Clinical Outcomes After Acute Coronary Syndromes or Revascularization Among People Living With HIV: A Systematic Review and Meta-Analysis.

Importance: Clinical outcomes after acute coronary syndromes (ACS) or percutaneous coronary interventions (PCIs) in people living with HIV have not been characterized in sufficient detail, and extant data have not been synthesized adequately. Objective: To better characterize clinical outcomes and postdischarge treatment of patients living with HIV after ACS or PCIs compared with patients in an HIV-negative control group. Data Sources: Ovid MEDLINE, Embase, and Web of Science were searched for all available longitudinal studies of patients living with HIV after ACS or PCIs from inception until August 2023. Study Selection: Included studies met the following criteria: patients living with HIV and HIV-negative comparator group included, patients presenting with ACS or undergoing PCI included, and longitudinal follow-up data collected after the initial event. Data Extraction and Synthesis: Data extraction was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Clinical outcome data were pooled using a random-effects model meta-analysis. Main Outcome and Measures: The following clinical outcomes were studied: all-cause mortality, major adverse cardiovascular events, cardiovascular death, recurrent ACS, stroke, new heart failure, total lesion revascularization, and total vessel revascularization. The maximally adjusted relative risk (RR) of clinical outcomes on follow-up comparing patients living with HIV with patients in control groups was taken as the main outcome measure. Results: A total of 15 studies including 9499 patients living with HIV (pooled proportion [range], 76.4% [64.3%-100%] male; pooled mean [range] age, 56.2 [47.0-63.0] years) and 1 531 117 patients without HIV in a control group (pooled proportion [range], 61.7% [59.7%-100%] male; pooled mean [range] age, 67.7 [42.0-69.4] years) were included; both populations were predominantly male, but patients living with HIV were younger by approximately 11 years. Patients living with HIV were also significantly more likely to be current smokers (pooled proportion [range], 59.1% [24.0%-75.0%] smokers vs 42.8% [26.0%-64.1%] smokers) and engage in illicit drug use (pooled proportion [range], 31.2% [2.0%-33.7%] drug use vs 6.8% [0%-11.5%] drug use) and had higher triglyceride (pooled mean [range], 233 [167-268] vs 171 [148-220] mg/dL) and lower high-density lipoprotein-cholesterol (pooled mean [range], 40 [26-43] vs 46 [29-46] mg/dL) levels. Populations with and without HIV were followed up for a pooled mean (range) of 16.2 (3.0-60.8) months and 11.9 (3.0-60.8) months, respectively. On postdischarge follow-up, patients living with HIV had lower prevalence of statin (pooled proportion [range], 53.3% [45.8%-96.1%] vs 59.9% [58.4%-99.0%]) and ß-blocker (pooled proportion [range], 54.0% [51.3%-90.0%] vs 60.6% [59.6%-93.6%]) prescriptions compared with those in the control group, but these differences were not statistically significant. There was a significantly increased risk among patients living with HIV vs those without HIV for all-cause mortality (RR, 1.64; 95% CI, 1.32-2.04), major adverse cardiovascular events (RR, 1.11; 95% CI, 1.01-1.22), recurrent ACS (RR, 1.83; 95% CI, 1.12-2.97), and admissions for new heart failure (RR, 3.39; 95% CI, 1.73-6.62). Conclusions and Relevance: These findings suggest the need for attention toward secondary prevention strategies to address poor outcomes of cardiovascular disease among patients living with HIV.

Persistence of significant secondary mitral regurgitation post-cardiac resynchronization therapy and survival: a systematic review and meta-analysis : Mitral regurgitation and mortality post-CRT.

