Trends of blood pressure control in the U.S. during the COVID-19 pandemic.

IMPORTANCE: COVID-19 altered lifestyles and disrupted routine health care. Whether blood pressure (BP) control worsened during COVID-19 is unknown. OBJECTIVE: To understand whether home BP control worsened during COVID-19 across the United States (US) . DESIGN, SETTING, AND PARTICIPANTS: A population-based analysis of home BP data from 72,706 participants enrolled in a digital health hypertension control program. Data was compared before (January 2019 to March 2020) and during (April 2020 to August 2020) COVID-19. MAIN OUTCOMES AND MEASURES: Monthly mean home BP readings, systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were quantified before and during the pandemic. Multivariable adjustments were made for age, sex, race, region, and months enrolled. Home BP readings were also classified based on monthly averages and highest home BP readings into risk groups: Stage 2 HTN: BP> = 135 or DBP> = 85; Uncontrolled HTN: SBP> = 145 or DBP> = 95; or Severely uncontrolled HTN: SBP> = 160 or DBP> = 100). RESULTS: Overall, 72,706 participants were enrolled in a digital health hypertension program between 1/1/2019 and 8/31/2020. Compared with participants pre-COVID-19 (n = 33,440), those during COVID-19 (n = 39,266) were of similar age (mean 53.0 ± 10.7 years vs 53.3 ± 10.8 years); sex (46% vs 50.6% female) and race (29.1% vs 34.2% non-white). Relative to pre-Covid (Apr-Aug 2019) the mean monthly number of home BP readings rose during COVID-19 (Apr-Aug, 2020), from 7.3 to 9.3 per month (P < .001). During COVID-19, participants had higher monthly adjusted mean SBP (131.6 mmHg vs. 127.5 mmHg, P < .001); DBP (80.2 mmHg vs. 79.2 mmHg, P < .001); and MAP (97.4 mmHg vs. 95.3 mmHg; P < .001). Relative to the pre-pandemic period, during COVID-19 the proportion of participants with a mean monthly BP classified as uncontrolled or severely uncontrolled hypertension also rose, 15% vs 19% and 4% vs 5%, respectively CONCLUSIONS AND RELEVANCE: Based on home BP readings, mean monthly BP rose modestly after COVID-19, despite increased utilization of home monitoring. Further studies are needed to examine the longitudinal effects of the pandemic on cardiovascular disease risk factors, the impact of these on long-term population health.

In-Hospital Mortality in Patients with Idiopathic Pulmonary Fibrosis: A US Cohort Study.

PURPOSE: In patients with idiopathic pulmonary fibrosis (IPF), hospitalizations are associated with high mortality. We sought to determine in-hospital mortality rates and factors associated with in-hospital mortality in patients with IPF. METHODS: Patients with IPF were identified from the Premier Healthcare Database, a representative administrative dataset that includes > 20% of hospital discharges in the US, using an algorithm based on diagnostic codes and billing data. We used logistic regression to analyze associations between patient-, hospital-, and treatment-related characteristics and a composite primary outcome of death during the index visit, lung transplant during the index visit and > 1 day after admission, or death during a readmission within 90 days. RESULTS: The cohort comprised 6665 patients with IPF hospitalized between October 2011 and October 2014. A total of 963 (14.4%) met the primary outcome. Factors significantly associated with a higher risk of the primary outcome included mechanical ventilation [odds ratio 4.65 (95% CI 3.73, 5.80)], admission to the intensive care unit [1.83 (1.52, 2.21)], treatment with opioids (3.06 [2.57, 3.65]), and a diagnosis of pneumonia [1.44 (1.21, 1.71)]. Factors significantly associated with a lower risk included concurrent chronic obstructive pulmonary disease [0.65 (0.55, 0.77)] and female sex [0.67 (0.57, 0.79)]. CONCLUSIONS: Patients with IPF, particularly those receiving mechanical ventilation or intensive care, are at substantial risk of death or lung transplant during hospitalization or death during a readmission within 90 days.

Interventions for Preventing Thromboembolic Events in Patients With Atrial Fibrillation: A Systematic Review.

