Association of Patient Reported Outcomes With Caregiver Burden in Older Patients With Advanced Heart Failure: Insights From the SUSTAIN-IT Study.

BACKGROUND: Caregivers of patients with advanced heart failure may experience burden in providing care, but whether changes in patient health status are associated with caregiver burden is unknown. METHODS: This observational study included older patients (60-80 years old) receiving advanced surgical heart failure therapies and their caregivers at 13 US sites. Patient health status was assessed using the 12-item Kansas City Cardiomyopathy Questionnaire (range, 0-100; higher scores are better). Caregiver burden was assessed using the Oberst Caregiving Burden Scale, which measures time on task (OCBS-time) and task difficulty (OCBS-difficulty; range, 1-5; lower scores are better). Measurements occurred before surgery and 12 months after in 3 advanced heart failure cohorts: patients receiving long-term left ventricular assist device support; heart transplantation with pretransplant left ventricular assist device support; and heart transplantation without pretransplant left ventricular assist device support. Multivariable linear regression was used to identify predictors of change in OCBS-time and OCBS-difficulty at 12 months. RESULTS: Of 162 caregivers, the mean age was 61.0±9.4 years, 139 (86%) were female, and 140 (86%) were the patient's spouse. At 12 months, 99 (61.1%) caregivers experienced improved OCBS-time, and 61 (37.7%) experienced improved OCBS-difficulty (versus no change or worse OCBS). A 10-point higher baseline 12-item Kansas City Cardiomyopathy Questionnaire predicted lower 12-month OCBS-time (ß=-0.09 [95% CI, -0.14 to -0.03]; P<0.001) and OCBS-difficulty (ß=-0.08 [95% CI, -0.12 to -0.05]; P<0.001). Each 10-point improvement in the 12-item Kansas City Cardiomyopathy Questionnaire predicted lower 12-month OCBS-time (ß=-0.07 [95% CI, -0.12 to -0.03]; P=0.002) and OCBS-difficulty (ß=-0.09 [95% CI, -0.12 to -0.06]; P<0.001). CONCLUSIONS: Among survivors at 12 months, baseline and change in patient health status were associated with subsequent caregiver time on task and task difficulty in dyads receiving advanced heart failure surgical therapies, highlighting the potential for serial 12-item Kansas City Cardiomyopathy Questionnaire assessments to identify caregivers at risk of increased burden. REGISTRATION: URL: https://www.clinicaltrials.gov; unique identifier: NCT02568930.

Time to bystander cardiopulmonary resuscitation by patient sex for out-of-hospital cardiac arrest.

BACKGROUND: Delays in bystander cardiopulmonary resuscitation (CPR) are associated with worse out-of-hospital cardiac arrest (OHCA) outcomes. Whether disparities exist in time to CPR between women and men is unknown. METHODS: We included witnessed OHCAs treated with bystander CPR from the Cardiac Arrest Registry Enhancing Survival between 2013-2021. The primary outcome was time to first bystander CPR, and secondary outcomes were survival to hospital discharge and favorable neurological survival. Hierarchical ordinal regression was used to model time to first CPR, which estimates the odds of having a 2-minute longer delay (from 0 to ≥10 minutes) in receiving bystander CPR. The model included sex, age, race, location of arrest, cardiac arrest etiology, day of week, and season as fixed effects and EMS agency as a random effect to account for clustering of patients within an agency. RESULTS: Of 78,043 patients with a witnessed OHCA that received bystander CPR, 25,197 (32.3%) were women. The median [IQR] time to first bystander CPR was 2 [1,5] minutes for both women and men. In adjusted analysis, time to bystander CPR was similar in men and women (p = 0.26). Moreover, there was a statistically significantly graded inverse association between time to bystander CPR and survival. CONCLUSION: For patients with witnessed OHCA that received bystander CPR, women and men had similar times to CPR, although 5-minute or greater delays in initiating CPR was not uncommon. Delays in bystander CPR in OHCA were associated with worse survival outcomes.

Association Between Delays in Time to Bystander CPR and Survival for Witnessed Cardiac Arrest in the United States.

