learned from hdPS.

Methods: Patients entered the cohort once diagnosed with atrial fibrillation in the 15% of Medicare fee-for-service claims database from 2011 to 2018. Patients could enter the study cohort upon receiving WATCHMAN or at an outpatient visit with an atrial fibrillation diagnosis, respectively. We used PS matching with a 1:3 ratio for patients in pLAAO and direct oral anticoagulant groups. In cohort 2, we implemented a multistep approach with information learned from hdPS. The Cox proportional hazards model was used to estimate hazard ratios of outcomes with 95% CIs.

Results: In cohort 1, we identified 1159 and 3477 patients in the pLAAO and direct oral anticoagulant groups with a mean age of 78.1 versus 77.5 years, 44.9% versus 40.8% of women, and a 1-year mortality rate of 8.02 versus 8.97/100 person-years (hazard ratio, 0.87 [95% CI, 0.69-1.09]). With the support of hdPS, in cohort 2, we excluded patients with malignant cancer and added frailty score in the PS model. We identified 953 and 2859 patients in the pLAAO and direct oral anticoagulant groups with a mean age of 78.1 versus 77.9 years, 47.2% versus 46.1% of women, and a 1-year mortality rate of 7.45 and 7.69/100 person-years (hazard ratio, 0.95 [95% CI, 0.73-1.24]).

Conclusions: No association was found between pLAAO and 1-year mortality, which is consistent with existing evidence from randomized controlled trials. The hdPS approach provides an opportunity to improve nonactive comparator selection in traditional PS analysis.

Background: In-hospital mortality risk prediction is an important tool for benchmarking quality and patient prognostication. Given changes in patient characteristics and treatments over time, a contemporary risk model for patients with acute myocardial infarction (MI) is needed.

Methods: Data from 313 825 acute MI hospitalizations between January 2019 and December 2020 for adults aged ≥18 years at 784 sites in the National Cardiovascular Data Registry Chest Pain-MI Registry were used to develop a risk-standardized model to predict in-hospital mortality. The sample was randomly divided into 70% development (n=220 014) and 30% validation (n=93 811) samples, and 23 separate registry-based patient characteristics at presentation were considered for model inclusion using stepwise logistic regression with 1000 bootstrapped samples. A simplified risk score was also developed for individual risk stratification.

Results: The mean age of the study cohort was 65.3 (SD 13.1) years, and 33.6% were women. The overall in-hospital mortality rate was 5.0% (n=15 822 deaths). The final model included 14 variables, with out-of-hospital cardiac arrest, cardiogenic shock, and ST-segment elevation MI as the strongest independent predictors of mortality. The model also included age, comorbidities (dyslipidemia, diabetes, prior percutaneous coronary intervention, cerebrovascular disease, and peripheral artery disease), heart failure on admission, heart rate, systolic blood pressure, glomerular filtration rate, and hemoglobin. The model demonstrated excellent discrimination (C-statistic, 0.868 [95% CI 0.865-0.871]) and good calibration, with similar performance across subgroups based on MI type, periods before and during the COVID-19 pandemic, and hospital volume. The simplified risk score included values from 0 to 25, with mortality risk ranging from 0.3% with a score of 0 to 1 up to 49.4% with a score >11.

Conclusions: This contemporary risk model accurately predicts in-hospital mortality for patients with acute MI and can be used for risk standardization across hospitals and at the bedside for patient prognostication.

Peripheral artery disease (PAD) is an atherosclerotic condition that affects a growing number of individuals worldwide, with estimates exceeding 220 million. One of the central hallmarks of PAD is lower extremity pain, which may present as intermittent claudication and atypical leg pain, and, in more severe cases, ischemic rest pain, neuropathic pain, or phantom limb pain in those who underwent amputation. Although the majority of individuals with PAD may experience pain that is chronic in nature, the pathogenesis and phenomenology of pain may differ. Nociceptive, inflammatory, and neuropathic mechanisms all play a role in the generation of pain. Pain in PAD results in severe disability and can copresent with distress, sickness behaviors such as avoidance and further deconditioning, and concomitant depression, anxiety, and addiction secondary to opioid use. These factors potentially lead to chronic pain interacting with a multitude of domains of functioning, including physical, emotional, and behavioral. Whereas pain is a normal adaptive response, self-defeating behaviors and cognitions contribute to the persistence or worsening of the chronic pain experience, disability, and distress. Much remains unknown about the phenomenology of pain in PAD and its clinical subgroups and how it affects outcomes. Borrowing from other chronic pain syndromes, multimodal pain management strategies that emphasize a biopsychosocial model have generated a solid evidence base for the use of cognitive behavioral approaches to manage pain. Multimodal pain management in PAD is not the norm, but theoretical pathways and road maps for further research, assessment, and clinical implementation are presented in this scientific statement.

Background: Increased burden of socially determined vulnerabilities (SDV), which include nonmedical conditions that contribute to patient health, is associated with incident heart failure (HF). Mediators of this association have not been examined. We aimed to determine if a healthy lifestyle mediates the association between SDV and HF.

Methods: We included adults aged 45 to 64 years old across the United States from the REGARDS cohort study (Reasons for Geographic and Racial Differences in Stroke) without evidence of HF at baseline. The primary exposure was a count of SDV based on the Healthy People 2030 framework. The primary outcome was incident HF. We assessed the role of a healthy behavior score (HBS range, 0-8) and its components (adherence to a Mediterranean diet, physical activity, lack of sedentary lifestyle, and smoking abstinence) as potential mediators of the association between SDV and incident HF.