Background: The comparative safety and effectiveness of treatments to prevent thromboembolic complications in atrial fibrillation (AF) remain uncertain. Purpose: To compare the effectiveness of medical and procedural therapies in preventing thromboembolic events and bleeding complications in adults with nonvalvular AF. Data Sources: English-language studies in several databases from 1 January 2000 to 14 February 2018. Study Selection: Two reviewers independently screened citations to identify comparative studies of treatments to prevent stroke in adults with nonvalvular AF who reported thromboembolic or bleeding complications. Data Extraction: Two reviewers independently abstracted data, assessed study quality and applicability, and rated strength of evidence. Data Synthesis: Data from 220 articles were included. Dabigatran and apixaban were superior and rivaroxaban and edoxaban were similar to warfarin in preventing stroke or systemic embolism. Apixaban and edoxaban were superior and rivaroxaban and dabigatran were similar to warfarin in reducing the risk for major bleeding. Treatment effects with dabigatran were similar in patients with renal dysfunction (interaction P > 0.05), and patients younger than 75 years had lower bleeding rates with dabigatran (interaction P < 0.001). The benefit of treatment with apixaban was consistent in many subgroups, including those with renal impairment, diabetes, and prior stroke (interaction P > 0.05 for all). The greatest bleeding risk reduction was observed in patients with a glomerular filtration rate less than 50 mL/min/1.73 m2 (P = 0.003). Similar treatment effects were observed for rivaroxaban and edoxaban in patients with prior stroke, diabetes, or heart failure (interaction P > 0.05 for all). Limitation: Heterogeneous study populations, interventions, and outcomes. Conclusion: The available direct-acting oral anticoagulants (DOACs) are at least as effective and safe as warfarin for patients with nonvalvular AF. The DOACs had similar benefits across several patient subgroups and seemed safe and efficacious for a wide range of patients with nonvalvular AF. Primary Funding Source: Patient-Centered Outcomes Research Institute. (PROSPERO: CRD42017069999).

The association of in-hospital guideline adherence and longitudinal postdischarge mortality in older patients with non-ST-segment elevation myocardial infarction.

BACKGROUND: Prior work has demonstrated that adherence to American College of Cardiology/American Heart Association guideline recommendations is associated with decreased in-hospital mortality in non-ST-segment elevation myocardial infarction (NSTEMI) patients; however, it is unknown whether this association persists after hospital discharge in older, real-world populations. METHODS: We evaluated 32,646 NSTEMI patients ≥65 years treated at 243 US hospitals participating in CRUSADE from 2003 to 2006, linked to Medicare longitudinal claims data (followed to January 1, 2010). Hospital composite adherence examined the use of 13 individual American College of Cardiology/American Heart Association Class IA guideline-recommended interventions. Among patients who survived to hospital discharge, we used Cox proportional hazards modeling to examine the association between hospital composite adherence and 1- and 3-year mortality conditional on surviving initial hospitalization and adjusting for patient baseline clinical factors and hospital characteristics. RESULTS: The overall median composite guideline adherence to all 13 interventions was 77.4% with median (25th, 75th percentiles) hospital adherence ranging from 66.7% (61.9%, 70.1%) in the lowest adherence quartile to 85.8% (83.7%, 88.7%) in the highest adherence quartiles. Overall survival at 1 and 3 years was 80.0% and 62.8%, respectively. Relative to patients treated at the lowest adherence hospitals, those treated at the highest had similar adjusted mortality risk at 1 year but significantly lower 3-year mortality risk (adjusted hazard ratio [95% CI] 0.90 [0.82-0.99]). For every 10% increase in adherence to all 13 hospital composite therapies, there was a 5% reduction in 3-year mortality risk (0.95 [0.91-0.98]). CONCLUSIONS: Use of guideline-based therapies during acute hospitalization for NSTEMI was associated with significant decreases in mortality up to 3 years post-hospital discharge.

Translation of acute coronary syndrome therapies: from evidence to routine clinical practice.

