Circulation-Cardiovascular Quality and Outcomes最新文献

Chronic coronary disease (CCD) is the leading cause of death in the United States. There is an ongoing imperative to disseminate evidence-based and patient-centered care recommendations that further align the management of patients with CCD to updated evidence-based guidelines. The writing committee developed a comprehensive CCD measure set comprising 10 performance measures and 3 quality measures, the focus of which is to include practical steps to specifically advance care in the CCD population. The measure set begins with an assessment of tobacco use and evidence-based cessation interventions. Also included are topics such as antiplatelet therapy, lipid assessment and low-density lipoprotein cholesterol goals, and guideline-directed management and therapy for hypertension and reduced left ventricular dysfunction in patients with CCD. The measure set concludes with an emphasis on the importance of cardiac rehabilitation referral and patient education, including symptom management and lifestyle modification.

Background: Although survival for out-of-hospital cardiac arrest (OHCA) is lower at emergency medical service (EMS) agencies serving Black/Hispanic communities, it is unknown whether this is due to practice differences.

Methods: Within the Cardiac Arrest Registry to Enhance Survival (CARES) registry in the United States, we conducted a survey from 2022 to 2023 of resuscitation practices at EMS agencies with ≥10 OHCAs annually between 2015 and 2019. We examined differences in dispatch, first responder, and EMS practices between agencies with majority Black/Hispanic catchment areas (>50% residents Black or Hispanic) and majority White catchment areas using χ² tests. We estimated each agency's risk-standardized rate of survival to hospital admission for OHCA using multivariable hierarchical logistic regression and evaluated whether survival differences between the 2 agency groups were attenuated after adjusting for resuscitation practice differences.

Results: Among 470 EMS agencies (181 707 OHCAs), 47 (10.0%) served a majority Black/Hispanic catchment area. At EMS agencies with Black/Hispanic catchment areas, dispatchers and police first responders were less likely to always recognize a cardiac arrest (29.8% versus 43.0%); police first responders were less likely to respond to OHCA (46.8% versus 68.9%), initiate CPR (59.6% versus 83.2%), or apply an automated external defibrillator (29.8% versus 60.0%); and EMS staff were less likely to assess CPR competency annually (46.5% versus 65.0%) and use waveform capnography (91.5% versus 99.5%), as compared with agencies with White catchment areas. EMS agencies serving majority Black/Hispanic catchment areas had 2% (95% CI, 0.9-3.1%; P<0.001) lower risk-standardized rates of survival, as compared with agencies serving majority White catchment areas, and survival differences were partly attenuated after adjusting for practice differences between EMS groups.

Conclusions: In the United States, we identified differences in dispatcher, first responder, and EMS practices for OHCA between agencies with majority Black/Hispanic and White catchment areas. These practice differences may partly account for disparities in OHCA survival between the 2 EMS agency groups.

Background: The ability of the American Heart Association Predicting Risk of Cardiovascular Disease Events (PREVENT) calculator to accurately assign 10-year atherosclerotic cardiovascular disease (ASCVD) risk in older individuals, including those aged ≥80 years, is unknown. This study compares PREVENT with the 2013 Pooled Cohort Equation (PCE) calculator for predicting 10-year ASCVD risk in a large cohort of older adults.

Methods: This was a prospective cohort study of adults without CVD from Australia and the United States aged ≥70 years (≥65 years, if US minorities). They were enrolled from 2010 to 2014 in the ASPREE trial (Aspirin in Reducing Events in the Elderly), a 5-year randomized trial of low-dose aspirin in community-dwelling older adults with posttrial observational follow-up extending to 2022. ASCVD events were adjudicated by expert panels. The discriminative ability of the 2 risk calculators was assessed by Harell C statistic following Cox regression in the 65- to 79-year age group and >80-year age group, separately. For calibration, predicted event numbers were calculated using PREVENT and PCE, scaled for the actual length of follow-up, and compared with the number of observed events in-trial and during extended follow-up.

Results: Among the 15 510 participants aged 65 to 79 years (median age, 73.2 years; 56.1% women), 1084 ASCVD events occurred (median follow-up, 8.3 years); PCE predicted 3102 events while PREVENT predicted 1290 events. For the 2787 participants ≥80 years (median age, 82.6 years; 59.2% women), 355 ASCVD events occurred (median follow-up, 7.4 years); PCE predicted 1067 events while PREVENT predicted 350 events. PREVENT showed superior discriminative performance compared with PCE (PREVENT versus PCE, C statistic, 0.793 versus 0.740; P<0.001 in participants aged 65 -79 years; 0.854 versus 0.799; P<0.001 in those aged ≥80 years).

Conclusions: The PREVENT risk calculator is superior to the PCE calculator in predicting ASCVD events in older adults from the United States and Australia, including those aged ≥80 years.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01038583. URL: https://www.isrctn.com; Unique identifier: ISRCTN83772183.

Background: Disparities between metro and nonmetro areas exist in health outcomes. The effect of residing areas on mortality for patients with congenital heart disease remains unclear. We evaluated the relationship of residing areas with survival outcomes after congenital heart surgery (CHS).

Methods: This is a retrospective cohort study of patients enrolled in the Pediatric Cardiac Care Consortium who had a history of CHS. Outcomes were tracked by the National Death Index through 2022. Logistic regression and Cox proportional hazards models were fitted to examine the associations between residence at CHS with in-hospital mortality and long-term survival after adjustment for covariates.