BACKGROUND: Prompt initiation of bystander cardiopulmonary resuscitation (CPR) is critical to survival for out-of-hospital cardiac arrest (OHCA). However, the association between delays in bystander CPR and OHCA survival is poorly understood. METHODS: In this observational study using a nationally representative US registry, we identified patients who received bystander CPR from a layperson for a witnessed OHCA from 2013 to 2021. Hierarchical logistic regression was used to estimate the association between time to CPR (<1 minute versus 2-3, 4-5, 6-7, 8-9, and ≥10-minute intervals) and survival to hospital discharge and favorable neurological survival (survival to discharge with cerebral performance category of 1 or 2 [ie, without severe neurological disability]). RESULTS: Of 78 048 patients with a witnessed OHCA treated with bystander CPR, the mean age was 63.5±15.7 years and 25, 197 (32.3%) were women. The median time to bystander CPR was 2 (1-5) minutes, with 10% of patients having a≥10-minute delay before initiation of CPR. Overall, 15 000 (19.2%) patients survived to hospital discharge and 13 159 (16.9%) had favorable neurological survival. There was a graded inverse relationship between time to bystander CPR and survival to hospital discharge (P for trend <0.001). Compared with patients who received CPR within 1 minute, those with a time to CPR of 2 to 3 minutes were 9% less likely to survive to discharge (adjusted odds ratio, 0.91 [95% CI, 0.87-0.95]) and those with a time to CPR 4 to 5 minutes were 27% less likely to survive (adjusted odds ratio, 0.73 [95% CI, 0.68-0.77]). A similar graded inverse relationship was found between time to bystander CPR and favorable neurological survival (P for trend <0.001). CONCLUSIONS: Among patients with witnessed OHCA, there was a dose-response relationship between delays in bystander initiation of CPR and lower survival rates.

Baseline Health Status and its Association With Subsequent Cardiovascular Events in Patients With Atrial Fibrillation.

BACKGROUND: Clinical practice guidelines recommend optimizing the health status of patients with atrial fibrillation (AF) as a primary treatment goal. Whether disease-specific health status is associated with subsequent clinical events is unknown. OBJECTIVES: The aim of this study was to investigate the association between health status and subsequent clinical events among patients with AF. METHODS: Using a prospective cohort study of patients with new-onset AF referred to 11 hospitals (n = 3,313, 68.4% men, mean age 67.8 ± 11.6 years), data were extracted from 3,296 patients (99.4%) who completed the disease-specific Atrial Fibrillation Effects on Quality-of-Life (AFEQT) questionnaire between 2012 and 2018. Factors associated with baseline AFEQT overall summary (OS) score and associations between major adverse cardiovascular or neurologic events (MACNE; a composite of all-cause death, stroke, or new-onset heart failure hospitalization) over 2 years were investigated. RESULTS: Overall, 517 participants (15.6%) had poor to fair health status (AFEQT OS <60), and 1,035 (31.2%) had fair to good health status (AFEQT OS 60 to <80) at baseline. Female sex, younger age, family history of AF, higher baseline heart rate, paroxysmal AF, initial visit to the emergency department, and history of heart failure were associated with lower AFEQT OS scores. Of those, 226 participants (6.8%) experienced MACNE; restricted cubic spline analysis with adjustment for factors associated with baseline AFEQT score showed a nonlinear increase in the risk for MACNE with AFEQT OS score <80. The strongest associations were observed for baseline AFEQT daily activity scores (for AFEQT daily activity score of <80 vs ≥80, HR: 1.65; 95% CI: 1.21-2.25). CONCLUSIONS: Diminished health status in patients with AF is common and is independently associated with subsequent adverse cardiovascular events.