Cardiac resynchronization therapy (CRT) significantly reduces secondary mitral regurgitation (MR) in patients with severe left ventricular systolic dysfunction. However, uncertainty remains as to whether improvement in secondary MR correlates with improvement with mortality seen in CRT. We conducted a meta-analysis to determine the association of persistent unimproved significant secondary MR (defined as moderate or moderate-to-severe or severe MR) compared to improved MR (no MR or mild MR) post-CRT with all-cause mortality, cardiovascular mortality, and heart failure hospitalization. A systematic search of PubMed, EMBASE, and Cochrane Library databases till July 31, 2022 identified studies reporting clinical outcomes by post-CRT secondary MR status. In 12 prospective studies of 4954 patients (weighted mean age 66.8 years, men 77.8%), the median duration of follow-up post-CRT at which patients were re-evaluated for significant secondary MR was 6 months and showed significant relative risk reduction of 30% compared to pre-CRT. The median duration of follow-up post-CRT for ascertainment of main clinical outcomes was 38 months. The random effects pooled hazard ratio (95% confidence interval) of all-cause mortality in patients with unimproved secondary MR compared to improved secondary MR was 2.00 (1.57-2.55); p < 0.001). There was insufficient data to evaluate secondary outcomes in a meta-analysis, but limited data that examined the relationship showed significant association of unimproved secondary MR with increased cardiovascular mortality and heart failure hospitalization. The findings of this meta-analysis suggest that lack of improvement in secondary MR post-CRT is associated with significantly elevated risk of all-cause mortality and possibly cardiovascular mortality and heart failure hospitalization. Future studies may investigate approaches to address persistent secondary MR post-CRT to help improved outcome in this population.

Risk of death and readmission among individuals with heart failure and HIV: A systematic review and meta-analysis.

The association between human immunodeficiency virus (HIV) status and readmissions and death outcomes in patients with established heart failure (HF) remains unclear. We conducted a systematic search of PubMed, EMBASE, Cochrane Library, and Web of Science up to March 1st, 2023, for cohort studies of adult patients (≥18 years) diagnosed with HF and recorded HIV status at baseline. Our analysis included 7 studies with 10,328 HF patients living with HIV and 48,757 HF patients without HIV. Compared to HF patients without HIV, those with HIV had a higher risk of all-cause deaths (HR: 1.20, 95% CI: 1.15-1.25). HIV infection was also associated with increased risks of HF-associated readmission (HR: 1.34, 95% CI: 1.03-1.75) and all-cause readmission (HR: 1.27, 95% CI: 1.10-1.46). Our study highlights the independent association between HIV and poor HF outcomes, emphasizing the need for improved management in individuals living with HIV.

Proprotein convertase subtilisn/kexin type 9 inhibitors and small interfering RNA therapy for cardiovascular risk reduction: A systematic review and meta-analysis.

BACKGROUND: Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of mortality worldwide. Atherosclerosis occurs due to accumulation of low-density lipoprotein cholesterol (LDL-c) in the arterial system. Thus, lipid lowering therapy is essential for both primary and secondary prevention. Proprotein convertase subtilisn/kexin type 9 (PCSK9) inhibitors (Evolocumab, Alirocumab) and small interfering RNA (siRNA) therapy (Inclisiran) have been demonstrated to lower LDL-c and ASCVD events in conjunction with maximally tolerated statin therapy. However, the degree of LDL-c reduction and the impact on reducing major adverse cardiac events, including their impact on mortality, remains unclear. OBJECTIVE: The purpose of this study is to examine the effects of PCSK9 inhibitors and small interfering RNA (siRNA) therapy on LDL-c reduction and major adverse cardiac events (MACE) and mortality by conducting a meta-analysis of randomized controlled trials. METHODS: Using Pubmed, Embase, Cochrane Library and clinicaltrials.gov until April 2023, we extracted randomized controlled trials (RCTs) of PCSK9 inhibitors (Evolocumab, Alirocumab) and siRNA therapy (Inclisiran) for lipid lowering and risk of MACE. Using random-effects models, we pooled the relative risks and 95% CIs and weighted least-squares mean difference in LDL-c levels. We estimated odds ratios with 95% CIs among MACE subtypes and all-cause mortality. Fixed-effect model was used, and heterogeneity was assessed using the I2 statistic. RESULTS: In all, 54 studies with 87,669 participants (142,262 person-years) met criteria for inclusion. LDL-c percent change was reported in 47 studies (n = 62,634) evaluating two PCSK9 inhibitors and siRNA therapy. Of those, 21 studies (n = 41,361) included treatment with Evolocumab (140mg), 22 (n = 11,751) included Alirocumab (75mg), and 4 studies (n = 9,522) included Inclisiran (284mg and 300mg). Compared with placebo, after a median of 24 weeks (IQR 12-52), Evolocumab reduced LDL-c by -61.09% (95% CI: -64.81, -57.38, p<0.01) and Alirocumab reduced LDL-c by -46.35% (95% CI: -51.75, -41.13, p<0.01). Inclisiran 284mg reduced LDL-c by -54.83% (95% CI: -59.04, -50.62, p = 0.05) and Inclisiran 300mg reduced LDL-c by -43.11% (95% CI: -52.42, -33.80, p = 0.01). After a median of 8 months (IQR 6-15), Evolocumab reduced the risk of myocardial infarction (MI), OR 0.72 (95% CI: 0.64, 0.81, p<0.01), coronary revascularization, 0.77 (95% CI: 0.70, 0.84, p<0.01), stroke, 0.79 (95% CI: 0.66, 0.94, p = 0.01) and overall MACE 0.85 (95% CI: 0.80, 0.89, p<0.01). Alirocumab reduced MI, 0.57 (0.38, 0.86, p = 0.01), cardiovascular mortality 0.35 (95% CI: 0.16, 0.77, p = 0.01), all-cause mortality 0.60 (95% CI: 0.43, 0.84, p<0.01), and overall MACE 0.35 (0.16, 0.77, p = 0.01). CONCLUSION: PCSK9 inhibitors (Evolocumab, Alirocumab) and siRNA therapy (Inclisiran) significantly reduced LDL-c by >40% in high-risk individuals. Additionally, both Alirocumab and Evolocumab reduced the risk of MACE, and Alirocumab reduced cardiovascular and all-cause mortality.