BACKGROUND: The use of evidence-based therapies has improved the outcome of patients with acute coronary syndrome (ACS), but there is a time lag between the generation of clinical evidence and its application in routine clinical practice. We sought to quantify temporal lags in the lifecycle of American College of Cardiology (ACC)/American Heart Association (AHA) class IA ACS therapies. METHODS: Using current and historical ACC/AHA guideline publications, we retrieved publication dates of pivotal clinical trials (PCTs) and class IA guideline-recommended therapies for patients with ST-elevation myocardial infarction (STEMI) and unstable angina (UA)/non-STEMI (NSTEMI). Clinical practice uptake data for each therapy were retrieved from the National Registry for Myocardial Infarction, Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines, and Acute Coronary Treatment and Intervention Outcomes Network Registry-Get with the Guidelines, which are registries containing publicly available peer-reviewed data. Descriptive data were calculated and compared for each phase of the evidence lifecycle for both STEMI and UA/NSTEMI drug classifications. RESULTS: We identified 11 class IA- and 4 class IB/IC-recommended therapies for acute, inhospital, and discharge use for patients with STEMI or UA/NSTEMI. The median time lags were 2 years (interquartile range [IQR], 1-4 years) from PCT to practice guideline recommendation, 14 years (IQR, 11-15 years) from guideline recommendation to 90% practice uptake, and overall, a 16-year median (IQR, 13-19 years) from PCT to 90% practice uptake. CONCLUSIONS: The time of PCT publication to meaningful uptake of class IA ACS therapies into clinical practice took a median of 16 years. This significant time lag indicates systemic barriers to the translation of therapeutics into routine clinical practice.

Medication non-adherence after myocardial infarction: an exploration of modifying factors.

BACKGROUND: Medication non-adherence is a major impediment to the management of cardiovascular disease risk factors. A better understanding of the modifying factors underlying medication non-adherence among individuals with known cardiovascular disease may inform approaches for addressing non-adherence. OBJECTIVE: The purpose of this study was to identify demographic and patient characteristics, medical comorbidities, psychosocial factors, and health belief-related factors associated with medication non-adherence among patients with known cardiovascular disease. DESIGN: We performed secondary analysis of baseline data from a randomized trial. PATIENTS: The study included 405 patients with a diagnosis of hypertension and history of acute myocardial infarction that was diagnosed within a three-year period prior to enrollment. MAIN MEASURES: Baseline demographics and patient characteristics, medical comorbidities, psychosocial factors, health belief-related factors, and patient-reported medication non-adherence were analyzed. KEY RESULTS: Of 405 patients, 173 (42.7 %) reported medication non-adherence. Factors associated with non-adherence in bivariate analysis included younger age, non-white race, having less than 12 years of education, smoking, financial insecurity, identifying as nervous or tense, higher life chaos score, greater worry about having a myocardial infarction, and greater worry about having a stroke. Using multivariable modeling, we determined that age (OR 0.97 per additional year, 95 % CI, 0.95-0.99), life chaos (OR 1.06 per additional point, 95 % CI, 1.00-1.11), and worry about stroke (OR 1.12 per additional point, 95 % CI, 1.01-1.25) remained significantly associated with self-reported medication non-adherence. CONCLUSIONS: We found that worry about having a stroke, higher life chaos, and younger age were all significantly associated with self-reported medication non-adherence in patients with cardiovascular disease and a history of myocardial infarction. Further research exploring these factors as targets for intervention is needed, as is additional research examining modifiable causes of medication non-adherence among patients with cardiovascular disease.

Rate- and rhythm-control therapies in patients with atrial fibrillation: a systematic review.

BACKGROUND: The comparative effectiveness of treatments for atrial fibrillation (AF) is uncertain. PURPOSE: To evaluate the comparative effectiveness of rate- and rhythm-control therapies. DATA SOURCES: English-language studies in PubMed, EMBASE, and the Cochrane Database of Systematic Reviews between January 2000 and November 2013. STUDY SELECTION: Two reviewers independently screened citations to identify comparative studies that assessed rate- or rhythm-control therapies in patients with AF. DATA EXTRACTION: Reviewers extracted data on study design, participant characteristics, interventions, outcomes, applicability, and quality. DATA SYNTHESIS: 200 articles (162 studies) involving 28,836 patients were included. When pharmacologic rate- and rhythm-control strategies were compared, strength of evidence (SOE) was moderate supporting comparable efficacy with regard to all-cause mortality (odds ratio [OR], 1.34 [95% CI, 0.89 to 2.02]), cardiac mortality (OR, 0.96 [CI, 0.77 to 1.20]), and stroke (OR, 0.99 [CI, 0.76 to 1.30]) in older patients with mild AF symptoms. Few studies compared rate-control therapies and included outcomes of interest, which limited conclusions. For the effect of rhythm-control therapies in reducing AF recurrence, SOE was high favoring pulmonary vein isolation versus antiarrhythmic medications (OR, 5.87 [CI, 3.18 to 10.85]) and the surgical maze procedure (including pulmonary vein isolation) done during other cardiac surgery versus other cardiac surgery alone (OR, 7.94 [CI, 3.63 to 17.36]). LIMITATION: Studies were heterogeneous in interventions, populations, settings, and outcomes. CONCLUSION: Pharmacologic rate- and rhythm-control strategies have comparable efficacy across outcomes in primarily older patients with mild AF symptoms. Pulmonary vein isolation is better than antiarrhythmic medications at reducing recurrences of AF in younger patients with paroxysmal AF and mild structural heart disease. Future research should address uncertainties related to subgroups of interest and the effect of different therapies on long-term clinical outcomes. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Willingness of Patients to Use Computers for Health Communication and Monitoring Following Myocardial Infarction.