Health status and clinical outcomes in older adults with chronic coronary disease: the ISCHEMIA trial

BACKGROUND: Whether initial invasive management in older vs younger adults with chronic coronary disease and moderate or severe ischemia improves health status or clinical outcomes is unknown. OBJECTIVES: The goal of this study was to examine the impact of age on health status and clinical outcomes with invasive vs conservative management in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial. METHODS: One-year angina-specific health status was assessed with the 7-item Seattle Angina Questionnaire (SAQ) (score range 0-100; higher scores indicate better health status). Cox proportional hazards models estimated the treatment effect of invasive vs conservative management as a function of age on the composite clinical outcome of cardiovascular death, myocardial infarction, or hospitalization for resuscitated cardiac arrest, unstable angina, or heart failure. RESULTS: Among 4,617 participants, 2,239 (48.5%) were aged <65 years, 1,713 (37.1%) were aged 65 to 74 years, and 665 (14.4%) were aged ≥75 years. Baseline SAQ summary scores were lower in participants aged <65 years. Fully adjusted differences in 1-year SAQ summary scores (invasive minus conservative) were 4.90 (95% CI: 3.56-6.24) at age 55 years, 3.48 (95% CI: 2.40-4.57) at age 65 years, and 2.13 (95% CI: 0.75-3.51) at age 75 years (Pinteraction = 0.008). Improvement in SAQ Angina Frequency was less dependent on age (Pinteraction = 0.08). There were no age differences between invasive vs conservative management on the composite clinical outcome (Pinteraction = 0.29). CONCLUSIONS: Older patients with chronic coronary disease and moderate or severe ischemia had consistent improvement in angina frequency but less improvement in angina-related health status with invasive management compared with younger patients. Invasive management was not associated with improved clinical outcomes in older or younger patients. (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).

Health Status and Clinical Outcomes in Older Adults With Chronic Coronary Disease: The ISCHEMIA Trial.

BACKGROUND: Whether initial invasive management in older vs younger adults with chronic coronary disease and moderate or severe ischemia improves health status or clinical outcomes is unknown. OBJECTIVES: The goal of this study was to examine the impact of age on health status and clinical outcomes with invasive vs conservative management in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial. METHODS: One-year angina-specific health status was assessed with the 7-item Seattle Angina Questionnaire (SAQ) (score range 0-100; higher scores indicate better health status). Cox proportional hazards models estimated the treatment effect of invasive vs conservative management as a function of age on the composite clinical outcome of cardiovascular death, myocardial infarction, or hospitalization for resuscitated cardiac arrest, unstable angina, or heart failure. RESULTS: Among 4,617 participants, 2,239 (48.5%) were aged <65 years, 1,713 (37.1%) were aged 65 to 74 years, and 665 (14.4%) were aged ≥75 years. Baseline SAQ summary scores were lower in participants aged <65 years. Fully adjusted differences in 1-year SAQ summary scores (invasive minus conservative) were 4.90 (95% CI: 3.56-6.24) at age 55 years, 3.48 (95% CI: 2.40-4.57) at age 65 years, and 2.13 (95% CI: 0.75-3.51) at age 75 years (Pinteraction = 0.008). Improvement in SAQ Angina Frequency was less dependent on age (Pinteraction = 0.08). There were no age differences between invasive vs conservative management on the composite clinical outcome (Pinteraction = 0.29). CONCLUSIONS: Older patients with chronic coronary disease and moderate or severe ischemia had consistent improvement in angina frequency but less improvement in angina-related health status with invasive management compared with younger patients. Invasive management was not associated with improved clinical outcomes in older or younger patients. (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).

Artificial intelligence-enabled mobile electrocardiograms for event prediction in paroxysmal atrial fibrillation.

Background: Paroxysmal atrial fibrillation (AF) often eludes early diagnosis, resulting in significant morbidity and mortality. Artificial intelligence (AI) has been used to predict AF from sinus rhythm electrocardiograms (ECGs), but AF prediction using sinus rhythm mobile electrocardiograms (mECG) remains unexplored. Objective: The purpose of this study was to investigate the utility of AI to predict AF events prospectively and retrospectively using sinus rhythm mECG data. Methods: We trained a neural network to predict AF events from sinus rhythm mECGs obtained from users of the Alivecor KardiaMobile 6L device. We tested our model on sinus rhythm mECGs within ±0-2 days, ±3-7 days, and ±8-30 days from AF events to determine the optimal screening window. Finally, we tested our model on mECGs from before an AF event to determine whether AF can be predicted prospectively. Results: We included 73,861 users with 267,614 mECGs (mean age 58.14 years; 35% women). Users with paroxysmal AF contributed 60.15% of mECGs. Model performance on the test set comprising control and study samples across all windows of interest showed an area under the curve (AUC) score of 0.760 (95% confidence interval [CI] 0.759-0.760), sensitivity of 0.703 (95% CI 0.700-0.705), specificity of 0.684 (95% CI 0.678-0.685), and accuracy of 69.4% (95% CI 0.692-0.700). Model performance was better on ±0-2 day samples (sensitivity 0.711; 95% CI 0.709-0.713) and worse on the ±8-30 day window (sensitivity 0.688; 95% CI 0.685-0.690), with performance on the ±3-7 day window falling in between (sensitivity 0.708; 95% CI 0.704-0.710). Conclusion: Neural networks can predict AF using a widely scalable and cost-effective mobile technology prospectively and retrospectively.