Comparing Lookback Periods to Ascertain Alzheimer's Disease and Related Dementias.

Claims data are a valuable resource for studying Alzheimer's disease and related dementias (ADRD). Alzheimer's disease and related dementias is often identified using a list of claims codes and a fixed lookback period of 3 years of data. However, a 1-year lookback or an approach using all-available lookback data could be beneficial based on different research questions. Thus, the purpose of this study was to compare 1-year and all-available lookback approaches to ascertaining ADRD compared to the standard 3-year approach. Using a cohort of Veterans hospitalized for heart failure (N = 373, 897), our results suggested high agreement (93% or greater) between the lookback periods. The 1-year lookback period had lower sensitivity (60%) and underestimated the prevalence of ADRD. These results suggest that 1-year and all-available lookback periods are viable approaches when using claims data.

Incidence of New Dementia Diagnosis in Veterans Admitted to Nursing Homes After Heart Failure Hospitalization.

BACKGROUND: Hospitalization with heart failure (HF) may signal an increased risk of Alzheimer's disease and related dementias (ADRD). Nursing homes routinely assess cognition but the association of these results with new ADRD diagnosis in a population at high risk of ADRD is not known. OBJECTIVE: To determine the association between nursing home cognitive assessment results and new diagnosis of dementia after heart failure hospitalization. METHODS: This retrospective cohort study included Veterans hospitalized for HF and discharged to nursing homes, from 2010 to 2015, without a prior diagnosis of ADRD. We determined mild, moderate, or severe cognitive impairment using multiple items of the nursing home admission assessment. We used Cox regression to determine the association of cognitive impairment with new ADRD diagnosis during 365 days of follow-up. RESULTS: The cohort included 7,472 residents, new diagnosis of ADRD occurred in 4,182 (56%). The adjusted hazard ratio of ADRD diagnosis was 4.5 (95% CI 4.2, 4.8) for the mild impairment group, 5.4 (95% CI 4.8, 5.9) for moderate impairment, and 4.0 (95% CI 3.2, 5.0) for severe impairment compared to the cognitively intact group. CONCLUSION: New ADRD diagnoses occurred in more than half of Veterans with HF admitted to nursing homes for post-acute care.

Acute Antipsychotic Use and Presence of Dysphagia Among Older Veterans with Heart Failure.