We describe the computer use characteristics of 406 post-myocardial infarction (MI) patients and their willingness to engage online for health communication and monitoring. Most participants were computer users (n = 259; 63.8%) and half (n = 209; 51.5%) read health information online at least monthly. However, most participants did not go online to track health conditions (n = 283; 69.7%), look at medical records (n = 287; 70.7%), or e-mail doctors (n = 351; 86.5%). Most participants would consider using a Web site to e-mail doctors (n = 275; 67.7%), share medical information with doctors (n = 302; 74.4%), send biological data to their doctor (n = 308; 75.9%), look at medical records (n = 321; 79.1%), track health conditions (n = 331; 81.5%), and read about health conditions (n = 332; 81.8%). Sharing health information online with family members (n = 181; 44.6%) or for support groups (n = 223; 54.9%) was not of much interest. Most post-MI participants reported they were interested in communicating with their provider and tracking their health conditions online. Because patients with a history of MI tend to be older and are disproportionately minority, researchers and clinicians must be careful to design interventions that embrace post-MI patients of diverse backgrounds that both improve their access to care and health outcomes.

Association of early physician follow-up and 30-day readmission after non-ST-segment-elevation myocardial infarction among older patients.

BACKGROUND: Hospital readmission rates within 30 days after acute myocardial infarction are a national performance metric. Previous data suggest that early physician follow-up after heart failure hospitalizations can reduce readmissions; whether these results can be extended to acute myocardial infarction is unclear. METHODS AND RESULTS: We analyzed data from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines (CRUSADE) Registry linked with Medicare claims from 2003 to 2006 for 25 872 non-ST-segment-elevation myocardial infarction patients ≥65 years of age discharged home from 228 hospitals with >25 patients and full revascularization capabilities. After adjusting for patient, treatment, and hospital characteristics, we examined the relationship between hospital-level physician follow-up within 7 days of discharge and 30-day all-cause readmission using logistic regression. The median hospital-level percentage of patients receiving early physician follow-up was 23.3% (interquartile range, 17.1%-29.1%). Among 24 165 patients with Medicare fee-for-service eligibility 30 days after discharge, 18.5% of patients were readmitted within 30 days of index hospitalization. Unadjusted and adjusted rates of 30-day readmission did not differ among quartiles of hospital-level early physician follow-up. Similarly, each 5% increase in hospital early follow-up was associated with an insignificant change in risk for readmission (adjusted odds ratio, 0.99; 95% confidence interval, 0.97-1.02; P=0.60). Sensitivity analyses extended these null findings to 30-day cardiovascular readmissions, high-risk subgroups, and early cardiology follow-up. CONCLUSIONS: Although rates of early physician follow-up after acute myocardial infarction varied among US hospitals, hospitals with higher early follow-up rates did not have lower 30-day readmission rates. Targeting strategies other than early physician follow-up may be necessary to reduce readmissions in this population.

Health City Cayman Islands and the globalization of health services delivery.

We describe a new health care campus under development in the Cayman Islands, Health City, based on the low-cost "focused factory" model. The construction of a multispecialty hospital opening in February 2014 less than a 4-hour flight away from the United States and convenient to both Central and South America for patients who already travel to the United States for clinical care could reshape the US health care marketplace and enhance access to affordable specialty health care in the region.

The impact of a measurement and feedback intervention on blood pressure control in ambulatory cardiology practice.