Impact of frailty on disease-specific health status in cardiovascular disease.

Frailty is a syndrome of older age that reflects an impaired physiological reserve and decreased ability to recover from medical stressors. While the impact of frailty on mortality in cardiovascular disease has been well described, its impact on cardiovascular disease-specific health status-cardiac symptoms, physical functioning and quality of life-has been less well studied. In this review, we summarise the impact of frailty on health status outcomes across different cardiovascular conditions. In heart failure, frail patients have markedly impaired disease-specific health status and are at risk for subsequent health status deteriorations. However, frail patients have similar or even greater health status improvements with interventions for heart failure, such as cardiac rehabilitation or guideline-directed medical therapy. In valvular heart disease, the impact of frailty on disease-specific health status is of even greater concern since management involves physiologically taxing procedures that can worsen health status. Frailty increases the risk of poor health status outcomes after transcatheter aortic valve intervention or surgical aortic valve replacement for aortic stenosis, but there is no evidence that frail patients benefit more from one procedure versus another. In both heart failure and valvular heart disease, health status improvements may reverse frailty, highlighting the overlap between cardiovascular disease and frailty and emphasising that treatment should typically not be withheld based on the presence of frailty alone. Meanwhile, data are limited on the impact of frailty on health status outcomes in the treatment of coronary artery disease, peripheral artery disease and atrial fibrillation, and requires further research.

Health Status Outcomes in Older Adults Undergoing Chronic Total Occlusion Percutaneous Coronary Intervention.

Background Although chronic total occlusions (CTOs) are common in older adults, they are less likely to be offered CTO percutaneous coronary intervention for angina relief than younger adults. The health status impact of CTO percutaneous coronary intervention in adults aged ≥75 years has not been studied. We sought to compare technical success rates and angina-related health status outcomes at 12 months between adults aged ≥75 and <75 years in the OPEN-CTO (Outcomes, Patient Health Status, and Efficiency in Chronic Total Occlusion) registry. Methods and Results Angina-related health status was assessed with the Seattle Angina Questionnaire (score range 0-100, higher scores denote less angina). Technical success rates were compared using hierarchical modified Poisson regression, and 12-month health status was compared using hierarchical multivariable linear regression between adults aged ≥75 and <75 years. Among 1000 participants, 19.8% were ≥75 years with a mean age of 79.5±4.1 years. Age ≥75 years was associated with a lower likelihood of technical success (adjusted risk ratio=0.92 [95% CI, 0.86-0.99; P=0.02]) and numerically higher rates of in-hospital major adverse cardiovascular events (9.1% versus 5.9%, P=0.10). There was no difference in Seattle Angina Questionnaire Summary Score at 12 months between adults aged ≥75 and <75 years (adjusted difference=0.9 [95% CI, -1.4 to 3.1; P=0.44]). Conclusions Despite modestly lower success rates and higher complication rates, adults aged ≥75 years experienced angina-related health status benefits after CTO-percutaneous coronary intervention that were similar in magnitude to adults aged <75 years. CTO percutaneous coronary intervention should not be withheld based on age alone in otherwise appropriate candidates.

Alignment of targeted temperature management treatment with patients' mortality risk for out-of-hospital cardiac arrest.