OBJECTIVE: Examine whether new antipsychotic (AP) exposure is associated with dysphagia in hospitalized patients with heart failure (HF). DESIGN: Retrospective cohort. SETTINGS AND PARTICIPANTS: AP-naïve Veterans hospitalized with HF and subsequently discharged to a skilled nursing facility (SNF) between October 1, 2010, and November 30, 2019. METHODS: We linked Veterans Health Administration (VHA) electronic medical records with Centers for Medicare & Medicaid (CMS) Minimum Data Set (MDS) version 3.0 assessments and CMS claims. The exposure variable was administration of ≥1 dose of a typical or atypical AP during hospitalization. Our main outcome measure was dysphagia presence defined by (1) inpatient dysphagia diagnosis codes and (2) the SNF admission MDS 3.0 swallowing-related items to examine post-acute care dysphagia status. Inverse probability of treatment weighting was used for risk adjustment. RESULTS: The analytic cohort consisted of 29,591 Veterans (mean age 78.5 ± 10.0 years; female 2.9%; n = 865). Acute APs were administered to 9.9% (n = 2941). Those receiving APs had differences in prior dementia [37.1%, n = 1091, vs 22.3%, n = 5942; standardized mean difference (SMD) = 0.33] and hospital delirium diagnoses (7.7%, n = 227 vs 2.8%, n = 754; SMD = 0.22). Acute AP exposure was associated with nearly double the risk for hospital dysphagia diagnosis codes [adjusted (adj.) relative risk (RR) 1.9, 95% CI 1.8, 2.1]. At the SNF admission MDS assessment, acute AP administration during hospitalization was associated with an increased dysphagia risk (adj. RR 1.2, 95% CI 1.0, 1.5) both in the oral (adj. RR 1.7, 95% CI 1.2, 2.0) and pharyngeal phases (adj. RR 1.3, 95% CI 1.0, 1.7). CONCLUSIONS AND IMPLICATIONS: In this retrospective study, AP medication exposure was associated with increased dysphagia coding and MDS assessment. Considering other adverse effects, acute AP should be cautiously administered during hospitalization, particularly in those with dementia. Swallowing function is critical to hydration, nutrition, and medical management of HF; therefore, when acute APs are initiated, a swallow evaluation should be considered.

Type 1 diabetes and risk of heart failure: A systematic review and meta-analysis.

AIM: Robust data on type 1 diabetes (T1DM) and the risk of heart failure (HF) is scarce. METHODS: We searched PubMed and EMBASE for relevant studies, abstracted data on HF incidence rate and adjusted relative risk (aRR) for T1DM, type 2 diabetes (T2DM) and controls, and pooled incidence rates and aRRs for HF across studies. RESULTS: Four studies including 61,885 T1DM patients, 4,599,213 non-diabetic controls, and 248,021 T2DM patients (three studies) were included. The pooled average proportions of men were 56%, 54%, and 55%, for T1DM, T2DM, and controls, respectively. The corresponding pooled average participants' ages were 40, 65 and 57 years, respectively. Over a 1 to 12 years follow-up, 1378, 3993, 18,945 HF events occurred among individuals with T1DM, T2DM, and controls, yielding pooled HF incidence rates of 5.8 (95%CI: 4.1-7.6), 10.0 (95% CI: 6.1-13.9), 2.3 (95% CI: 1.5-3.2) per 1000 person-years, respectively. Compared to controls, T1DM patients had a 3-fold higher HF risk (aRR 3.4, 95% CI 2.71-4.26). The RR of HF was âˆ¼ 5-fold higher in women (aRR: 4.9, 95% CI: 4.1-5.9) vs. 3-fold higher in men (aRR: 3.0, 95% CI: 2.2-4.0). CONCLUSIONS: Individuals with T1DM had a substantially higher risk of HF compared to those without diabetes.

Performance of Cardiovascular Risk Prediction Models Among People Living With HIV: A Systematic Review and Meta-analysis.