BACKGROUND: Although hypertension is a modifiable cardiovascular risk factor, up to one-third of ambulatory patients have uncontrolled blood pressure (BP). We evaluated the impact of a targeted provider feedback intervention on rates of BP control. METHODS: Clinic BP readings were aggregated among approximately 3,000 hypertensive patients followed up in 42 outpatient cardiology clinic practices at a large quaternary care academic medical center. Physician practices received quarterly reports on BP control rates. Provider-specific reports were benchmarked vs overall peer performance and distributed quarterly between September 2011 and September 2012. Rates of BP control were evaluated before and after the intervention. Medical record reviews were performed for a subset of patients with uncontrolled BP before (n = 300) and after (n = 300) the intervention to evaluate provider responses and interventions. RESULTS: At baseline, 27.9% of clinic patients had uncontrolled BP. After one 1 of reports, the rate of uncontrolled BP remained unchanged (27.7%, P = .86). Analysis of provider performance revealed a subset of providers who consistently outperform their peers. In the sample of patients selected for medical record reviews, at baseline (n = 300) and follow-up (n = 300), cardiologists discussed BP in 80% of clinic notes for patients with uncontrolled BP. Cardiologists more frequently documented repeat measurements after the intervention (28.0% vs 35.7%, P = .04). No other changes were found in documentation of provider responses to BP. CONCLUSIONS: Clinician-specific audit and feedback reports as a stand-alone intervention did not affect overall BP control rates in cardiology clinics. Future BP control interventions should consider real-time patient-specific reminders, provider incentive programs, and patient engagement interventions.

Implications of prior myocardial infarction for patients presenting with an acute myocardial infarction.

BACKGROUND: Prior myocardial infarction (MI) is a known risk factor for long-term mortality among acute MI patients; but its prevalence and implications for the short-term outcomes of patients with a new, acute MI remain uncertain. METHODS: We studied a total of 319,152 consecutively enrolled ST-segment elevation MI (STEMI) and non-STEMI (NSTEMI) patients in the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines (01/2007-03/2012). Baseline characteristics, home and in-hospital treatments, mortality rates, and major bleeding were compared separately for STEMI and NSTEMI by prior MI status, with adjustment for mortality and major bleeding. RESULTS: Prior MI was documented in 19% of STEMI (n = 124,535) and 29% of NSTEMI (n = 194,617) patients, who were older, were more likely to have comorbidities or prior revascularization, and were more commonly taking secondary prevention medications at home. Guideline-recommended treatments in-hospital and at discharge did not differ in prior-MI STEMI patients, but invasive management was lower for prior-MI NSTEMI patients. The frequency of in-hospital mortality was higher for prior-MI STEMI (5.9% vs. 5.2%) and NSTEMI patients (4.3% vs. 3.4%). After adjustment, the excess mortality risk associated with prior MI was no longer present for STEMI (odds ratio = 1.06, 95% CI 0.97-1.15), with only modest excess risk for NSTEMI (odds ratio = 1.10, 95% CI 1.04-1.15). The risk of in-hospital major bleeding was marginally lower for prior-MI NSTEMI. CONCLUSION: More than 20% of patients with acute MI treated in contemporary practice have a history of a prior MI; despite differences in the baseline risk profile, there was little difference in the adjusted risk of in-hospital mortality by prior-MI status.

Single-photon emission computed tomography myocardial perfusion imaging-assessed stress perfusion defect severity is associated with mortality independent of ethnicity in an Asian population.

BACKGROUND: Ischemic heart disease is growing by epidemic proportions in Asia. Among patients in Western populations with similar myocardial perfusion imaging (MPI) ischemia severity, ethnicity is independently associated with mortality. We aimed to determine the differential prognostic value of MPI abnormality severity among three major Asian ethnic groups. METHODS: From 16,921 consecutive patients, we used summed stress score to define increasing abnormal scan severity groups (minimal, mild, moderate, and severe) among Chinese, Indian, and Malay patients. We determined mortality from the national death registry. Using multivariable Cox regression models, we examined the association between ethnicity and mortality. RESULTS: Chinese patients were older than Indians or Malays. Annual all-cause death rates increased with increasing abnormal scan severity in all three ethnicities. After adjustment, ethnicity was not associated with mortality. With Chinese as the reference group, adjusted hazard ratio and 95% CI for Malays and Indians were 1.29 (0.95-1.77) and 1.06 (0.74-1.50) in the minimally abnormal scan group, and 1.20 (0.75-1.91) and 0.82 (0.47-1.45) in the severely abnormal scan group, respectively. CONCLUSIONS: Mortality risk is related to the severity of scan abnormality and is independent of ethnicity in Asians. Our findings emphasize the continued utility of MPI in guiding risk stratification in Asia.