Results: Among 28 504 eligible patients (47.0% female patients) with a history of CHS, 19 772 (69.4%) patients resided in metro areas. Patients with congenital heart disease living in nonmetro areas at CHS had a lower (86.5%) 30-year survival rate following discharge from initial CHS versus patients living in metro areas (88.4%). After adjustment for sex, birth era, congenital heart disease severity, and presence of chromosomal abnormality, residing in nonmetro areas was associated with an increased risk of long-term mortality (adjusted hazard ratio, 1.12 [95% CI, 1.03-1.21]). Further adjustment for the neighborhood socioeconomic status attenuated the observed reduction in risk of death between nonmetro and metro areas. Patients with mild congenital heart disease who resided in nonmetro and not adjacent to metro areas were independently associated with an increased risk of long-term death (adjusted hazard ratio, 1.34 [95% CI, 1.00-1.77]), after adjustment for covariates and neighborhood socioeconomic status.

Conclusions: Residence in nonmetro areas at CHS is associated with an increased risk of death both in the immediate postoperative period in-hospital and on the long-term up to 30 years after CHS discharge, but this association is explained by differential neighborhood socioeconomic status at the time of CHS. These findings provide opportunities for targeted interventions to reduce disparities and improve outcomes for all patients after CHS.

Background: Patients hospitalized with symptoms of acute coronary syndrome remain at high risk for adverse events postdischarge, highlighting a need for modifiable therapeutic targets. The role of sedentary behavior in this risk and the potential benefits of replacing sedentary time with other activities remain unclear. This study examined the association between sedentary behavior and 1-year cardiac events/mortality among patients evaluated for acute coronary syndrome and estimated risk reductions from substituting alternative activities for sedentary time.

Methods: Patients presenting to the emergency department of a New York City hospital with acute coronary syndrome symptoms were enrolled from 2016 to 2020. Sedentary behavior, light-intensity physical activity, moderate-to-vigorous physical activity, and sleep were measured via a wrist-mounted accelerometer worn for 30 days postdischarge. Cardiac events and all-cause mortality were ascertained 1 year postdischarge via participant contact, electronic health records, and the Social Security Death Index. Participants were categorized into tertiles of sedentary time, with tertile 1 representing the lowest sedentary time and tertile 3 the highest. Cox proportional hazards regression models were used to evaluate associations.

Results: Of 609 participants (mean age, 62 years; 52% male, 58% Hispanic), 8.2% experienced a cardiac event or died within 1 year. Mean sedentary time was 13.6 h/d (SD, 1.8). Sedentary time was associated with increased risk of cardiac events/mortality (tertile 2: hazard ratio [HR], 0.95 [95% CI, 0.37-2.40]; tertile 3: HR, 2.58 [95% CI, 1.11-6.03]; P_trend=0.011). In isotemporal substitution analyses, replacing 30 minutes of sedentary time (referent) with sleep (HR, 0.86 [95% CI, 0.78-0.95]), light-intensity physical activity (HR, 0.49 [95% CI, 0.32-0.75]), or moderate-to-vigorous physical activity (HR, 0.39 [95% CI, 0.16-0.96]) was associated with lower cardiac event/mortality risk.

Conclusions: Sedentary behavior was associated with increased risk of 1-year cardiac events/mortality among patients evaluated for acute coronary syndrome. Replacing sedentary behavior with sleep, light-intensity physical activity, or moderate-to-vigorous physical activity was associated with lower risk. These findings highlight reducing sedentary behavior as a potential strategy to improve posthospitalization outcomes.

Background: Older adults with concomitant heart failure (HF) and Alzheimer's Disease and Related Dementias (ADRD) are at high risk for adverse outcomes, including health care utilization and mortality. Increasingly, adults with these conditions want to maximize quality of life and days at home (DAH). This study aimed to determine the association between ADRD and DAH following HF hospitalization.

Methods: This retrospective cohort analysis draws from a 20% random sample from 2017 to 2019 Medicare claims of beneficiaries who survived HF hospitalization. The primary outcome was mean DAH 6 months post-hospitalization. Exposure was defined as the presence of diagnosed ADRD, extracted from the Master Beneficiary Summary Base File Chronic Conditions subfile. Multivariable negative binomial regression was used to examine the adjusted association between ADRD and DAH, with covariates selected in accordance with the Andersen model of health care utilization.

Results: The 74,908 Medicare beneficiaries in the cohort had a mean age of 79.1 years (SD 11); half were men (50.0%) and 82.3% were non-Hispanic White. Overall, 18% (n=14,396) had ADRD. Beneficiaries with concomitant ADRD were older, more likely to be female, and more likely to have dual Medicaid/Medicare eligibility compared with those without ADRD. Although DAH in the 6 months preceding admission was similar, following hospitalization those with concomitant ADRD had less time at home (mean DAH 120.7 [65.9] for those with ADRD versus 136.4 [59.7] for those without ADRD). When adjusting for patient characteristics, hospitalization course, and hospital and geographic-level fixed effects, this difference persisted: patients with HF and ADRD spent an estimated 6% fewer DAH post-hospitalization (incidence rate ratio, 0.94 0.93-0.95). In the 6 months post-hospitalization, 10.2% of patients with HF and ADRD spent ≤7 DAH. The odds of spending ≤7 DAH were 24% higher for patients with ADRD (odds ratio, 1.24 [95% CI, 1.16-1.33]).

Conclusions: Following HF hospitalization, Medicare beneficiaries with ADRD spent significantly fewer DAH than those without ADRD. Identifying and addressing the unmet needs of this population after hospitalization is crucial.