Importance: Extant data on the performance of cardiovascular disease (CVD) risk score models in people living with HIV have not been synthesized. Objective: To synthesize available data on the performance of the various CVD risk scores in people living with HIV. Data Sources: PubMed and Embase were searched from inception through January 31, 2021. Study Selection: Selected studies (1) were chosen based on cohort design, (2) included adults with a diagnosis of HIV, (3) assessed CVD outcomes, and (4) had available data on a minimum of 1 CVD risk score. Data Extraction and Synthesis: Relevant data related to study characteristics, CVD outcome, and risk prediction models were extracted in duplicate. Measures of calibration and discrimination are presented in tables and qualitatively summarized. Additionally, where possible, estimates of discrimination and calibration measures were combined and stratified by type of risk model. Main Outcomes and Measures: Measures of calibration and discrimination. Results: Nine unique observational studies involving 75 304 people (weighted average age, 42 years; 59 490 male individuals [79%]) living with HIV were included. In the studies reporting these data, 86% were receiving antiretroviral therapy and had a weighted average CD4+ count of 449 cells/µL. Included in the study were current smokers (50%), patients with diabetes (5%), and patients with hypertension (25%). Ten risk prediction scores (6 in the general population and 4 in the HIV-specific population) were analyzed. Most risk scores had a moderate performance in discrimination (C statistic: 0.7-0.8), without a significant difference in performance between the risk scores of the general and HIV-specific populations. One of the HIV-specific risk models (Data Collection on Adverse Effects of Anti-HIV Drugs Cohort 2016) and 2 of the general population risk models (Framingham Risk Score [FRS] and Pooled Cohort Equation [PCE] 10 year) had the highest performance in discrimination. In general, models tended to underpredict CVD risk, except for FRS and PCE 10-year scores, which were better calibrated. There was substantial heterogeneity across the studies, with only a few studies contributing data for each risk score. Conclusions and Relevance: Results of this systematic review and meta-analysis suggest that general population and HIV-specific CVD risk models had comparable, moderate discrimination ability in people living with HIV, with a general tendency to underpredict risk. These results reinforce the current recommendations provided by the American College of Cardiology/American Heart Association guidelines to consider HIV as a risk-enhancing factor when estimating CVD risk.

Particulate matter 2.5, metropolitan status, and heart failure outcomes in US counties: A nationwide ecologic analysis.

The relationship between particulate matter with a diameter of 2.5 micrometers or less (PM2.5) and heart failure (HF) hospitalizations and mortality in the US is unclear. Prior studies are limited to studying the effects of daily PM2.5 exposure on HF hospitalizations in specific geographic regions. Because PM2.5 can vary by geography, this study examines the effects of annual ambient PM2.5 exposure on HF hospitalizations and mortality at a county-level across the US. A cross-sectional analysis of county-level ambient PM2.5 concentration, HF hospitalizations, and HF mortality across 3135 US counties nationwide was performed, adjusting for county-level demographics, socioeconomic factors, comorbidities, and healthcare-associated behaviors. There was a moderate correlation between county PM2.5 and HF hospitalization among Medicare beneficiaries (r = 0.41) and a weak correlation between county PM2.5 and HF mortality (r = 0.08) (p-values < 0.01). After adjustment for various county level covariates, every 1 ug/m3 increase in annual PM2.5 concentration was associated with an increase of 0.51 HF Hospitalizations/1,000 Medicare Beneficiaries and 0.74 HF deaths/100,000 residents (p-values < 0.05). In addition, the relationship between PM2.5 and HF hospitalizations was similar when factoring in metropolitan status of the counties. In conclusion, increased ambient PM2.5 concentration level was associated with increased incidence of HF hospitalizations and mortality at the county level across the US. This calls for future studies exploring policies that reduce ambient particulate matter pollution and their downstream effects on potentially improving HF outcomes.

Two decade trends in cardiovascular disease outcomes and cardiovascular risk factors among US veterans living with HIV.