Variability in performance measures for assessment of hypertension control.

BACKGROUND: Definitions of multiple performance measures exist for the assessment of blood pressure control; however, limited data on how these technical variations may affect actual measured performance are available. METHODS: We evaluated patients with hypertension followed routinely by cardiologists at Duke University Health System from 2009 to 2010. Provider hypertension control was compared based on reading at the last clinic visit vs the average blood pressure across all visits. The impact of home blood pressure measurements and patient exclusions endorsed by the American Heart Association, the American College of Cardiology, and the Physician Consortium for Performance Improvement were evaluated using medical record reviews. RESULTS: Among 5,552 hypertensive patients, the rate of blood pressure control based on last clinic visit was 69.1%; however, significant clinic-to-clinic variability was seen in serial clinic blood pressure measurements in individual patients (average 18 mm Hg). As a result, provider performance ratings varied considerably depending on whether a single reading or average blood pressure reading was used. The inclusion of home blood pressure measurements resulted in modestly higher rates of blood pressure control performance (+6% overall). Similarly, excluding patients who met guideline-recommended exclusion criteria increased blood pressure control rates only slightly (+3% overall). In contrast, excluding patients who were on 2 or more antihypertensive medications would have raised blood pressure control rates to 96% overall. CONCLUSION: Depending on definitions used, overall and provider-specific blood pressure control rates can vary considerably. Technical aspects of blood pressure performance measures may affect perceived quality gaps and comparative provider ratings.

Balancing the risk of mortality and major bleeding in the treatment of NSTEMI patients - a report from the National Cardiovascular Data Registry.

OBJECTIVES: We sought to describe real-world patterns of care in NSTEMI patients across different risk profiles for bleeding and mortality. BACKGROUND: The NCDR ACTION Registry-GWTG in-hospital mortality and major bleeding risk scores were developed to assess patient risk and optimize treatment decisions. However, little is known about the alignment of contemporary clinical management patterns with these risk estimates. METHODS: We studied 61,366 NSTEMI patients in the NCDR ACTION-Registry-GWTG from January 2007 to March 2009, stratifying them into four groups based on estimated risk of mortality and major bleeding. RESULTS: There were 24,709 (40.3%) patients in each of the concordant risk groups (low:low; high:high) and 5974 (9.7%) in each of the discordant risk groups (low:high; high:low). Subjects at high estimated risk for both mortality and major bleeding were least likely to receive guideline-based adjunctive pharmacotherapy or to undergo angiography within 48 hours but most likely to receive an excess dose of an antithrombotic agent. Patients at low estimated risk for mortality and bleeding received the most intensive adjunctive therapy and were most likely to undergo invasive angiography. CONCLUSION: There are significant differences in contemporary patterns of care across varying risk profiles of mortality and major bleeding. Despite practice patterns which seem to emphasize avoiding harm with reduced use of antithrombotic therapy, patients at high risk for major bleeding continue to receive excess doses of antithrombotic therapy. Additional performance improvement efforts are needed to optimize outcomes in NSTEMI patients with high risk for both bleeding and mortality.

The association between smoking and long-term outcomes after non-ST-segment elevation myocardial infarction in older patients.