Results: We included 13 on 525 participants. The median HBS was 4, with 16% with low HBS (0-2), 55% with moderate HBS (3-5), and 29% with high HBS (6-8). Increasing burden of SDV was associated with a stepwise increase in incident HF (adjusted hazard ratio, 1.84 [95% CI, 1.32-2.52] for 1 SDV, 2.59 [95% CI, 1.87-3.60] for 2 SDV, and 4.20 [95% CI, 3.08-5.73] for ≥3 SDV). There was no statistically significant mediation of HBS for the association of SDV count of 1 and incident HF. HBS score mediated 10.6% of the association between SDV count of 2 and incident HF and 11.1% of the association for those with ≥3 SDV. This increased to 10.8% and 18.3%, respectively, in the complete case analysis. Regarding individual components of HBS as mediators, only avoidance of a sedentary lifestyle was statistically significant (8.6% mediation) for the association of SDV count of 2 and incident HF.

Conclusions: A healthy lifestyle plays a small role in mediating the association between high SDV count and incident HF.

Background: Although racial disparities have been described in resuscitation, little is known about potential bias in race classification of out-of-hospital cardiac arrest (OHCA).

Methods: We conducted a retrospective cohort study of adults treated by emergency medical services (EMS) for nontraumatic OHCA in King County, WA between January 1, 2018, and December 31, 2021. We assessed agreement using κ and evaluated patterns of missingness between EMS-assessed race versus comprehensive race classification from hospital and death records. Using multivariable logistic regression adjusting for Utstein data elements, we analyzed the association between race and OHCA survival across different sources.

Results: Among 5909 eligible OHCA patients, the average age was 64.0 years, 35.4% were female, and 16.1% survived to hospital discharge. Based on comprehensive race classification, 68.7% were White, 12.8% Black, 12.1% Asian, 2.5% multiracial, 2.3% Native Hawaiian/other Pacific Islander, and 1.6% American Indian/Alaska Native. EMS did not classify race in 43.7%. The κ coefficient between EMS and comprehensive race classification was 0.88 (95% CI, 0.86-0.90), though agreement varied substantially by specific race and was lowest among American Indian/Alaska Native (39.5%). Missingness in EMS records varied according to race and was greater among those classified as American Indian/Alaska Native (60.8%), Native Hawaiian/other Pacific Islander (58.8%), Asian (57.8%), or multiracial (54.1%) compared with White (40.6%) or Black (40.4%). In multivariable models using EMS-classified race, the odds ratio (OR) of survival was not significantly different for any race group compared with the White race, that is, OR. However, when using comprehensive race classification, OR of survival was significantly lower among Native Hawaiian/other Pacific Islander (OR, 0.57 [95% CI, 0.33-0.97]) and among multiracial (OR, 0.40 [95% CI, 0.20-0.75]) compared with White race.

Conclusions: In adult OHCA, race misclassification and missingness influenced its association with survival. Efforts should continue to evaluate best practices to classify race correctly and comprehensively.

Background: The absence of practice standards in vasoactive agent usage for acute decompensated heart failure has resulted in significant treatment variability across hospitals, potentially affecting patient outcomes. This study aimed to assess temporal trends and institutional differences in vasodilator and inotrope/vasopressor utilization among patients with acute decompensated heart failure, considering their clinical phenotypes.

Methods: Data were extracted from a government-funded multicenter registry covering the Tokyo metropolitan area, comprising consecutive patients hospitalized in intensive/cardiovascular care units with a primary diagnosis of acute decompensated heart failure between January 2013 and December 2021. Clinical phenotypes, that is, pulmonary congestion or tissue hypoperfusion, were defined through a comprehensive assessment of clinical signs and symptoms, vital signs, and laboratory findings. We assessed the frequency and temporal trends in phenotype-based drug utilization of vasoactive agents and investigated institutional characteristics associated with adopting the phenotype-based approach using generalized linear mixed-effects models, with random intercepts to account for hospital-level variability.

Results: Among 37 293 patients (median age, 80 years; 43.7% female), 88.6% and 21.2% had pulmonary congestion and tissue hypoperfusion status, respectively. Throughout the study period, both overall and phenotype-based vasodilator utilizations showed significant declines, with overall usage dropping from 61.4% in 2013 to 48.6% in 2021 (P_trend<0.001). Conversely, no temporal changes were observed in overall inotrope/vasopressor utilization from 24.6% in 2013 to 25.8% in 2021 or the proportion of phenotype-based utilization. Notably, there was considerable variability in phenotype-based drug utilization among hospitals, with a median ranging from 48.3% to 77.8%. In multivariable-adjusted models, a higher number of board-certified cardiologists were significantly associated with lower rates of phenotype-based vasodilator utilization and reduced inappropriate inotrope/vasopressor utilization, while tertiary care hospitals were linked to more appropriate inotrope/vasopressor utilization.

Conclusions: Substantial variability existed among hospitals in phenotype-based drug utilization of vasoactive agents for patients with acute decompensated heart failure, highlighting the need for standardized treatment protocols.

Registration: URL: https://www.umin.ac.jp/ctr/index.htm; Unique identifier: UMIN000013128.