Coomprhensive data on temporal trends in cardiovascular disease (CVD) risk factors and outcomes in people living with HIV are limited. Using retrospective data on 50,284 US Veterans living with HIV (VLWH) who received care in the VA from 2001 to 2019, we calculated the prevalence and incidence estimates of CVD risk factors and outcomes, as well as the average annual percent changes (AAPC) in the estimates. The mean age of the Veterans increased from 47.8 (9.1) years to 58.0 (12.4) years during the study period. The population remained predominantly (>95%) male and majority Black (∼50%). The prevalence of the CVD outcomes increased progressively over the study period: coronary artery disease (3.9%-18.7%), peripheral artery disease (2.3%, 10.3%), ischemic cerebrovascular disease (1.1%-9.9%), and heart failure (2.4%-10.5%). There was a progressive increase in risk factor burden, except for smoking which declined after 2015. The AAPC in prevalence was statistically significant for the CVD outcomes and risk factors. When adjusted for age, the predicted prevalence of CVD risk factors and outcomes showed comparable (but attenuated) trends. There was generally a comparable (but attenuated) trend in incidence of CVD outcomes, procedures, and risk factors over the study period. The use of statins increased from 10.6% (2001) to 40.8% (2019). Antiretroviral therapy usage increased from 77.7% (2001) to 85.0% (2019). In conclusion, in a retrospective analysis of large-scale VA data we found the burden and incidence of several CVD risk factors and outcomes have increased among VLWH over the past 20 years.

Associations between cumulative social risk, psychosocial risk, and ideal cardiovascular health: Insights from the HeartSCORE study.

Background: Limited studies have assessed the effects of psychosocial risk factors on achievement of ideal cardiovascular health (CVH). Methods: Using the Heart Strategies Concentrating on Risk Evaluation (HeartSCORE) cohort, we examined the cross-sectional associations of cumulative social risk (CSR) and three psychosocial factors (depression, stress, perceived discrimination) with ideal CVH. CSR was calculated by assigning one point for each of: low family income, low education level, minority race (Black), and single-living status. Ideal CVH was calculated by assigning one point for ideal levels of each factor in American Heart Association's Life's Simple 7. Ideal CVH was dichotomized into fewer versus higher by combining participants achieving <3 versus ≥3 factors. Logistic regression models were used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) of having fewer ideal CVH factors. Psychosocial factors were assessed as mediators of the association between CSR and ideal CVH. Results: We included 2000 participants (mean age 59.1 [7.5] years, 34.6% male, 42.7% Black, and 29.1% with low income), among whom 60.6% had <3 ideal CVH factors. The odds of having fewer ideal CVH factors increased significantly with increasing CSR scores from 1 to 2, to ≥3 compared to individuals with CSR score of zero, after adjusting for age and sex (OR [95% CIs]: 1.77 [1.41 - 2.22]; 2.09 [1.62 - 2.69] 2.67 [1.97 - 3.62], respectively). Taking the components of ideal CVH separately, higher CSR was directly associated with odds of being in 'non-ideal' category for six of the seven factors, but was inversely associated with probability of being in 'non-ideal' category for cholesterol. The association was modestly attenuated after adjusting for depression, stress, and perceived discrimination (corresponding OR [95% CI]: 1.69 [1.34 - 2.12], 1.96 [1.51 - 2.55], 2.34 [1.71 - 3.20]). The psychosocial factors appeared to mediate between 10% and 20% of relationship between CSR and ideal CVH. Conclusions: Increased CSR was associated with lower probability of achieving ideal CVH factors. A modest amount of the effect of CSR on ideal CVH appeared to be mediated by depression, stress and perceived discrimination. Public health strategies aimed at improving ideal cardiovascular health may benefit from including interventions targeting social and psychosocial risk factors.

Long-term Cardiovascular Manifestations and Complications of COVID-19: Spectrum and Approach to Diagnosis and Management.

Survivors of coronavirus disease 2019 (COVID-19) may experience persistent symptoms, abnormal diagnostic test findings, incident disease in specific organ systems, or progression of existing disease. Post-acute COVID-19 syndrome (PACS) is defined by persistent, recurrent, or new symptoms, findings, or diagnoses beyond four weeks after the initial infection. PACS has been characterized as a multi-organ syndrome, often with cardiopulmonary symptoms that include fatigue, dyspnea, chest pain, and palpitations. Cardiovascular pathologies in PACS include new-onset arrhythmia, myocarditis, unmasked coronary artery disease, and diastolic dysfunction as well as abnormal findings on electrocardiogram, troponin testing, and cardiac magnetic resonance imaging. In this review, we discuss the cardiovascular symptoms, pathophysiology, clinical investigation, and management strategies for cardiopulmonary symptoms of PACS. We offer a treatment algorithm for primary care clinicians encountering patients with cardiopulmonary PACS and discuss ongoing research on this topic.