BACKGROUND: Prior studies have observed that smokers have paradoxically favorable 1-year mortality rates after acute coronary syndromes, but it is unknown whether this association extends to long-term outcomes and to older patients. METHODS: We identified 38,628 patients aged ≥65 years participating in the CRUSADE Registry between February 2003 and December 2006 with non-ST-segment elevation myocardial infarction and linked these patients to Medicare claims data to assess longitudinal outcomes. Cox proportional hazard models were used to examine the association between smoking, 30-day, and long-term outcomes. RESULTS: Overall, 4,876 (13%) were current/recent smokers and 33,752 (87%) were nonsmokers. Compared with nonsmokers, smokers were younger and more likely to be male and to receive in-hospital revascularization (all P < .001) but less likely to have hypertension, diabetes mellitus, and renal insufficiency. Compared with nonsmokers, the unadjusted 30-day mortality was lower (8.7% vs 10.3%, P = .0004), but the adjusted 30-day mortality was similar (adjusted hazard ratio [HR] 1.08, 95% CI 0.97-1.20). Over a median of 3.6 years of follow-up, smokers had lower crude long-term mortality rates (53% vs 55% at 6 years, P = .001) but significantly higher long-term mortality rates after adjustment (adjusted HR 1.28, 95% CI 1.21-1.34). Smokers also had higher risks of all-cause readmission (HR 1.13, 95% CI 1.09-1.17) and recurrent myocardial infarction (HR 1.23, 95% CI 1.13-1.34). CONCLUSIONS: Among older non-ST-segment elevation myocardial infarction patients, we found that smokers had significantly higher long-term risks for both mortality and recurrent myocardial infarction. These results support ongoing efforts to promote smoking cessation, even among older patients.

Impact of choice of imaging modality accompanying outpatient exercise stress testing on outcomes and resource use after revascularization for acute coronary syndromes.

BACKGROUND: Exercise stress testing is commonly obtained after percutaneous coronary intervention (PCI) performed for acute coronary syndromes (ACS). We compared the relationships between exercise echocardiography and nuclear testing after ACS-related PCI on outcomes and resource use. METHODS: Longitudinal observational study using fee-for-service Medicare claims to identify patients undergoing outpatient exercise stress testing with imaging within 15 months after PCI performed for ACS between 2003 and 2004. RESULTS: Of 63,100 patients undergoing stress testing 3 to 15 months post-PCI, 31,731 (50.3%) underwent an exercise stress test with imaging. Among 29,279 patients undergoing exercise stress testing with imaging, 15.5% received echocardiography. Echocardiography recipients had higher rates of repeat stress testing (adjusted hazard ratio [HR] 2.60, CI 2.19-3.10) compared with those undergoing nuclear imaging in the 90 days after testing, but lower rates of revascularization (adjusted HR 0.87, CI 0.76-0.98) and coronary angiography (adjusted HR 0.88, CI 0.80-0.97). None of these differences persisted subsequent to 90 days after stress testing. Rates of death and readmission for myocardial infarction rates were similar. Total Medicare payments were lower initially after echocardiography (incremental difference $498, CI 488-507), an effect attributed primarily to lower reimbursement for the stress test itself, but not significantly different after 14 months after testing. CONCLUSIONS: In this study using administrative data, echocardiography recipients initially had fewer invasive procedures but higher rates of repeat testing than nuclear testing recipients. However, these differences between echo and nuclear testing did not persist over longer time frames.

The Effect of a Digital Mental Health Program on Anxiety and Depression Symptoms: Retrospective Analysis of Clinical Severity.

BACKGROUND: Evidence-based digital health programs have shown efficacy in being primary tools to improve emotional and mental health, as well as offering supplementary support to individuals undergoing psychotherapy for anxiety, depression, and other mental health disorders. However, information is lacking about the dose response to digital mental health interventions. OBJECTIVE: The objective of the study was to examine the effect of time in program and program usage on symptom change among individuals enrolled in a real-world comprehensive digital mental health program (myStrength) who are experiencing severe anxiety or depression. METHODS: Eligible participants (N=18,626) were adults aged 18 years and older who were enrolled in myStrength for at least four weeks as part of their employee wellness benefit program, who completed baseline, the 2-week, 2-month, and 6-month surveys querying symptoms of anxiety (Generalized Anxiety Disorder-7 [GAD-7]) and depression (Patient Health Questionnaire-9 [PHQ-9]). Linear growth curve models were used to analyze the effect of average weekly program usage on subsequent GAD-7 and PHQ-9 scores for participants with scores indicating severe anxiety (GAD-7≥15) or depression (PHQ-9≥15). All models were adjusted for baseline score and demographics. RESULTS: Participants in the study (N=1519) were 77.4% female (1176/1519), had a mean age of 45 years (SD 14 years), and had an average enrollment time of 3 months. At baseline, participants reported an average of 9.39 (SD 6.04) on the GAD-7 and 11.0 (SD 6.6) on the PHQ-9. Those who reported 6-month results had an average of 8.18 (SD 6.15) on the GAD-7 and 9.18 (SD 6.79) on the PHQ-9. Participants with severe scores (n=506) experienced a significant improvement of 2.97 (SE 0.35) and 3.97 (SE 0.46) at each time point for anxiety and depression, respectively (t=-8.53 and t=-8.69, respectively; Ps<.001). Those with severe baseline scores also saw a reduction of 0.27 (SE 0.08) and 0.25 (SE 0.09) points in anxiety and depression, respectively, for each additional program activity per week (t=-3.47 and t=-2.66, respectively; Ps<.05). CONCLUSIONS: For participants with severe baseline scores, the study found a clinically significant reduction of approximately 9 points for anxiety and 12 points for depression after 6 months of enrollment, suggesting that interventions targeting mental health must maintain active, ongoing engagement when symptoms are present and be available as a continuous resource to maximize clinical impact, specifically in those experiencing severe anxiety or depression. Moreover, a dosing effect was shown, indicating improvement in outcomes among participants who engaged with the program every other day for both anxiety and depression. This suggests that digital mental health programs that provide both interesting and evidence-based activities could be more successful in further improving mental health outcomes.