OBJECTIVE: To examine whether TTM treatment was aligned with predicted mortality risk in patients with resuscitated OHCA during a period when it was a class I guideline-recommended therapy. METHODS: Within the Cardiac Arrest Registry to Enhance Survival for OHCA, we identified adult patients with OHCA who survived to hospital admission and were presumed eligible for TTM. Multivariable models were constructed using pre-hospital variables to predict in-hospital death in patients with shockable and non-shockable rhythms. Within each rhythm category, we divided patients into deciles of predicted mortality risk and examined TTM treatment rates across deciles. RESULTS: From 2013-2019, there were 25,882 successfully resuscitated patients with shockable rhythms and 43,414 patients with non-shockable rhythms presumed eligible for TTM. Of patients with shockable rhythms, predicted in-hospital mortality ranged from 16%-78% in deciles 1-10. TTM treatment increased from 44% in decile 1 to 59% in decile 10 (P for trend < 0.001), but over a third of patients in deciles 4-9 were not treated with TTM. Of patients with non-shockable rhythms, predicted mortality ranged from 48%-95% in deciles 1-10. Although TTM treatment rates increased from 36% in decile 1 to 43% in decile 10 (P for trend 0.003), TTM treatment rates were agnostic to mortality risk (44% to 47%) from decile 2-9. CONCLUSION: TTM treatment patterns were not well-aligned with patients' mortality risk during a period when it was a guideline-recommended treatment for OHCA. Identifying strategies to better align guideline-recommended treatments with patients' mortality risk is critical for efforts to improve OHCA survival.

Catheter ablation of atrial fibrillation results in significant QTc prolongation in the postoperative period.

BACKGROUND: The corrected QT interval (QTc) is a measure of ventricular repolarization time, and a prolonged QTc increases risk for malignant ventricular arrhythmias. Pulmonary vein isolation (PVI) may increase QTc but its effects have not been well studied. OBJECTIVE: Determine the incidence, risk factors, and outcomes of patients presenting for PVI in sinus and atrial fibrillation with postoperative QTc prolongation in a large cohort. METHODS: We performed a single-center retrospective study of consecutive atrial fibrillation ablations. QTc durations using Bazett correction were obtained from electrocardiograms at different postoperative intervals and compared to preoperative QTc. We studied clinical outcomes including clinically significant ventricular arrhythmia and death. A multivariable model was used to identify factors associated with clinically significant QTc prolongation, defined as ΔQTc ≥60 ms or new QTc duration ≥500 ms. RESULTS: A total of 352 PVIs were included in this study. We observed a statistically significant increase in mean QTc compared to baseline (446.3 ± 37.8 ms) on postoperative day (POD)0 (471.7 ± 38.2 ms, P < .001) and at POD1 (456.5 ± 35.0 ms, P < .001). There was no significant difference at 1 month (452.4 ± 33.5 ms, P = .39) and 3 months (447.3 ± 40.0 ms, P = .78). Sixty-six patients (19.2%) developed ΔQTc ≥60 ms or QTc ≥500 ms on POD0, with 4.1% persisting past 90 days. Female sex (odds ratio [OR] = 1.82, 95% confidence interval [CI] =1.01-3.29, P = .047) and history of coronary artery disease (OR = 2.16, 95% CI = 1.03-4.55, P = .042) were independently predictive of QTc prolongation ≥500 ms or ΔQTc ≥60 ms. There were no episodes of clinically significant ventricular arrhythmia or death attributable to arrhythmia. CONCLUSION: QTc duration increased significantly immediately post-PVI and returned to baseline by 1 month. PVI did not provoke significant ventricular arrhythmias in our cohort.

Quality Improvement and Public Reporting in STEMI Care.

Mortality rates for patients with ST-segment elevation myocardial infarction (STEMI) remain high despite development of novel drugs and interventions over the past several decades. There is significant variability between hospitals in use of evidence-based treatments, and substantial opportunities exist to optimize care pathways and reduce disparities in care delivery. Quality improvement interventions implemented at local, regional, and national levels have improved care processes and patient outcomes. This article reviews evidence for quality improvement interventions along the spectrum of STEMI care, describes existing systems for quality measurement, and examines local and national policy interventions, with special attention to public reporting programs.