Utilization of Palliative Care in Veterans Admitted With Heart Failure Experiencing Homelessness.

CONTEXT: Patients experiencing housing insecurity have numerous barriers affecting their utilization of medical care. OBJECTIVES: Determine if housing insecurity is associated with palliative care (PC) encounters and hospice services in patients with heart failure who receive care in United States Veterans Affairs (VA) medical centers. METHODS: This retrospective study included inpatients in VA hospitals with a primary diagnosis of congestive heart failure from 2010 to 2020. Housing stability was collected from coding and separated into three cohorts: at risk for homelessness, experiencing homelessness, and stably housed. The primary outcome was a PC encounter during admission and the stably housed cohort was used as the analytic reference. Inverse-probability-weighting (IPTW) was calculated to adjust the likelihood of receiving PC during the index admission. RESULTS: Seventy thousand eight hundred fourty nine veterans were identified. Veterans were identified as at risk for homelessness (n=4039, 5.7%), experiencing homelessness (n=1967, 2.8%) and stably housed (n=64,843, 91.5%). PC was delivered to veterans at risk for homelessness (n=484, 12.0%), veterans experiencing homelessness, (n=161, 8.2%) and patients with stable housing (n=6249, 9.6%). Relative to the stably housed and adjusted for IPTW, those at risk for homelessness received PC services similarly (adjusted OR=1.06, 95% CI 0.94,1.19) and those experiencing homelessness were at lower odds of receiving PC services (adjusted OR=0.62, 95% CI 0.52,0.75). CONCLUSION: Housing stability may be a factor in Veterans receiving PC during hospitalization for heart failure. While the logistical challenges of delivering PC and hospice to people experiencing homelessness are daunting, advocating for these services shows commitment to reducing suffering in life-limiting Illness.

Severe Hypoglycemia and Incidence of QT Interval Prolongation Among Adults With Type 2 Diabetes.

CONTEXT: There is a paucity of large-scale epidemiological studies on the link between severe hypoglycemia (SH) and corrected QT (QTc) interval prolongation in type 2 diabetes (T2DM). OBJECTIVE: To evaluate the association of SH with QTc prolongation in adults with T2DM. METHODS: Prospective cohort analysis of participants enrolled in the ACCORD (Action to Control Cardiovascular Risk in Diabetes) study without QTc prolongation at baseline. SH was assessed over a 24-month period. Incident QTc prolongation was ascertained using follow-up electrocardiograms. Modified Poisson regression was used to generate the risk ratio (RR) and 95% CI for QTc prolongation. RESULTS: Among 8277 participants (mean age 62.6 years [SD 6.5], 38.7% women, 62.8% White), 324 had ≥1 SH episode (3.9%). Over a median of 5 years, 517 individuals developed QTc prolongation (6.3%). Participants with SH had a 66% higher risk of QTc prolongation (RR 1.66, 95% CI 1.16-2.38). The incidence of QTc prolongation was 10.3% (27/261) and 14.3% (9/63) for participants with 1 and ≥2 SH, respectively. Compared with no SH, RRs for patients with 1 and ≥2 SH episodes were 1.57 (95% CI 1.04-2.39) and 2.01 (95% CI 1.07-3.78), respectively. Age modified the association of SH with QTc prolongation (PInteraction = .008). The association remained significant among younger participants (<61.9 years [median age]: RR 2.63, 95% CI 1.49-4.64), but was nonsignificant among older participants (≥61.9 years: RR 1.37, 95% CI 0.87-2.17). CONCLUSION: In a large population with T2DM, SH was associated with an increased risk of QTc prolongation independently of other risk factors such as cardiac autonomic neuropathy. The association was strongest among younger participants.

Outcomes in heart failure patients discharged to skilled nursing facilities with delirium.