Downstream procedures and outcomes after stress testing for chest pain without known coronary artery disease in the United States.

BACKGROUND: Millions of Americans with suspected coronary artery disease undergo noninvasive cardiac stress testing annually. Downstream procedures and subsequent outcomes among symptomatic patients without known coronary disease referred for stress testing are not well characterized in contemporary community practice. METHODS: We examined administrative insurance billing data from a national insurance provider from November 2004 through June 2007. After excluding patients with prior cardiac disease or chest pain evaluation, we identified 80,676 people age 40 to 64 years with outpatient cardiac stress testing within 30 days after an office visit for chest pain. We evaluated rates of invasive coronary angiography, coronary revascularization, and cardiovascular events after stress testing. RESULTS: Within 60 days, only 8.8% of stress test patients underwent cardiac catheterization and only 2.7% underwent revascularization; within 1 year, only 0.5% died and had myocardial infarction or stroke. There were marked geographic variations in 1-year rates of catheterization (3.8%-14.8%) and revascularization (1.2%-3.0%) across 20 hospital referral regions. CONCLUSIONS: In this large national cohort of middle-aged patients without previously coded cardiac diagnosis who were referred for stress testing after outpatient chest pain evaluation, few proceeded to invasive angiography or revascularization, and subsequent cardiovascular events were infrequent.

Safety and effectiveness of antithrombotic strategies in older adult patients with atrial fibrillation and non-ST elevation myocardial infarction.

BACKGROUND: We aimed to study the comparative safety and effectiveness of various antithrombotic treatment strategies among older adults with non-ST elevation myocardial infarction (NSTEMI) and atrial fibrillation (AF). METHODS: Using the CRUSADE registry linked to longitudinal Medicare claims data, we examined NSTEMI patients aged ≥ 65 years with a concomitant diagnosis of AF. Multivariable Cox analysis was used to compare risk of rehospitalization for bleeding and a major cardiac composite end point of death, readmission for myocardial infarction, or stroke, according to discharge antithrombotic strategy. RESULTS: Among 7619 NSTEMI patients with AF, 29% were discharged on aspirin alone; 37%, on aspirin + clopidogrel; 7%, on warfarin alone; 17%, on aspirin + warfarin; and 10%, on warfarin + aspirin + clopidogrel. There was no difference in predicted stroke risk between groups. By 1 year, 12.2% of patients were rehospitalized for bleeding, and 33.1% had a major cardiac event. Relative to aspirin alone, antithrombotic intensification was associated with increased bleeding risk (aspirin + clopidogrel adjusted HR 1.22, 95% CI 1.03-1.46 and warfarin + aspirin HR 1.46, 95% CI 1.21-1.80). Patients treated with aspirin + clopidogrel + warfarin had the highest observed bleeding risk (HR 1.65, 95% CI 1.30-2.10). One-year risk of the major cardiac end point was similar between groups, although, relative to aspirin only, there was a trend toward lower risk for the warfarin + aspirin group (HR 0.88, 95% CI 0.78-1.00). CONCLUSIONS: Older NSTEMI patients with AF are at high risk for subsequent bleeding and major cardiac events. Increased antithrombotic management was associated with increased bleeding risk. Further investigation is needed to clarify whether these risks are counterbalanced by reduced thromboembolic events in this population.