AIM: Heart failure (HF) outcomes are disproportionately worse in patients discharged to skilled nursing facilities (SNF) as opposed to home. We hypothesized that dementia and delirium were key factors influencing these differences. Our aim was to explore the associations of dementia and delirium with risk of hospital readmission and mortality in HF patients discharged to SNF. METHODS AND RESULTS: The study population included Veterans hospitalized for a primary diagnosis of HF and discharged to SNFs between 2010 and 2015. Pre-existing dementia was identified based on International Classification of Diseases-9 codes. Delirium was determined using the Minimum Data Set 3.0 Confusion Assessment Method algorithm. Proportional hazard regression analyses were used to model outcomes and were adjusted for covariates of interest. Patients (n = 21 655) were older (77.0 ± 10.5 years) and predominantly male (96.9%). Four groups were created according to presence (+) or absence (-) of dementia and delirium. Relative to the dementia-/delirium- group, the dementia-/delirium+ group was associated with increased 30 day mortality [adjusted hazard ratio (HR) = 2.2, 95% confidence interval (CI) = 1.7, 3.0] and 365 day mortality (adjusted HR = 1.5, 95% CI = 1.3, 1.7). Readmission was highest in the dementia-/delirium+ group after 30 days (HR = 1.2, 95% CI = 1.0, 1.5). In the group with dementia (delirium-/dementia+), 30 day mortality (12.8%; HR = 0.7, 95% CI = 0.7, 0.8) and readmissions (5.3%; HR = 1.0, 95% CI = 0.8, 1.1) were not different relative to the reference group. CONCLUSIONS: Delirium, independent of pre-existing dementia, confers increased risk of hospital readmission and mortality in HF patients discharged to SNFs. Managing HF after hospitalization is a complex cognitive task and an increased focus on mental status in the acute care setting prior to discharge is needed to improve HF management and transitional care, mitigate adverse outcomes, and reduce healthcare costs.

Variation in statin prescription among veterans with HIV and known atherosclerotic cardiovascular disease.

BACKGROUND: People with HIV have increased atherosclerotic cardiovascular disease (ASCVD) risk, worse outcomes following incident ASCVD, and experience gaps in cardiovascular care, highlighting the need to improve delivery of preventive therapies in this population. OBJECTIVE: Assess patient-level correlates and inter-facility variations in statin prescription among Veterans with HIV and known ASCVD. METHODS: We studied Veterans with HIV and existing ASCVD, ie, coronary artery disease (CAD), ischemic cerebrovascular disease (ICVD), and peripheral arterial disease (PAD), who received care across 130 VA medical centers for the years 2018-2019. We assessed correlates of statin prescription using two-level hierarchical multivariable logistic regression. Median odds ratios (MORs) were used to quantify inter-facility variation in statin prescription. RESULTS: Nine thousand six hundred eight Veterans with HIV and known ASCVD (mean age 64.3 ± 8.9 years, 97% male, 48% Black) were included. Only 68% of the participants were prescribed any-statin. Substantially higher statin prescription was observed for those with diabetes (adjusted odds ratio [OR] = 2.3, 95% confidence interval [CI], 2.0-2.6), history of coronary revascularization (OR = 4.0, CI, 3.2-5.0), and receiving antiretroviral therapy (OR = 3.0, CI, 2.7-3.4). Blacks (OR = 0.7, CI, 0.6-0.9), those with non-coronary ASCVD, ie, ICVD and/or PAD only, (OR 0.53, 95% CI: 0.48-0.57), and those with history of illicit substance use (OR=0.7, CI, 0.6-0.9) were less likely to be prescribed statins. There was significant variation in statin prescription across VA facilities (10th, 90th centile: 55%, 78%), with an estimated 20% higher likelihood of difference in statin prescription practice for two clinically similar individuals treated at two comparable facilities (adjusted MOR = 1.21, CI, 1.18-1.24), and a greater variation observed for Blacks or those with non-coronary ASCVD or history of illicit drug use. CONCLUSION: In an analysis of large-scale VA data, we found suboptimal statin prescription and significant interfacility variation in statin prescription among Veterans with HIV and known ASCVD, particularly among Blacks and those with a history of non-coronary ASCVD.